Diagnosis and Treatment
Many psychologists are interested in classifying and treating disorders that cause distress and impairment. Clinical psychologists, in particular, have specialized training that teaches them to recognize characteristic symptom clusters (sometimes called syndromes) and apply empirically supported theories and techniques to treat the disorders.
The first step in any successful treatment is the correct identification of the problem(s) at hand. This may sound simple, but because multiple problems often cluster together and symptoms of different disorders can overlap with one another, the process of differential diagnosis can be quite complex and requires a psychologist to be very patient, observant, objective, and thorough in his or her exploration. Most psychologists also use a common diagnostic system that many different professionals are familiar with (the DSM-IV-TR, mentioned previously) and that makes accurate diagnosis somewhat easier. The DSM system provides psychologists not only with an approved set of diagnostic labels that facilitate communication and record keeping but also empirically validated diagnostic criteria for each disorder, descriptions of associated features and prevalence data, suggestions of other disorders to double-check and rule out as part of a differential diagnosis, and a standardized method of recording information on five different dimensions or axes (American Psychiatric Association, 2000).
Even with a classification system like the DSM in place, treating mental disorders (also referred to as psychotherapy or simply therapy) can be difficult and complex work. People are complicated, and so are their problems and their motivations for change. Each new client represents a single-case design experiment, of sorts, in that once a psychologist has identified the problems and potential solutions (i.e., the hypotheses), he or she uses theory to develop and implement interventions (i.e., the independent variables) and then evaluates the outcomes (i.e., the dependent variables) of therapy.
The theories used depend in part on the training background of the psychologist, what the scientific literature says about certain treatment methods for certain disorders, and the preferences of the client. Each theoretical perspective on therapy has its own concepts, definitions, and explanations for the causes and treatments of mental disorders. Although some sources indicate that there are over 400 unique theories of psychotherapy (Kottler, 2002), most psychologists agree that there are only a handful of primary perspectives; the different combinations and points of emphasis of these perspectives can account for the wide variety of therapeutic approaches.
The biological or medical perspective needs to be mentioned here, because even though most psychologists do not typically receive medical training, it is still important for them to know what the current medication options are, how they work, and what some of the potential side effects might be so they can liaise with prescribing physicians as part of a treatment team. Additionally, although hotly debated and controversial within the disciplines of both psychology and medicine, there are situations in which a psychologist could receive training and certification for limited prescription privileges. Essentially, the biological perspective looks for changes in the structure or functioning of the physical body to explain abnormal behavior and emotional states. If medical researchers can identify biological causes, then finding a way to reverse or minimize those physical changes becomes an obvious target for medical treatments. For example, changes in levels of certain chemicals or neurotransmitters in the brain, particularly decreases in serotonin, can cause increases in depressive symptoms. Therefore, finding a medication that has the net result of increasing serotonin levels should theoretically help minimize or eliminate those symptoms. This is, in fact, the very strategy employed when a professional prescribes a selective serotonin reuptake inhibitor (SSRI) for depressive symptoms that are severe enough to impair a person’s day-to-day functioning. By blocking the natural processes of reuptake and breakdown of serotonin, more of it remains in the synaptic gaps and is therefore readily available to receptors on other neurons in the brain. Unfortunately, there may be side effects that result from interfering with these processes, and that is why close monitoring and considerable medical knowledge and experience with dosage and side-effects profiles are critical. The medications used today have a much milder side-effects profile than those used just a few decades ago, and pharmaceutical companies spend record amounts on research and development of new medications each year. Other biomedical treatments besides psychotropic medications exist—for example, electroconvulsive shock therapy (ECT) and various forms of psychosurgery (e.g., severing the corpus callosum in cases of severe epilepsy).
Sigmund Freud (one of the most influential and controversial figures in psychology) developed and promoted the psychodynamic model in the early 1900s in Europe. Although not very scientific, his theory of personality development and functioning was certainly very descriptive and continues to impact our thinking today. If you’ve ever heard someone described as being anal-retentive because he or she is excessively neat and a little too high-strung, then you are familiar with some of Freud’s concepts. Freud believed that people were driven by unconscious forces and wishes rooted in their past, and that only by uncovering and understanding the unconscious could a person develop into a healthy, mature adult. Although his training as a neurologist caused him to approach many issues from a medical perspective, Freud’s model also had the advantage of incorporating some of the effective elements of moral therapy mentioned previously, most notably listening to patients talk and providing a safe environment in which to express and process emotions. Freud and his colleagues and students expanded and modified the psychodynamic model, and the image from traditional psychoanalysis of a patient lying on a couch and talking about anything and everything while the clinician listens in an intent but detached and objective manner is what many people think of when asked to describe psychotherapy. The notion of the unconscious, or at least differing states of consciousness, descriptions of coping strategies or defense mechanisms, and the concept of resistance as a natural and predictable part of the therapeutic relationship are all important and relevant in discussions of psychotherapy today (Kottler, 2002).
Carl Rogers and Abraham Maslow, the pioneers of the Humanistic perspective, also made significant contributions to our understanding of psychotherapy and the therapeutic alliance. Humanism, at its core, holds the beliefs that all people have intrinsic worth and that unrealistic and unhealthy demands, or conditions of worth, placed on them by significant others as well as themselves interfere with natural development and achievement. Rogers and Maslow taught people that if they could experience therapeutic acceptance from someone else, then they could accept themselves, keep things in proper perspective, and live their day-to-day lives in a more fulfilling manner. Although overly optimistic in some ways, this perspective teaches psychologists the importance of listening to and connecting with their clients in therapy, experiencing the moment, and avoiding being overly judgmental or critical of people (Kottler, 2002).
In the early 1900s, psychology was gaining momentum as a distinct profession and a relatively new branch of science, particularly in America. Psychologists such as James Watson, one of the forefathers of the psychological perspective of behaviorism, proposed that psychologists use the methods of science to better understand and predict observable behavior. Watson believed that if you couldn’t measure it, it couldn’t be studied scientifically, and therefore was not worthy of a true scientist’s attention. His focus on controlling and measuring observable behavior under strict experimental conditions contributed greatly to our understanding of how people learn and develop new behavioral responses. Students of Watson, including Rosalie Rayner and Mary Cover Jones, developed methods that showed how people could learn anxiety and fear, and just as importantly, how these responses could be unlearned and replaced with new behaviors. Other behaviorists, notably B. F. Skinner, have also had considerable influence on the field of psychology because of work with operant conditioning models of learning. Many of the strategies used to control dysfunctional behaviors have at their roots behavioral concepts and interventions. If you have ever witnessed children spending time in “time out” or being asked to eat their vegetables before getting dessert, then you know something about behavior and the context it occurs in, and how behavior can be modified by cues and contingencies.
Psychologists can apply the same principles in therapy. Systematic attention to positive behavior change and selective ignoring of inappropriate or maladaptive behaviors are one example. Differential reinforcement of prosocial behaviors (e.g., eye contact and smiling) in people recovering from an active phase of schizophrenia is another example. Token economies rewarding achievement and engagement in adaptive behaviors in children with pervasive developmental disorders such as mental retardation are yet another example. The applications are practically limitless once you understand the theory and principles of learning. Furthermore, because behaviorism has its roots in empirical psychology, it is relatively easy to evaluate effectiveness of an intervention because assessment is a built-in and continuous element of therapy (Kazdin, 2001). Albert Bandura, the father of social learning theory, took the work of people like Pavlov, Watson, Thorndike, and Skinner and created a comprehensive and integrated model of learning that included cognitive and social components. Although Watson and Skinner might disagree, most psychologists today believe that a person’s thoughts and internal emotional states are valid targets for psychological intervention. The difficulty has always lain in the scientific measurement of these aspects, but there are ways of collecting good, meaningful data if you understand the strengths and limitations of things like self-report measures. Behavioral and cognitive applications of psychology have evolved and merged into one general discipline, often called cognitive behavioral therapy (CBT), and is heavily emphasized in many psychology training programs because of its documented effectiveness and scientific underpinnings.
Last but not least there is the sociocultural or systemic perspective on therapy. Proponents of this model argue that treating symptoms within an individual essentially ignores the fact that people do not live and function in isolation, but rather move in circles as a part of various systems (family, couples, community, culture, etc.). They also contend that linear models of abnormal behavior are too simplistic, and that circular models involving feedback loops are more descriptive and accurate. The idea is that a member of a system can both cause change in and be changed by other members and dynamics within the system (Gladding, 2006). The emphasis on understanding ethnic and cultural influences also helps psychologists be sensitive to differences between themselves and their clients, and not to assume that values about, beliefs of, and goals for therapy are always going to be the same. There are entire specialties within psychology, such as multicultural psychology and marriage and family therapy, that have many of these key concepts and values at their core. They provide psychologists with a broader perspective and an ability to treat problems in context where possible and necessary, and give clients more options in terms of the type of psychological treatments available.
The research literature on the effectiveness of therapy is clear: seeking professional help is clearly more effective than waiting or doing nothing, and up to the point of diminishing returns more time in therapy is usually better than less (Miller & Rollnick, 2002). However, psychologists have been less successful identifying the exact components of therapy that are necessary for changes to occur. Some argue it is the systematic measurement and control of behavioral contingencies that allows for new learning to occur. Others insist it is the supportive relationship between a psychologist and a client that facilitates a natural developmental process. Still others maintain it is the cathartic release of emotion and constructive identification and resolution of conflict within the individual that creates new insights and choices. Finally, there are those who contend that truly changing a problem or symptom cannot occur until the system (e.g., the family, the community, or the culture) that elicits and maintains such behaviors is also changed.
Even the time required for therapy to be effective varies depending on the client, his or her problems, the treatment setting, and the primary orientation of the clinician. Although more therapy is generally better, there are circumstances in which a single session can be helpful in facilitating meaningful change and relief from symptoms (Kottler, 2002). This is in stark contrast to the classic model of psychoanalytic psychotherapy, which required patients to attend multiple sessions per week for several years. A typical course of therapy today at an outpatient facility would probably require meeting for 45 to 90 minutes once a week (or every other week) for several weeks to months. The psychologist and the client would spend the initial portion of therapy getting to know each other, gathering important information about the presenting problem(s), identifying goals and expectations for treatment, and creating a treatment plan. Implementing interventions consistent with the treatment plan and client goals would occur in the next phase, followed by evaluation of outcomes, termination (if goals had been accomplished and there were not any other issues to address), and follow-up (including checkups or booster sessions, as they are sometimes called) as necessary. Note that assessment in some form should occur at each and every stage of therapy, and is often required in order to fully document and evaluate the effectiveness of therapy.
With a few exceptions, there is no one simple answer and no one perfect treatment. Psychologists view the complexities and ambiguities of treatment as an important challenge, and as reasons to be even more disciplined and systematic in their work. An important part of the discipline of psychology, in particular conducting therapy, is the code of ethics that anyone identifying himself or herself as a psychologist must follow. This code of ethics was developed by the American Psychological Association and contains five general principles and several more specific standards to guide the practice of psychology (American Psychological Association, 2002). The code of ethics serves to protect the public from unscrupulous or incompetent psychologists, and also preserves the integrity of the profession by defining and enforcing standards of behavior that go above and beyond what is simply legal or illegal.
Read more about Abnormal Psychology:
- What is Abnormal Psychology
- History of Abnormal Psychology
- Assessment and Research
- Summary and References