CHAPTER 2: Medical and Psychological Theories, Frames of Reference, and Models of Mental Health and Mental Illness

Chapter 2: Medical and Psychological Theories, Frames of Reference, and Models of Mental Health and Mental Illness

Introduction

• Theories:

  • Help explain how mental health problems develop.

  • Provide ideas for client interventions.

  • Assist in the analysis of clinical observations and predicting future client behavior and actions.

• Frames of Reference:

  • Encompass a specific professional domain area.

  • Include mechanisms for change from dysfunction to function.

• Models:

  • Synthesize theoretical and philosophical information.

  • Organize professional thinking about client performance.

Psychoanalytical Theory

• Based on the work of Sigmund Freud.

• Mental disorders are determined by our relationships (object relations) with objects in our environment.

• Lifelong patterns of object relations start in early childhood.

• Humans possess innate drives to satisfy personal needs.

• Theory of Object Relations:

  • Focuses on the significance of relationships and symbols.

Components of the Theory of Object Relations

• Id:

  • Represents the infantile aspect, driven only to satisfy one's personal needs.

• Superego:

  • Represents societal competence, driven to please others; it adheres to rules and conveys the conscience, informing what is right or wrong.

• Ego:

  • Functions to control anxiety, serving as the balancing drive among id, superego, and reality demands.

  • Involves memory, perception, and reality testing.

Defense Mechanisms

• Control impulses and actions, mediating between the id, superego, and reality demands.

• Help in understanding why individuals behave and respond in specific ways to stressful situations.

• Mental disorders arise when the ego cannot successfully mediate between the id, superego, and reality.

Use of Symbols

• Objects or symbols in dreams are considered key to interpreting unconscious conflicts.

• Occupational therapy uses symbols in arts, crafts, and daily activities for therapeutic value.

• Provides a structured framework for understanding mental functioning.

Developmental Theory

• People mature through a series of stages that follow a fixed sequence.

• If emotional or social growth is interrupted, it can result in a developmental lag.

  • This is a discrepancy between expected behavior for a given stage and actual behavior.

  • Developmental level is evaluated based on stage, not age.

• Mental health problems often occur when individuals fail to master developmental tasks.

• Occupational therapy can design situations that facilitate growth in areas where a lag is identified.

Occupational Therapy and Developmental Theory

• There are consistencies in various intervention methods aligned with developmental theory.

• Psychosocial (Erikson's term):

  • Relates to the psyche or self and the participation in society.

• A related concept in psychiatric occupational therapy is the development of adaptive skills.

Behavioral Theories

• Grounded in research by Pavlov and Skinner.

• Learning Process:

  • Behaviors with pleasurable outcomes tend to be repeated.

  • Behaviors with unpleasant consequences tend not to be repeated.

• Development occurs through the learning outcomes of actions.

Application in Occupational Therapy

• Adaptive behaviors are crucial for completing everyday occupations.

• Maladaptive behaviors can be developed if undesirable behaviors receive encouragement.

Behavior Modification Techniques

• Occupational therapy aims to change behaviors through modifying consequences following the action (action-consequence approach).

• Behavior Treatment Plan Components:

  • Identification of terminal behavior.

  • Establishment of a baseline for maladaptive behavior using recording methods.

  • Determination of reinforcement (positive or negative).

  • Establishment of reinforcement schedules.

Reinforcement Techniques

• Reinforcement:

  • Positive Reinforcement: Addition of something desired to enhance behavior.

  • Negative Reinforcement: Removal of something adverse to enhance behavior.

• Other behavioral techniques include:

  • Shaping.

  • Chaining (forward and backward).

  • Systematic desensitization.

Critiques of Behavioral Therapies

• While behavioral therapies yield quick results, they face criticism for treating individuals mechanically and relying on punitive measures.

• Modified behavioral concepts include Mosey’s activities therapy and social skills training.

Cognitive Behavioral Therapy

• Human behavior is significantly influenced by individual thoughts and beliefs.

• Individuals with mental disorders often exhibit maladaptive thinking, resulting in undesirable behaviors.

  • For example, continually thinking “nobody likes me” may lead to introverted actions that further alienate others.

Cognitive Links

• Cognitive behavioral approaches seek to link a triggering event to the individual's thoughts about that event and the elicited emotional responses.

Key Figures within Cognitive Behavioral Therapy

• Aaron Beck's approach includes:

  • Homework completion.

  • Cognitive rehearsal.

  • Self-monitoring.

  • Reattribution techniques.

• Albert Ellis developed rational-emotive therapy (RET), based on the ABCs (Activating event, Belief, Consequence) of human experience.

• Albert Bandura's focus on social modeling is relevant within occupational therapy practice.

Applications of Cognitive Behavioral Approaches in Occupational Therapy

• Utilizations of negative reinforcement to facilitate behavioral change.

• Techniques mentioned include:

  • Communication skills development.

  • Assertive training.

  • Problem solving and feelings management.

  • Taylor’s emphasis on anger management.

  • Babiss and dialectical behavior therapy applications.

Cognitive Enhancement Therapy

• Based on neurodevelopment and neuroplasticity principles.

• Derived from the disciplines of psychology, neurophysiology, sociology, neuropsychology, and psychiatry.

• Aimed at individuals with cognitive disorders such as schizophrenia and schizoaffective disorder.

Focus of Cognitive Enhancement Therapy

• Emphasizes cognitive learning and social cognition through various modalities:

  • Computer-based training programs.

  • Socratic questioning techniques.

  • Small group partnerships.

  • Real social role experiences.

• The occupational therapy professional acts as a coach to help clients establish and meet occupational goals as well as enhance their social interaction skills.

Client-Centered Humanistic Therapy

• Developed by Carl Rogers.

• Focuses on personal satisfaction in occupational performance as it aligns with individual meaning.

• Individuals inherently possess the potential for self-directed growth and development.

• Mental health issues arise when individuals lack awareness of their feelings and available choices.

Role of the Occupational Therapy Professional

• Provides unconditional positive regard for the client.

• Functions as a mirror reflecting the client’s thoughts and behaviors.

• Employs techniques such as:

  • Open invitations for dialogue.

  • Minimal responses.

  • Reflection of feelings.

  • Paraphrasing.

  • Withholding judgment.

Neuroscience Theories

• Explains that mind and emotion stem from biochemical and electrical brain activity.

• Normal functioning requires anatomically normal brain structures.

• Medical treatments include:

  • Psychosurgery.

  • Neurochemistry (pharmaceuticals).

  • Electroconvulsive therapy (ECT).

Application of Neuroscience in Occupational Therapy

• Implementation examples include:

  • Lorna-Jean King’s sensory integration approach targeting postural activities for individuals with schizophrenia.

  • Allen's focus on adapting environments to accommodate disabilities.

  • Brown’s evaluations for sensory processing assessment applicable to adults and adolescents.

Psychiatric and Psychosocial Rehabilitation

• Developed at Sargent College of Allied Health Professions in Boston.

• Draws from rehabilitation techniques across multiple theories.

• Classified as an atheoretical approach without a specific theoretical framework; strictly a rehabilitation methodology.

• Concentrates on functioning optimally within the community using available resources.

• Oriented toward present and future functionalities.

Goals and Values of Psychiatric Rehabilitation

• Goals:

  • Recovery.

  • Community integration.

  • Quality of life.

• Values:

  • Self-direction (self-determination, dignity, hope).

Phases of Rehabilitation Process

• Conducted through a three-stage process:

  • Rehabilitation diagnosis.

  • Rehabilitation planning.

  • Rehabilitation intervention.

Psychiatric Rehabilitation Assumptions

1. Functioning adequately in a chosen environment is preferable.

2. Successful functioning hinges on the availability of skills and resources.

3. Lacking skills can be cultivated through training; existing but weak skills can be enhanced through practice.

4. Environmental supports and resources facilitate functional success.

5. A belief in and hope for the future significantly bolsters rehabilitation outcomes.

Explanatory Models from Other Cultures

• Importance of Cultural Acceptance:

  • Occupational therapy professionals must acknowledge and respect cultural explanations for emotional distress and abnormal behavior that clients find meaningful.

  • There is noted overlap between cultural understandings of mental distress and the diagnostic criteria set in the DSM-5-TR.

  • The DSM-5-TR includes specific culture-bound concepts of distress.

Examples of Cultural Concepts of Distress

• Emotional distress and abnormal behavior explanations across cultures can include:

  • Possession by spiritual forces, ghosts, animals, or evil spirits.

  • Sorcery and witchcraft beliefs.

  • Concerns about the loss of semen (real or imagined).

  • Beliefs surrounding genital withdrawal or reduction.

  • The idea of a 'wind' affecting physical and mental health.

  • Overthinking leading to mental strain.

  • Sickness caused by external agents.

  • Inherent constitutional vulnerability to stress.

  • Departure of the soul leading to distress.

Specific Cultural Syndromes

1. Dhat syndrome:

   • Anxiety related to the perceived loss of semen, emphasized in Ayurvedic medical traditions in South Asia (India, Pakistan) but recognized historically in other cultures.

2. Kufungisisa:

   • Anxiety and depression stemming from excessive thinking, prevalent in Zimbabwe and Nigeria.

3. Susto:

   • Trauma or fright resulting in the soul leaving the body, implicated in various forms of mental, emotional, and physical distress in Mexico and Latin American countries.