History, Concepts & Stigma - Chapter 1

 

Introduction

For psychologists psychopathology is a field in which deviations from normal or everyday psychological functioning are being studied. Clinical psychology is a sector of psychology that deals with understanding and treating psychopathology.

Explaining Psychopathology

The view of what causes mental health problems has changed over time. We will examine the historical perspective of demonic possessions on explaining psychopathology and the contemporary models of explanation such as the medical model and psychological model.

Medical models: work with underlying biological or medical causes to explain psychopathology.

Psychological models: seek to explain psychopathology in terms of psychological rather than biological processes.

Demonic Possessions: since many forms of psychopathology seem to appear together with what looks like a personality change in the individual and which is noticed as one of the first symptoms, the historical explanation described this person as being ‘possessed’. The change in their behaviour was attributed to someone/something having taken over their personality. This has led the sufferers to be persecuted and physically abused instead of being cared for. Demonology is a term which describes the belief that someone with symptoms of psychopathology is under the possession of bad spirits.

The Medical or Disease Model

In the 19th century it became evident that many mental or psychological illnesses could be explained in terms of biological or medical accounts. The somatogenic hypothesis describes explanations of psychological problems in terms of physical or biological impairments. The discovery was made that syphilis had a biological cause and that later stages of the disease, such as dementia, gradual blindness, and paralysis, caused dramatic changes in one’s personality. This finding contributed to the mental disorder known as general paresis. Psychiatry is a scientific approach based on medicine to primarily identify the biological causes of psychopathology and treating them with medication or surgery.

The medical model provides important implications for how we view mental health but:

  1. Often times it is a person’s dysfunctional experiences and not biological dysfunctions that account for psychopathology.

  2. The medical model tries to reduce the complex psychological and emotional aspects of psychopathology to simple biology.

  3. The view that something is broken and needs to be fixed in the individuals is problematic, as psychopathology may just be a normal behaviour but in an extreme form. Labelling psychopathology as a normal process gone wrong or broken can lead to stigmatizing these individuals and viewing them as second-class citizens.

It is a widespread belief that people with mental health problems are dangerous, hard to talk to and that (some of) the mental health problems are self-inflicted. Psychopathology should be viewed as dimensional, and not as a discrete phenomenon that is set apart from normal experience. Medical models of mental health can often make a sufferer feel like a victim and powerless in regard to the condition and their future life. They feel socially excluded and often experience low self-esteem and depression after a psychiatric diagnosis.

From Asylums to Community Care

Not too long ago, prior to the 18th century, mental illnesses were seen as ‘madness’, and were not treated in hospitals like non-mental diseases are. With the decrease of non-mental diseases, many hospices were transformed to asylums for the confinement of sufferers of mental health problems. Treatments were unnecessarily cruel and painful, and these asylums over time not only accepted those with mental issues, but also other people who fell below the societal desirable standards, like poor people and young pregnant women. These approaches towards the mentally ill are probably part of the roots of the nowadays still running negative stigma towards sufferers of mental illnesses. The 19th century thankfully came with people advocating more humane treatments, like Philippe Pinel who began removing the chains and restraints of patients, and treated the patients as sick people, instead of animals. The Quaker movement (UK) developed the moral treatment approach, which abandons medical approaches and instead implements understanding, hope, occupational therapy, and moral responsibility.

Because most of the care started to rely on the (undereducated) nurses and caretakers, many patients were simply restrained. This often lead to patients developing social breakdown syndrome, making the patients aggressive, exerting challenging behaviour for the caretakers, and a lack of interest in personal welfare and hygiene. Therapeutic refinements of the hospital environment were: 1) the token economy, which consists of a reward system where patients can earn ‘tokens’ for various desired items or privileges, and 2) milieu therapies, which were implemented to develop productivity, feelings of self-respect, independence, and responsibility. This was achieved by mutual respect between staff and patients, and the opportunity for the patients to express themselves with vocational and recreational activities. It was shown that patients exposed to this kind of therapy were more likely to be discharged earlier and less likely to relapse.

Because of modern therapy and medical treatments, many people are not confided to a life in a mental health facility. Many return back to a state where they are capable of living quite a normal life. For people who still need some sort of after-care, there are assertive outreach programmes which help people who are recovering from psychosis to live a normal life as independent as possible.

Defining Psychopathology

Abnormal Psychology is an alternative term used to define psychopathology. This definition has a negative connotation though, suggesting that an individual is malfunctioning and thereby attaching a stigma to the individual. Service user groups communicate these labels that are often times attached to individuals with mental health problems. Two examples are Rethink and “Time To Change”, programmes with the aim to educate people about mental health, and fight against discrimination and negative stigma.

Deviations from the Statistical Norm

In clinical psychology the statistical norm, an average example of behaviour, is used to decide whether a certain disorder meets diagnostic criteria. Mental retardation is often diagnosed by an IQ score significantly below the norm of 100. Problematic is the view that individuals with exceptionally high IQ scores, which are also statistically rare, would not be considered as exhibiting psychopathology.

Deviations from Social Norms

It is quite difficult to use deviations from social norms as evidence for psychopathology, as different cultures have very different views on what is socially normal. Also, cultural factors are a great influence on how psychopathology manifests itself in the individual. This includes 1) the degree of vulnerability of an individual to causal factors and 2) the ‘culture-bound’ symptoms of psychopathology. Two examples of ‘culture-bound’ effects are Ataque de Nervios, a form of panic disorder found in Latinos from the Caribbean and Seiziman, a state of psychological paralysis found in the Haitian community.

Maladaptive Behaviour

We cannot define psychopathology solely in terms of maladaptive behaviour. Not all maladaptive behaviours are a result of psychopathology. One can say that many forms of psychopathology serve as protective or adaptive functions and do not represent maladaptive behaviour. Harmful dysfunction refers to the assumption that psychopathology is somehow defined by the abnormal functioning of an otherwise normal process.

Distress and Impairment

A useful way of describing psychopathology is the degree of distress and impairment the sufferers expresses. The individual can judge his or her own ‘normality’, which enables self judgment of their needs. Yet, this approach does not define a standard by which behaviour should be judged. Often times a person exhibiting psychopathology does not report experiences of personal distress, for example because they do not want to admit that they are behaving unusual, when they don’t experience any personal distress (e.g. antisocial personality disorder sufferers) or they don’t experience any distress yet (e.g. people abusing substances)

Explanatory Approaches to Psychopathology

In order to understand many mental health problems, different paradigms are used to gather information about the brain and mind. Symptoms can be explained at different levels, some of which are genetics, behaviour, biology or cognition. These different paradigms are categorized under biological and psychological models:

Biological Models

Genetics is the study of heredity and the inheriting of characteristics, and is therefore often used to look at the role that heredity plays in psychopathology. Some methods are 1) concordance studies, which look at different family members and the relation between a psychological disorder and the amount of shared genetic material, 2) twin studies, where monozygotic twins (identical genes) and dizygotic twins (50% shared genes) are compared to see if there is a genetic explanation in psychopathology. Many psychopathologies don’t occur spontaneously due to a person’s genes, but are rather a result of the combination of a genetic predisposition and some environmental influence. This is also known as the diathesis-stress model, which suggests that a problem develops from an interaction between the expression of our genes and the environment we experience. This model also supports the measure of heritability, which measures the degree to which some quality is explained by our genes, ranging from 0 to 1.

The field of molecular genetics is also involved in identifying which individual genes are involved in the transmission of symptoms seen in psychopathology. A method of achieving this is with genetic linkage analysis, which identifies the role of genes by linking some gene responsible for a specific characteristic (e.g. eye colour) with psychopathology symptoms. So if some eye colour is strongly co-occurring with a psychopathology symptom in a family, it is quite likely that the genes important for this symptom is found on the same chromosome as the one for eye colour. A downside to this method is that some symptom is often not relatable to a single gene, but instead to a greater amount of genes interacting. Another subfield of genetics is the field of epigenetics, which does not focus on the altering of the genetic code, but on the expression of current existing genes. There can be many reasons why some genes are or aren’t expressed at a certain point in an organisms life, the field of epigenetics is concerned with finding out what can alter the expression of a gene and what implications these differences in expression might have on the individual.

Neuroscience seeks to understand psychopathology by looking at an individual’s biology to help explain symptoms, where the bigger focus is on the brain structure, its function, and also the neuroendocrine system, since hormones contribute a lot to behaviour. The two brain hemispheres are connected by the corpus callosum, which is a bundle of nerve fibres. The cerebral cortex, the outer layer of tissue, consists of four lobes. The occipital lobe, located at the back of the brain, is associated with visual perception. The temporal lobe, can be found behind the temples to the side of the head, and it’s involved with functions such as hearing, memory, emotion, language, illusions, and processing tastes and smells, and the parietal lobe is associated with visuomotor coordination. Located at the front of the head is the frontal lobe, which is known to be important for higher cognitions like problem solving, controlling voluntary movements, willpower, and planning. Especially the frontal lobes are often implicated in many psychopathologies, seeing as they have such a major executive function over behaviour. Below these lobes many other structures can be found, and some of them are collectively known as the limbic system, which is thought to be involved in emotion and learning. The limbic system consists of the mammillary body, thalamus, fornix, hypothalamus, amygdala, and the hippocampus. The hippocampus is known for being involved in spatial learning, and the amygdala is crucial for processing emotions and learning from them.

The main method of communication between brain structures and thus neurons, is with neurotransmitters. These are chemicals that are the main component of regulating brain functioning. For example, dopamine is often associated with schizophrenia and psychotic symptoms. Serotonin is linked to depression and mood disorders, and norepinephrine and Gamma-aminobutyric acid (GABA) are thought to play a role in anxiety symptoms.

Psychological Models

Psychological models attempt to provide psychological explanations of psychopathology. The model sees mental health problems as normal reactions to adaptions to stressful life conditions.

Sigmund Freud (1856-1939), neurologist and psychiatrist, attempted together with Joseph Breuer to explain symptoms such as hysteria and paralysis that could not be explained by medical causes. Using hypnosis, the symptoms of Freud’s clients eased just talking about repressed experiences and emotions. On these cases, Freud built his theory of psychoanalysis. This theory tries to explain normal and abnormal psychological functioning in regard to defence mechanisms being used against anxiety and depression. He coined the concept of three psychological forces:

  • Id: describes innate instinctual, especially sexual, needs

  • Ego: rational; tries to control the id’s impulses with ego defence mechanisms that also reduce the anxiety that the id impulses may generate.

  • Superego: develops out of the other two psychological forces, and is responsible for integrating ‘values’, such as those learned from society or our parents.

Freud said that psychological health can only be attained if all three forces are in balance and that we develop defence mechanisms in order to avoid conflicts between the three forces or conflicts arising from external factors.

Freud believed that by the way children go through stages of development they could develop psychopathology. Failing to adjust to a particular stage of development could lead to the individual becoming fixated on this stage. The stages are:

Oral stage: refers to the first 18 months of life where the child is dependent on the food from the mother. Failing to receive food could lead to ‘oral stage characteristics’, such as extreme dependence on others.

  • Anal stage: (18 months to 3 years)

  • Phallic stage: (3 to 5 years)

  • Latency stage: (5-12 years)

  • Genital stage: ( 12 years to adulthood)

The concepts of the psychoanalytic approach are difficult to observe, measure, and objectively define, which is why this theory is not applied by many psychologists today.

The behavioural model explains psychopathology in terms of learned reactions to life experiences. The learning theory, based on principles of classical conditioning (e.g. dog salivating) and operant conditioning (e.g. Skinner box), explain how dysfunctional behaviour can be acquired just like adaptive behaviour. For example, many emotional disorders are explained by classical conditioning such as specific phobias or even post-traumatic stress disorder (PTSD).

Behaviour therapy is set on the principles of classical conditioning and operant conditioning, the goal of which is to ‘unlearn’ behaviours or emotions that are maladaptive. Behaviour modification is a therapy that focuses on the principles of operant conditioning.

The cognitive model describes how psychopathology develops through the acquisition of irrational beliefs, the development of dysfunctional ways of thinking and information processing biases. According to Albert Ellis (1962), people judge their own behaviour according to the irrational beliefs they developed, which cause emotional distress (e.g. anxiety). Aaron Beck developed a successful cognitive therapy against depression, which rests on the idea that people develop unrealistic expectations that guide their view of themselves, the world and their future.

When the dysfunctional beliefs which maintain the symptoms of psychopathology are identified, they can be changed and replaced by functional cognitions. Cognitive behaviour therapy aims at changing behaviours and cognitions. Even though this approach has been widely adopted and successful, there is not much known about the origin of the dysfunctional thoughts. The dysfunctional thoughts could merely be a symptom of psychopathology rather than a cause of it.

The humanistic-existential approach works with the view that individuals can acquire insight into their lives from a wide spectrum of perspectives, and only by gaining this insight can they achieve insights into their emotional and behavioural problems. Then, psychopathology and conflicts can be resolved.

Client-centred therapy is an approach in which the therapist makes use of empathy and unconditional positive regard to help the client achieve a sense of positive self-worth.

This approach places little emphasis on the acquisition of psychopathology, but tries to place the client from a phenomenological perspective, such as one consisting of fears and conflicts, into one that is functional (e.g. where the client feels self-worthy). This form of therapy is used only by some clinical psychologists, as the humanistic and existentialist approach is hard to evaluate.

Mental Health and Stigma

Many still hold negative views of those with mental illnesses. This might be explained due to a lack of knowledge, which is why it is important that people are educated about mental health, so that sufferers will feel less stigmatized and be treated the same as anyone else.

What is mental health stigma and where is it seen?

There are two types of mental health stigma: social stigma which is directed at others who are suffering from some sort of mental health problem, and perceived stigma (or self-stigma) which are the internalised feelings of discrimination a sufferer experiences due to their condition. The latter can be quite discouraging and result in a negative impact on possible treatment outcomes. Some of the biggest stigmas are that 1) patients are often dangerous, 2) that some disorders are self-inflicted, and 3) that sufferers are often hard to talk to.

What causes these stigmas?

Misguided views that the mentally ill are dangerous or shouldn’t be part of the society might be the basis why some still think that these people should be excluded and treated differently. Current views on mental health can still be stigmatizing, such as the medical model which implies that sufferers are different from others, or the fact that a label is put on those suffering from a mental issue does not help to alleviate any negative stigma. Another source of misguided views on mental health are the media.

Why does stigma matter?

Stigma can be discriminating, which results in social exclusion, low self-esteem, poor social support, and poor subjective quality of life. All of these factors have a huge impact on the treatment of mental disorders, like slowing down the recovery or even worse demotivating the sufferer from undergoing any treatment.

How can we eliminate stigma?

Much is done to eliminate stigma, like the Time to Change campaign (UK), which attempts to educate people about mental health with the use of blogs, videos, TV ads and events. Campaigns like these that are made to make contact between individuals with and without mental illnesses, have been shown to improve the attitudes towards people with mental health problems, promote people’s behaviour for anti-stigma engagement, and lastly increase the willingness of people to be open about any mental health problem they might experience in the future.

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