Kring et al. - Psychopathology

1.7

• mood can be distinguished from emotion

• emotion

  • expression

  • experience

  • physiology

• object relations theory

  • importance of relationships

• attachment theory

  • attachment styles

case study-amina

Amina, a 17-year-old girl who lived with her parents and her 15-year-old brother, was referred for family-focused therapy (FFT) for bipolar disorder as an adjunct to medication treatment. She had received a diagnosis of bipolar I disorder in early adolescence and was treated with lithium carbonate and quetiapine but had never fully responded to medications.

During an individual assessment session, Amina explained that she thought about suicide almost daily and had made two prior attempts, both by overdosing on her parents’ medications. Amina had kept both attempts secret from her parents. Ethically, clinicians need to take steps to keep a client safe, and in this case, one measure would be to let Amina’s parents know about her suicidality. The clinician explained this to Amina.

The first goal in FFT is to provide psychoeducation about bipolar disorder. As the symptoms of bipolar disorder were being reviewed, the clinician asked Amina to discuss her suicide attempts with her parents. When Amina did so, her parents were surprised. Her father, who had experienced his own father’s suicide, was particularly concerned.

After psychoeducation, a goal in FFT is to choose one problem for the family to address and to help them learn new problem-solving skills in the process. In this family, the focus of problem solving was how to keep Amina safe from her suicidal impulses. To begin problem solving, the therapist worked with the family to define the problem and its context. The therapist asked the family to discuss situations that seemed to place Amina at most risk for suicide. The family was able to pinpoint that both previous attempts had followed interpersonal losses.

The next phase of problem solving is to generate potential solutions. To help with this process, the clinician framed questions in the problem-solving process for the family, including whether Amina could share her suicidal thoughts with her parents, how to establish whether she was safe, what responses would be helpful from them and what other protective actions should be taken. Using this structure, the family was able to agree on the plan that Amina would phone or page her parents when she was feeling self-destructive. Amina and her parents generated a plan in which her parents would help Amina engage in positive and calming activities until her suicidal thoughts were less intrusive. Amina and her parents reported feeling closer and more optimistic.

The therapist then began to conduct the next phase of therapy, which focused directly on symptom management. This phase consisted of training Amina to monitor her moods, to identify triggers for mood changes and to help her cope with those triggers.

As is typical in FFT, the clinician introduced the communication enhancement module during session eight. A goal of this module is to role-play new communication skills. Family members practise skills such as ‘active listening’ by paraphrasing and labelling the others’ statements and by asking clarifying questions. At first, Amina and her brother protested against the role-play exercises.

Amina experienced another loss during this period when her one and only close long-term friend announced that she was going to be moving out of state. Amina took an overdose of paracetamol in a suicide attempt. Soon after overdosing, she became afraid, induced vomiting and later told her parents about the attempt.

The next session focused on the suicide attempt. Her parents, particularly her father, were hurt and angry. Amina in turn reacted angrily and defensively. The therapist asked the family to practise active listening skills regarding Amina’s suicidality. Amina explained that she had acted without even thinking about the family agreement because she had been so distressed about the idea of losing her friend. Amina’s parents were able to validate her feelings using active listening skills. The therapist reminded the parents that suicidal actions are common in bipolar disorder and noted that Amina’s ability to be honest about her suicide attempt was an indicator of better family connectedness. The therapist also recommended that Amina see her psychiatrist, who increased her dosage of lithium.

By the end of treatment after nine months, Amina had not made any more suicide attempts, had become more willing to take her medications and felt closer to her parents. Like many people with bipolar disorder, though, she remained mildly depressed. Amina and her family continued to see the therapist once every three months for ongoing support.

• what are some of the useful personal skills that amina was able to develop during the therapy sessions

• how do you think she will be able to use these in the future to help her cope

1.8

• paradigm

  • set of basic assumptions

  • determines how to conceptualise and study a topic

• 3 major contemporary paradigms

  • genetic/neuroscientific

  • cognitive-behavioural

  • psychodynamic/humanistic

• important facots

  • environment

  • experience

  • gender

  • culture

  • society

  • quality of relationships

• diathesis-stress paradigm

• predispositions increases a person’s chance of deceloping a disorder but does not guarantee it

case study - Arthur

Arthur’s childhood had not been a particularly happy one. His mother died suddenly when he was only six and for the next 10 years, he lived either with his father or with a maternal aunt. His father drank heavily, seldom managing to get through any day without some alcohol. His father’s income was so irregular that he could seldom pay bills on time or afford to live in any but the most run-down neighbourhoods. At times Arthur’s father was totally incapable of caring for himself, let alone his son. Arthur would then spend weeks, sometimes months, with his aunt in a nearby suburb.

Despite these early life circumstances, Arthur completed high school and entered university. He qualified for government financial assistance, but he also needed to work as a waiter and bartender to make ends meet. During these university years, he felt an acute self-consciousness with people he felt had authority over him — his boss, his lecturers and even some of his classmates, with whom he compared himself unfavourably.

Like many people at university, Arthur attended his fair share of parties, where he drank heavily. By his final year, however, he was drinking daily, often as a way to deal with the stress of studying and working at the same time.

Two years after university, Arthur married his girlfriend. He could never quite believe that his wife, as intelligent as she was beautiful, really cared for him. As the years wore on, his doubts about himself and about her feelings towards him would continue to grow. He felt she was far brighter than he and he worried that she would make more money than he would.

After university, Arthur began a job at a publishing company, serving as an editorial assistant. This job proved to be even more stressful than college. The deadlines and demands of the senior editors were difficult. He constantly questioned whether he had what it took to be an editor. Like his father, he often drank to deal with this stress.

Several years later, when it seemed that life should be getting easier, he found himself in even greater turmoil. Now 32 years old, with a fairly secure job that paid reasonably well, he was arguing more often with his wife. She continually complained about his drinking; he denied that there was a problem. After all, he was only drinking four beers a night. His wife wanted to start a family, but he was not sure if he wanted to have this additional stress in his life. His brooding over his marriage led him to drink even more heavily until finally, one day, he realised he was drinking too much and needed to seek help.

Depending on the paradigm you adopt, your conceptualisation of this case may differ. If you hold a genetic point of view, you are attentive to the family history, noting that Arthur’s father had similar difficulties with alcohol. You are probably aware of the research (to be reviewed in the chapter on substance use disorders) that suggests a genetic contribution to alcohol use disorder. You do not discount environmental contributions to Arthur’s problems, and you hypothesise about the ways in which genetic factors interact with different environmental factors (e.g., stress and work and in his relationships), which may in turn increase the likelihood that he will turn to alcohol to cope.

Now suppose that you are committed to a cognitive–behavioural perspective, which encourages you to approach psychological disorders in terms of reinforcement patterns as well as cognitive variables. You may focus on Arthur’s self-consciousness at university, which seems related to the fact that, compared with his fellow students, he grew up with few advantages. Economic insecurity and hardship may have made him unduly sensitive to criticism and rejection. Alcohol has been his escape from such tensions. But heavy drinking, coupled with persistent doubt about his own worth as a human being, has worsened an already deteriorating marital relationship, further undermining his confidence. As a cognitive–behavioural therapist, you may decide on cognitive–behavioural therapy to convince Arthur that he need not obtain universal approval for every undertaking.

If you adopt an integrative perspective, you might follow more than one of these strategies. You would acknowledge the likely genetic contribution to Arthur’s alcohol use disorder, but you would also identify key triggers (e.g., job stress) that might lead to greater bouts of drinking. You would likely employ many of the therapeutic techniques noted in this chapter.

• what are the disadvantages of a purely simplistic explanation of Arthur’s problems that focuses on only one paradigm?

• which of the paradigms would be most useful in helping Arthur feel confident in overcoming his problems?