Psych 361 week 13

-        Some historical and current context

o   Homosexuality as a diagnosable disorder and therefore needing change

o   Changes in the DSM

§  Homosexuality dropped in 1973 from DSM-II’s outright pathologizing in favor of “sexual orientation disturbance” (bothered and wanting to change) no real difference

§  Altered in DSM-III to “ego-dystonic homosexuality” – one is mentally disordered if societal prejudice made one want to change

§  Altered again in DSM-IIIR to “sexual disorder not otherwise specified”, defined as “persistent and marked distress about one’s sexual orientation”. Different to 1973 change? (and opening door to heterosexuals wanting to become gay?)

§  Retained in DSM-IV and DSM-IV-TR

§  Entirely out of DSM-5

o   June 2013 Supreme Court ruling against the Defense of Marriage Act, an anti-gay rights law

o   Some states banning sexual reorientation/conversion therapy but still an unsettled issue. In fact, there is a return to the past with increase in state laws against LGBTQ due to political pressure from Republican and some evangelical groups

-        The myth of therapeutic neutrality

o   Therapists never make ethically or politically neutral decisions

o   Psychiatric/psychological neutrality is a myth

o   Naturalness of and familiarity with our therapeutic practices blind us to non-empirical biases “a fish doesn’t know it is swimming in water”

o   Mental health professionals should (ethical statement – but with scientific consequences too?) know the water they are swimming in – we should worry more

-        Differences do not imply or prove pathogens – a widely misunderstood fact

o   Some argue homosexuality is pathological because homosexuals differ from heterosexuals in a particular way, like how they were raised

o   Flawed argument – one has to assume beforehand that a phenomenon is abnormal to adduce differences as proof of pathology. Cf. Bieber et al. (1962), flawed study both methodologically and logically

-        No cure without a disease

o   Until the 1980s or so, most therapists worked to reduce homosexual attraction and increase heterosexual attraction in homosexuals

o   Little time spent encouraging health professionals to change their negative biases

o   My question: “how can therapists honestly speak of nonprejudiced when they participate in or tacitly support therapy regimens that by their very existence and regardless of their effectiveness condone the societal prejudice and perhaps also impede social change?” (Davison, 1974)

o   Availability of a technique encourages its use

-        Clinical problems as clinicians’ constructions

o   Clients usually come with vague and complex complaints

o   Clinician transforms these complaints into a diagnosis, e.g., DSM or functional analysis (SORC)

§  Psychological problems are for the most part constructions of the clinician – a general argument that goes way beyond homosexuality

§  Argument has been that a gay patient’s problems are caused by or associated with their homosexuality – faulty reasoning from correlation to causation and a reflection of the (unrecognized) belief that same-sex attraction is abnormal

-        Discrimination, hate crimes, and the “voluntary” desire among gays to change sexual orientation

o   Acceptance of gay marriage has been spreading at an unexpectedly high rate in recent years

o   But legal pressure and especially societal biases against homosexuality remain in large portions of the country and throughout the world (and are becoming worse, given recent laws being enacted primarily in “red” states after years of progressive changes)

o   Gays and lesbians are still discriminated against

§  Hate crimes

§  Heterosexism and “minority stress” (“micro aggressions” recent term)

§  Gay or trans insanity/diminished responsibility legal defense

§  Loathing, self-hatred, minority stress, religious prohibitions – determinants of “voluntary” requests for change of sexual orientation

-        A proposal regarding sexual reorientation therapy

o   “at first glance, a model of psychiatric practice based on the contention that people should just be helped ot learn to do the things they want to do seems uncomplicated and desirable. But it is an unobtainable model. Unlike a technician, a psychiatrist cannot avoid communicating and at times imposing his own values upon his patients. The patient usually has considerable difficulty in finding the ways in which he would wish to change his behavior, but as he talks to the psychiatrist, his wants and needs become clearer. In the very process of defining his needs in the presence of a figure who is viewed as wise and authoritarian, the patient is profoundly influenced. He ends up wanting some of the things the psychiatrist thinks he should want”

o   Davison’s proposal: don’t attempt sexual orientation change even if the patient asks for it

-        Not can but ought – empirical versus ethical questions

o   Keeping the empirical distinct from the ethical and political

o   But ineffective treatments can make people feel worse – is this where the ethical overlaps with the empirical?

o   Davison’s sure-fire and fast cure for all ailments

-        The therapist as secular priest

o   Perry London (1964) therapist as secular priest – looked to and functions as a strong influence in moral/ethical as well as empirical/practical issues

o   Who makes the goal decisions? Better to assume it’s the therapist (even if it isn’t entirely) what is the balance? What is more expedient to believe? What is more ethical to believe?

-        Psychotherapy, politics, and morality

o   Individual intervention as a community psychology enterprise – taking institutional perspective

o   psychosocial interventions as part of social institutions

-        the role of stress in physical and mental health

o   suppression of immune system – vulnerability to infections and slower healing

o   variety of psychological problems, like anxiety, depression, race-related stress from open aggression to microaggressions

o   cardiovascular diseases

o   damage to muscles

o   inhibited growth in children

o   AIDS – initially a behavioral problem

o   Compliance issues in prevention and treatment

o   Interference with efficiency, effectiveness, and enjoyment

o   Both short-term and long-term

-        A psychological perspective on stress

o   A stressor sets the stage for stress

o   Stress is in the eye of the beholder – appraisal is key

o   Stress arises when (perceived) demands exceed resources

o   Stress in the early years can have effects across the lifespan and into old age. Now is a good time to learn stress management

o   Caveat – individual (idiographic) analysis is necessary, and seldom is one approach adequate

-        Individual and intrapsychic approaches to stress management

o   Arousal reduction

§  Relaxation training, medication/mindfulness aka mindfulness-based stress reduction), hypnosis

§  Biofeedback

§  Muscle relaxation training, sometimes assisted by biofeedback

·        Evidence unclear as to the need for biofeedback gadgetry

§  Evidence that these can be helpful in lowering stress levels

§  Immune function can be improved by relaxation training as well

·        Must be practiced regularly over a long period of time for enduring benefits

§  May enhance the individual’s sense of self-efficacy, the belief that one is not merely a pawn at the mercy of uncontrollable forces that are not always benign (Bandura, 1997). This cognitive conceptualization leads to next approach to arousal reduction – cognitive change

§  Albert Ellis (1962) and Aaron Beck (1976)

·        Focus on altering people’s belief systems (like Ellis’s replacing should with would), improving the clarity of their logical interpretations of experience, enhancing accuracy of perceptions (Beck)

§  Providing information to reduce uncertainty and enhance people’s sense of control has also been helpful in reducing stress

§  Problem-solving and journaling are also a part of cognitive restructuring

o   Cognitive restructuring

§  Ellis’s Rational-Emotive-Behavior therapy

·        A-B-C

·        “rational” = useful for survival, enjoyment, productivity

·        Unproductive beliefs

o   Form (musturbation and awfulizing)

o   Content (perfection and approval)

·        The role of values (e.g., how to decide what is “rational” and “unproductive”)

·        Changing should into woulds can reduce stress and enhance performance

·        acceptance versus control – hot issue

§  Beck’s Cognitive Therapy

·        A-B-C (primary focus on analyzing the accuracy of antecedents, but also interest in schemas, beliefs, similar to Ellis)

·        Distortions of reality, cognitive biases in construing the A

o   Arbitrary inference

o   Selective abstraction

o   Overgeneralization

o   Magnification or minimization

o   All-or-none (dichotomous) thinking

§  Cognitive biases in construing the A

·        Arbitrary inference: a conclusion drawn in the absence of sufficient evidence or of any evidence at all

·        Selective abstraction: a conclusion drawn on the basis of but one of many elements in a situation

·        Overgeneralization: overall sweeping conclusion drawn on the basis of a single, perhaps trivial, event

·        Beck’s cognitive biases

o   Magnification or minimization: exaggerations in evaluating performance

o   All-or-none thinking: judging events as either all good or all bad

o   Arousal reduction via problem-solving but also acceptance

§  Assumption: stress can be reduced by construing problems as normal and fixable and then fixing them (contrast with acceptance)

§  Pirsig’s “Zen and the art of motorcycle maintenance” – problems as interesting challenges amenable to calm analysis and solution

§  But not everything needs to be or can be fixed – acceptance can reduce stress. Empathy also, conveying understanding rather than rushing to what is broken (female vs. male characteristic?)

·        Primary vs. secondary (inferential)

§  Relabeling/reframing

o   Arousal reduction via journaling

§  Writing about feelings related to stressful experiences can reduce colds, anxiety, and depression

-        Environmental and instrumental approaches to stress management

o   If the thermostat is set to 100 degrees, you are going to sweat. So do something – change the thermostat, your clothing

o   Social support reduces stress and enhances well-being. Attendance at religious services may also help

o   Architectural/environmental design influences our feelings, cf. “unwanted social interaction” and more green spaces in lower-income LA schools

o   Assertiveness can change your social environment. Learn to be assertive

o   Acquired skills can too

o   Institutional change a la community psychology

-        Instrumental approaches

o   Asserting your rights

o   Emotional intelligence – understanding others (recall empathy and also see familiar graph on next slide on communication), social mores, blending your emotions with your intellect

o   Self-efficacy – acquiring a belief in one’s ability to perform enhances positive motivation and effort and reduces depression (esp. relevant in older adults, who tend to attribute lower performance in many domains to inevitable age-related losses in ability)

o   Don’t avoid (manageable) stressors

o   Learn communication skills

-        Positive psychology and stress management

o   Positive psychology: a development tracing back to Abraham Maslow that emphasizes the cultivation of positives, like love and joy, to complement the usual focus on reducing bad stuff, what we have been concentrating on so far – the usual approaches to managing your stress

o   Substitute good stuff to supplant the bad

§  E.g., certain religious or spiritual beliefs, existential meaning-making, doing good for others

-        Resilience

o   Some strategies (very cognitive and behavioral):

§  Learn to emphasize the positive instead of dwelling on the negative

§  Re-evaluate your narrative, your perceptions, your story

§  Remember past successes at coping

§  Seek out social support and help/support others (recall environmental change)

§  Purpose and meaning (cf. Rogers, Frankl, Existentialism in general)

-        Leading the good life

o   Burnout and questions of purpose and meaning

o   “positive psychology” – the study of human happiness, fulfilling the human potential (Maslow’s “B” needs)

o   Sometimes one should be distressed – the matter of values, morality, etc.

-        The complexities of stress management and leading a good life

o   Individual/intrapsychic modes of stress management

§  Relaxation, mindfulness/meditation, hypnosis, biofeedback

§  Cognitive restructuring (cognitive aspects of CBT)

§  Journaling

o   Acting on the environment

§  Skills training – remedying instrumental skills deficits

§  Or not acting on the environment – acceptance, empathy

§  Changing the physical or social environment (social action for social change, community psychology

§  values