Alternatives to the Medical Model

The Behaviorist Explanation of Mental Illness

Processes of learning can also be used to explain the origin of mental disorder - abnormal behaviour is assumed to be learned in the same way that any other types of behaviour is learned. This can occur through different types of learning, classical and operant conditioning 

Classical Conditioning:

  • This happens when an emotional response e.g. fear or anxiety becomes associated with a particular neutral stimulus
  • Famously demonstrated by Pavlov (1903) - taught dogs to salivate at the sound of a bell that they associated with the presentation of food 
  • If a person is regularly exposed to a particcular stimulus with an unpleasant experience then the stimulus will evoke the fearful or disgusted response - cases that are extremely unpleasant or distressing just one coupling with the stimulus may create the lasting association 
  • An example of this is Little Albert by Watson and Rayner (1920) demonstrating a phobia can be learned through classical conditioning
  • Albert was a healthy, normal 11 month old who was put througha series of trial then exposed to a sudden loud noise that would cause him to burst into tears 
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The Behaviorist Explanation of Mental Illness

  • Experimenters presented a white rat (which Albert initally liked) then hit a hammer against a metal bar to induce fear - this was repeated, eventually Little Albert only had to see the rat and would demostrate a fearful response e.g. crying and crawling away 
  • Though the phobia was deliberatly induced - the porcess could be applied to real-life situations e.g. developing Hydrophobia due to falling into water (neutral stimulus) at a young age where they couldnt swim and being submerged (Unconditioned response of fear/panic) and therefore develop a life-long aversion to water (conditioned response)

Operant Conditioning:

  • This explains how consequences of different behaviours (reinforcers) shape subsequent behaviour 
  • Humans learn by consequence when behaviour is reinforced, that behaviour becomes more likely to be repeated (Skinner 1938) 
  • If behaviour is not reinforced but punished it is less likely to be repeated (punishment less effectibbe than reinforcement) 
  • The process can be observed through addictive behaviour (alcohol, drugs, gambling)
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The Behaviorist Explanation of Mental Illness

  • If you try gambling and have success = behaviour reinforced, what starts as voluntary behaviour then becomes addictive (a complusive need to keep playing) 
  • One reason that gambling is addictive is that it creates an intermittent schedule of reinforcement - this has a stronger behavioural effect than continous positive rewards e.g hoping that the next one will be a success
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The Cognitive Explanation of Mental Illness

  • This explanation is more concerned with the processes of thinking, attention and the perception that underlie abnormal behaviour. Cognitive psychologists found that the beviouist approach ignores the ability of people to reflect on and consciously control their behaviour - CE addresses symptoms and causes of mental disorder though examining irrational and maladaptive beliefs 
  • It relies on the idea that the cognitions of a person with a mental illness are somehow faulty - they way in which they percieve and think about situations are what cause the difficulty rather than the situation 
  • People who tend to think negatively will make associated thinking errors or biases that warp their emotions and behaviour 
  • Cognitive distortion is another term for irrational thinking - individual who forms an inaccurate perception of reality that ould be highly negative or disturbed
  • Nothing deliberate or controlled about cognitive distortion - occurs automatically (Beck 1976) 
  • The cognitive theory for emotional disorders was outlined by Beck and by his student Burns (1989) - recognised while adverse events happen in everbodies lives - specific distortions of thought can lead to negative emotional and behavioural consequences e.g. anxiety and depression  
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The Cognitive Explanation of Mental Illness

Common cognitive disorders are:

  • Over-generalisation: viewing one unfortunate events as a part of a neverending struggle or defeat, expressed as ' Everything always goes wrong for me'
  • Filtering: giving greater consideration and focus to negative aspects, while downplaying positive ones, expressed as 'It doesnt matter that I passed the test, I got that one answer wrong and I let myself down'
  • Catastophisation: making a mountain out of a mole hill, feeling like an outcome/situation is far worse or will be than what it actaully is, expressed as 'I got the customer's order wrong, I'm going to be fired and I will never get a job again'
  • Dichotomous Reasoning: all-or-nothing thinking, seeing the world as black or white, expressed as 'He's perfect, nothing ever goes wrong for him - he's so good at everything'
  • It is suggested by Beck that maladaptive thinking patterns form at childhood - known as 'schema development' where different disorders are categorised by schemas
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The Cognitive Explanation of Mental Illness

  • e.g. depression involves a traid of negative schemas - early experiences forms dysfunctional bieliefs which may be traggered by adverse life events (death of a loved one, illness, loss of job/relationship) and activate the underlying assumptions
  • From then incomin information is processed with a negative bias = emotial, cognitive and bahvioural syptoms of depression 
  • Beck's thoery of influence of schemas on processing had been applied to anxiety disorders
  • Though difficult early experiences can lead to development of the negative triad it does not mean the person will develop a mental disorder - trauma or a serious life event must happen
  • Beck and other cognitive theorists believed the nature of schema formation and information processing can be changed through therapeutic techniques which form the main non-medication routes for anxiety and depression 

Cognitive-Behavioural Therapy:

  • Most commonly used psychological therapy (usually for depression) 
  • Takes place 1 x a week/fortnight, for between 5-20 sessions 
  • It involves helping the patient identify irrational and unhelpful thoughts and trying to change them 
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The Cognitive Explanation of Mental Illness (CBT)

  • This involves showing the patient links between their thinking, behaviour and emotions e.g. by drawing diagrams 
  • Rationale for CBT is that our thoughts affect our feeling/behaviour so by changing our thoughts we change our behaviour 
  • Some form of CBT focus on directly encouraging changes to behaviour 
  • The aims in treating depression are:

1. Re-establish previous levels of activity 

2. Re-establish a social life 

3. Challenge patterns of negative thinking 

4. Learn to spot early signs of recurring depression 

  • Therapy is collabrative e.g. terapist and patient will agree on what the patient wants to change - and can ask them to express their negative beliefs e.g. in relation to their social life
  • A depressed patient might believe in not going out as they think they wont enjoy it 
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The Cognitive Explanation of Mental Illness (CBT)

  • Therapist might respond by vigorous argument to convince them they will enjoy going out
  • CBT might alsoo combine behaviour activation - patients are encouraged to take part in activities they normally enjoy but ceased engaging in as they are depressed 
  • They record the activity in a diary - normally they enjoy it - the evidence can then be used to challenge the patient when they next say that they will not do something as they wont enjoy it

Evaluation: (Debates)

  • Usefullness of Research: CBT is widely considered useful, it is recommeded as the first-line treatment of depression. Butler et al 2006, reviewed studies of CBT and found 16 published analyses which included the results of smaller studies, and concluded that CBT was very effective for treating depression. NICE recommended CBT as the most effective psychological treatment for moderate and severe depression
  • Nature vs. Nurture:  Has both elements of nature and nurture, types of faulty cognitions that may cause depression e.g. part of underlying cognitive structures (nature) that are influenced by learning and ecperience (nurture). Contrastingly the behaviourist explanation relies solely on nurture - saying maladaptive behaviours, e.g. gambling/irrational fear, are a product of external enviromental stimuli 
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Evaluation of Both Continued

Elements from both approaches influence CBT as a treatment for mental illness, which in turn draws on innante cognitive processes and enviromental stimuli through behaviourl activation 

  • Freewill vs. Determinism: The behaviourist of mental illness can be considered as deterministic - as maladaptive behaviours are seen as a product of interaction with the enviroment - little to suggest we can change or influence them. But the cognitive approach suggests that the way in which we think about negative events can change our patterns of behaviour - this can be seen during CBT sessions where clients are encouraged to confront cognitive distortions to improve their emotional health
  • Psychology as a Science: Behaviourists look at taking a highly scientific approach to their work - in mental health they seek a casual link between a known event in a persons life which resulted in a particular outcome. Cognitive explanations are harder to demonstrate empirically as they rely on self-report of distroted conditions and maladaptive behaviours - CBT is an approach that combines cognitive and behaviourist principles - this can be seen as scientific as it is evidence-based and there is considereable evidence to support it's effectiveness
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The Psychodynamic Explanation of Mental Illness

An older approach to the treatment of mental illness is the psychodynamic approach, back to the work of Sigmund Freud in the 19th and early 20th c. A very theoretical approach to mental illness that emphasises the influence of the unconscious mind on symptoms and the influence of early trauma and the quality of early relationships on later mental health but the behaviourist and cognitive approaches are based on scientific research - psychodynamic is clinically derived 

Freuds Hydraulic Model:

  • He got the idea 'hyrdraulic model' from literature where phrases such as 'to cry oneself out' or 'to blow off steam' were commonly usec to describe emotional resposes
  • The phrases suggest that the mind is a system in which psychic energy behaves in the same way as physical energy 
  • He believed that like energy, psychic energy could be discharged or transformed but not destroyed 
  • Trauma and the inability to express instincts resulted in a build up of psychic energy that led to symptoms of mental disorder 
  • One aim of the psychodynamic therapy is catharsis - the release of the accumulated psychic energy 
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The Psychodynamic Explanation of Mental Illness

Freud's Ideas about Sexual Trauma and Fantasy:

  • His view of psychosexuality is the most socially sensitive and controversial aspect of his theory
  • In early work Freud propsed sedution theory, emphasing the role of childhood sexual abuse in causing psychological problems - he famously put it 'whatever case and whatever symptoms we take as our starting point, in the end we infailably come to the realm of sexual experience' (1896) 
  • The term 'sexual experience' is braod and describes a range of sexual traumas e.g. case of Anna O - whose deafness in early childhood ws linked to her childhood experience of her eavesdropping on her parents having sex (Breuer and Freud 1896)
  • Freud identified sexual abuse as a major cause ps psychopathology 
  • In later work Freud shifted emphasis to sexual fantasy (considered to be a mistake) - in the case of Dora (1905), Freud suggested that Dora's symptom of psychological loss of voice was not the result of being molested by a family friend but due to a suppressed desirfe for him 
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The Psychodynamic Explanation of Mental Illness

Freudian Theory of Depression:

  • He propsed some cases of depression could be linked to experiences of the loss of a parent, or rejection by a parent 
  • He drew a parrell between the feelings adults have when mourning someone and the experience of depression years after a childhood loss experience 
  • Important part of adult mourning = anger and he said that the same anger is important for children's responses to loss 
  • The child's anger at being 'abandoned' through seperation or rejection cannot be expressed because of love for the object of the anger so it is repressed - turning inwards which causes guilt and low self-esteem as the ego 'rages against itself'

A Psychodynamic Explanation for Schizophrenia:

  • S is a complex and serious mental illness involving hallucinations (mainly auditory) and delusions - irrational beliefs (persecution) 
  • One psychodymanic approach came from Fromm-Reichmann (1948) - based on her patients accounts of their childhoods and proposed the exsistence of a schizophrenogenic mother
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The Psychodynamic Explanation of Mental Illness

  • The term 'schizophrenogenic' refers to a factor that causes schizophrenia - she propsed that families that were chracterised by high emotional tension and secrecy and if the mother was cold and domineering in her attitude - children were at a high risk of developing schizophrenia 
  • Fromm-Reichmann drew a link from the secrecy to the development of the delusions of persecution 

Psychodynamic Therapies for Depression:

  • Originated with the work of Freud - the original form (Classical psychoanaylsis) is intensive, takes place 4-5 times a week, lasting several years 
  • Psychoanalytical psychotherapy is slightly less intensive and long-term, usually 1-3 times a week for 1-5 years 
  • Traditionally psychoanalysis patients lie on a sofa and P and therapist don't face each other - now, usually in psychotherapy, P's and T's are more likely to face each other on comfty chairs
  • On psychoanalysis or psychoanalytical psychotherapy - no attmept to teach patient more constructive patterns of thinking or behaviour - emphasis is on exploring the P's past and linking that to their current symptoms 
  • Early experiences of loss or rejection are more important in depression - may be explored
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The Psychodynamic Explanation of Mental Illness

  • Patient may vividly recall these experiences (abreaction) and 'discharge' the associated emotion (catharsis) - could be very angry/upset 
  • Often the negative emotions can be transferred onto the therapist - treated as if they were the absent or rejecting parent - therapist can feed this back to the patient who can gain insight into the way in which they transfer anger onto other people 
  • From a psychodynamic perspective, relationship difficulties are often associated with depression are often the result of transferring anger from early losses 
  • More modern Breif Psychodymanic Therapy (BDT) rather than waiting for negative emotions to be transferred to the therapist - patients are educated about the links between their current functioning and their past experiences 

Evaluation:

  • Usefullness of Research: In spite of scientific limitations of Freudian theory - psychodynamic therpies have proved useful for many people. Psychodynamic therapies proven useful for many people - aim to discharge pent-up emotion and also to give patients insight into their condition and the possible origins which means they can exercise more free will and prevent their past experiences determining their symptoms, psychodynamic therapies are long-term
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The Psychodynamic Explanation of Mental Illness

they are also more expensive meaning it is uncommon in the Uk National Health Service (NHS) but it is recommended by the National Institute for Clinical Excellence (NICE) - for complex cases of depression. The practical application is a strength of the apporach.

  • Nature vs. Nurture: Psychodynamic approach acknowledges the importance of both (nature in the form of instincts, nurture in form of parenting). Freud identified two basic intincts: eros (life instinct) and thanos (death instinct) - he explored how these interact with parenting behaviour e.g. during the Oedipus complex a child's life instinct is expressed towards their opposite sex parent - while death instinct is towards the same sex parent. The fact noth nature and nurture are present in psychodynamic is a strength - but most modern psychologists disagree with Freud's idea of instincts and his empahsis on particular interactions with parents (OC)
  • Freewill vs. Determinism: fairly determininstic due to emphasises on the way our current feelings and motives are determined by the unconscious mind (contains both instincts and mental representations of early relationships). However, it can offer the idea of freewill as you can gain insight into the unconscious influences through dreams, slips of the tongue and interpretations from a therapist - once aware of the influnces people can make conscious decisions to act in particular ways - Having both is a strengh of the approach
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The Psychodynamic Explanation of Mental Illness

  • Psychology as a Science: This approach is widely seen by modern psychologists as poor science, Freud's ideas were derived from self-analysis and interpretations of what his patients said to him in therapy. Contrasts with modern psychologial theory which tend to be the product of systematic research on larger groups of participants. Another reason it is seen as poor science is that the difficulty involved in testing his ideas in a scientific manner - the unconscious mind in not observable and Freud's theory fails to lead to predictions that can be tested through thorough research - his own evidence tended to be in the form of case studies - not repeatable and can be interpreted in different ways. This can be seen as a weakness of the approach although it does make it more subjective, although falsifable.
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