Theoretical Models in Clinical Psychology PSYC 4500: Introduction to Clinical PsychologyBrett Deacon, Ph.D.September 17, 2013
From Last Class • Diagnosing mental disorders • Kirk, Gomory, & Cohen chapter
Schedule • Today: Theoretical models in psychology • Satel & Lilienfeld response paper due – please turn in now • Thursday: Exam #1
Questions for Kirk, Gomory, & Cohen (2013) Chapter, due today • List and describe what you believe to be the three most significant problems associated with the DSM diagnostic system raised by the authors.
Exam Review • General notes • Part I: 25 multiple choice/true false questions • Handful of questions answered in book only • Part II: 25 points worth of matching, fill in the blank, short answer, brief essay • All questions from lecture material • Part II of the exam focuses on lecture material given particular emphasis
Exam Review • Chapter 1 • Nature of clinical psychology • Clinical psychology vs. related professions • Different training models
Exam Review • Science and Pseudoscience • Pignotti article • Why science matters in clinical psychology • Essential features of science • Essential features of pseudoscience
Exam Review • Chapter 3 • Psychoanalytic models – personality structure and levels, psychosexual stages, defense mechanisms, current status • Humanistic Models – key assumptions of Client-Centered Therapy
Exam Review • Chapter 3 • Behavioral models – classical and operant conditioning, how to understand a client’s symptoms using this model • Cognitive models – key assumptions, how to understand a client’s symptoms using this model
Exam Review • Chapter 4 • Satel & Lilienfeld chapter • Behavioral genetics; family, twin, & adoption studies; current status • Omit pp. 107-115 (brain anatomy and function)
Exam Review • Chapter 5 • Kirk, Gomory, & Cohen chapter • pp. 128-133 only for the first exam • Classifying mental disorders • Diagnosis – how it works, criticisms • Characteristics of the DSM-IV
Models in Clinical Psychology • Theoretical model – simplified pattern that shows how something might work • “Science is built of facts the way a house is built of bricks, but an accumulation of facts is no more science than a pile of bricks is a house.” -Henri Poincare • Models are necessary and incredibly useful, but may also be problematic
Models in Clinical Psychology • 1. They may be wrong. • Example: Actual quote from a medical chart: “From a psychodynamic perspective, he could be using his OCD as a shield against other psychological conflicts or fears regarding dating, education, and career.” -psychiatry resident
Models in Clinical Psychology • 2. They may be pseudoscientific, thereby failing to advance knowledge. • Example: TFT
Models in Clinical Psychology • 3. They may cause harm • Example: The “schizophrenogenic mother” idea that schizophrenia was caused by mothers who displayed rejecting behavior to their children, imperviousness to the feelings of others, and rigid moralism concerning sex and fear of intimacy
Psychoanalytic and Humanistic Models • Development and influence on contemporary mental health practice • Popular ideas: • Problems are symbolic, treatment must uncover the hidden meaning of symptoms • The therapeutic relationship is necessary and sufficient for overcoming problems • FiLCHeRS analysis: problems with falsifiability, comprehensiveness, honesty, sufficiency
The Behavioral Model • Arose in reaction to psychoanalytic model • Disagreement with the “deeper meaning” of symptoms • Rejection of immeasurable concepts as speculative and nonscientific • Emphasis on experimentally demonstrable principles of conditioning and learning
Classical Conditioning • First demonstrated by Ivan Pavlov (1927) • Process by which a neutral stimulus acquires the power to elicit a response by being repeatedly paired with an unconditioned stimulus
Classical Conditioning How classically conditioned responses are acquired: • An unconditioned stimulus (meat) automatically elicits an unconditioned response (salivation) • A neutral stimulus (bell) is repeatedly paired with the unconditioned stimulus (meat) • Eventually, the neutral stimulus (bell) becomes a conditioned stimulus that has the power to elicit the response (now called a conditioned response)
Classical Conditioning • Everyday examples of classical conditioning: • The Office: http://www.youtube.com/watch?v=WfZfMIHwSkU • Product advertisements • http://www.youtube.com/watch?v=Avq2LAcPdj0
Classical Conditioning • How are conditioned responses extinguished? • Repeatedly presenting the CS in the absence of the UCS • Drinking Coke in the absence of cuddly polar bears • Eating a Hardees Western Burger not in the presence of a scantily-clad Padma Lakshimi
Classical Conditioning – Clinical Applications While sitting in the passenger seat, Patti gets in an argument with her boyfriend and gestures toward him in anger. He loses control of the car on the highway, spins off the highway and almost runs into a bridge. He immediately accuses her of being crazy and trying to kill them both. Patti feels terrified and ashamed. She subsequently experiences high anxiety, intrusive recollections of the event, and occasional flashbacks when driving. She avoids driving whenever possible, particularly driving on highways, near bridges, and especially near the scene of the car accident. She avoids watching TV shows with car chases. She seeks therapy when her anxiety persists for weeks and starts to affect her quality of life.
Classical Conditioning – Clinical Applications • In Patti’s example, identify the: • Unconditioned stimulus • Unconditioned response • Conditioned stimulus • Conditioned response • Examples of stimulus generalization
Classical Conditioning – Clinical Applications • How would you help Patti extinguish her conditioned fear?
Operant Conditioning • Behavior is modified by its consequences • Pleasurable consequences strengthen behavior • Positive reinforcement • Negative reinforcement • Aversive consequences weaken behavior • Positive punishment • Negative punishment • http://canitbesaturdaynow.com/dived/video/adhd_cure/ • http://www.youtube.com/watch?v=JA96Fba-WHk
Operant Conditioning • Negative reinforcement is not the same thing as punishment! • Reinforcement strengthens behavior • Punishment weakens behavior
Operant Conditioning – Clinical Applications Irene is a recovering heroin addict with mild mental retardation. On the inpatient substance abuse unit, she often engages in a form of self-injurious behavior in which she stares at a staff member, smiles, strikes her ears with her hands, and repeats the word “no” while shaking her head. Staff members typically respond by approaching her, gently grabbing her hands, and reminding her that such behavior is not acceptable. The persistent nature of this behavior is a serious concern among staff members who don’t want Irene to hurt herself but are also concerned that she is manipulating them.
Operant Conditioning – Clinical Applications • What operant conditioning process is maintaining Irene’s self-injurious behavior? • What operant conditioning process is maintaining the staff’s response to Irene’s self-injurious behavior? • How could you use operant conditioning to change Irene’s behavior?
The Basic Cognitive Principle • People are upset not because of events or situations, but by the meaning that people give to events or situations • When the meaning is negative, negative emotions result
The Cognitive Model • Emotions are specific to particular ways in which we interpret events and situations • Depression: personal loss • Anger: perceived unfairness • Guilt: you broke your own rules • Anxiety: Potential threat or danger
Cognitive Models – Clinical Applications Alex is extremely anxious in the presence of people he believes are immoral or mentally deficient. He is concerned that he will literally take on these characteristics via physical proximity to such individuals. Alex takes special care to not inhale, or swallow, in unison with perceived immoral or mentally deficient persons in order to prevent himself from becoming like them.
Cognitive Models – Clinical Applications • Can classical and/or operant conditioning explain the development of this problem? • From a cognitive perspective, why does Alex have this problem? • How might Alex’s avoidance and safety-seeking behavior actually be maintaining this problem? • How would you use cognitive principles to help Alex overcome this problem?
Biological Models • Satel & Lilienfeld article • Chapter 4 • Read about: • Brain imaging (scanning) techniques • Logical issues in interpreting biological findings • Behavioral genetic research methods (twin, family, and adoption studies) and findings
Biological Models • The biomedical model • Assumptions: • Mental disorders are caused by biological abnormalities principally located in the brain • There is no meaningful distinction between mental diseases and physical diseases • Biological treatment is emphasized
Questions for Satel & Lilienfeld (2013) Chapter, due next Tuesday • The biomedical model dominates addictions research and treatment in the US • List and describe what you believe to be the three most significant problems associated with the brain disease theory of addiction raised by the authors.
National Institute of Mental Health “Mental disorders are brain disorders, a simple and profound truth that has completely altered the way that we approach diagnosis and ultimately will alter the way we treat them.” –Thomas Insel (2006)
Beyond Atheoretical Diagnosis “…the DSM’s [atheoretical] approach may have outlived its usefulness and is in fact potentially misleading. Although there is a large body of research that indicates a neurobiological basis for most mental disorders, the DSM definitions are virtually devoid of biology.”
The Primary Goal of DSM-5: A Neuroscience-Based Taxonomy “It is our goal to translate basic and clinical neuroscience research relating brain structure, brain function, and behavior into a classification of psychiatric disorders based on etiology and pathophysiology.”
The Goal of DSM-5 • Did you know the goal of the DSM-5 task force was to create a neuroscience-based diagnostic classification? • What is your reaction to this goal?
The Reality, 10 Years Later • DSM-5 task force chairs David Kupferand Darrel Regier (2011): • “…we anticipated that these emerging diagnostic and treatment advances would impact the diagnosis and classification of mental disorders faster than what has actually occurred…”
What Happened? • The anticipated scientific breakthroughs did not occur • Little evidence for biological etiology • Genetics, molecular biology, and neuroimaging have not identified a single biological marker that is useful in diagnosing or in predicting treatment response to any mental disorder
Missing Evidence • No biological test appears as a diagnostic criterion for any mental disorder in DSM-5 • Notably, one DSM-IV disorder was subsequently discovered to have a definitive, testable biological cause. Which one?
Missing Evidence • Rett’s disorder – pervasive developmental disorder in DSM-IV • Caused by genetic mutations • Eliminated from DSM-5 • Rationale: it has a known biological cause, unlike other disorders in the DSM which have unspecified etiologies
DSM-5 Will Remain Atheoretical • “It is important to emphasize that DSM-5 does not represent a radical departure from the past” –Kupfer & Regier(2011) • APA President Jeffrey Lieberman: “The last thing we want to do is be defensive or apologetic about the state of our field. But at the same time, we’re not satisfied with it either. There’s nothing we’d like better than to have more scientific progress.” • Hopes for neuroscience-based diagnosis and treatment have been deferred
A Dream Deferred • Kupferand Regier(2011): • “As we gradually build on our knowledge of mental disorders, we begin bridging the gap between what lies behind us (presumed etiologies based on phenomenology) and what we hope lies ahead (identifiable pathophysiologic etiologies)” • “…the point at which such data can be meaningfully used by clinicians is soon coming…”
A Few Questions • Do you share the APA’s “hope” that mental disorders will be shown to be “identifiable pathophysiologic entities?”
Biomedical Model Critique • Are mental disorders biologically-based brain diseases? Chemical imbalances? • Has biomedical research developed diagnostically useful biological tests? • Has biomedical research developed diagnostically more effective medications? • Are mental health outcomes improving? • Has the biomedical approach been a success? For whom?
Biomedical Model Critique • Fruits of the biomedical revolution • Knowledge of the biological basis of mental disorder • Chemical imbalance story • Stigma • Lack of clinical innovation • Poor long-term outcomes of medications • Increased chronicity and severity of mental disorders, especially in children