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CHAPTER ONE
1.1 WHAT IS CLINICAL PSYCHOLOGY?
Clinical psychology is an exciting and growing field that encompasses both research and practice related to psychopathology and to mental and physical health. Understanding, treating and preventing mental health problems and their associate effect is the business of clinical psychology .. The word “Clinical”, derived from the Latin and Greek words for Bed, suggests the treatment of individuals who are ill. But clinical psychology has come to mean a broader area than just mental illness of individuals. Among the ultimate aims of clinical psychology are the psychological well-being and beneficial behavior of persons; therefore, it focuses on internal psychobiological conditions and on external social and physical environments within which individuals function. In a recent attempt to define and describe clinical psychology, J.H. Resnick (1991) has proposed the following definition and description of clinical psychology: “The field of clinical psychology involves research, teaching, and services relevant to the applications of principles, methods and procedures for understanding, predicting and alleviating intellectual, emotional, biological, psychological, social and behavioral maladjustment, disability and discomfort, applied to a wide range of client population”. Thus, clinical psychology uses what is known about the principles of human behavior to help people with the numerous troubles and concerns they experience during the course of life in their relationships, emotions, and physical selves. For example, a clinical psychologist might evaluate a child using intellectual and educational tests to determine if the child has a learning disability or an attention problem that might contribute to poor school performance.. People experiencing Alcohol addiction, hallucinations, compulsive eating, sexual dysfunctions, physical abuse, suicidal Impulses, and head injuries are a few of the many problem areas that are of interest to clinical psychologists.
1.2 HISTORICAL OVERVIEW OF CLINICAL PSYCHOLOGY INTRODUCTION
The history of clinical psychology, like that of many fields, is typically presented as a collection of names and dates. It is important to understand the individuals who have shaped the field of clinical psychology and to know when landmark events in the field occurred. Tracing the progression of the development of the field and the individuals who have influenced it provides an important perspective on the roots of clinical psychology as it exists today. However, the primary significance of clinical psychology's relatively short history does not lie in names and dates. Rather,
its historical importance comes From an understanding of the factors that have shaped the field into its current form and the forces that are likely to influence its development in the future. The field came into being for two reasons.
First, throughout history there has been a need to provide care and services for individuals who
are experiencing psychological problems, and clinical psychology emerged in part to help meet this need. The needs of individuals with psychological problems had been addressed in very different ways over the course of history before clinical psychology stepped in to help fill this role.
Second, some of the founders of scientific psychology in the late 1800s and early 1900s felt that
one objective of their new science should be to contribute to the welfare of others. William James, G. Stanley Hall. and other founders of American psychology shared a belief that one of the responsibilities of the new field of psychology was to benefit human welfare in a broad sense. Thus, a societal need existed, and some members of the psychological community felt a responsibility to fill this need. As we will point out, however, the greatest growth of clinical psychology occurred during the second half of the twentieth century, spurred by events that began during the First and Second World Wars.
EARLY APPROACHES TO MENTAL HEALTH CARE
The commitment to helping individuals in psychological distress certainly did not begin with the field of clinical psychology. The major functions that are served by clinical psychologists today (understanding and aiding individuals who are suffering from psychological disorders or are experiencing significant psychological distress) were met by other individuals and institutions in societies for centuries before the emergence of psychology as a profession. For much of recorded history, treatment of psychological problems was carried out by religious institutions. The treatment of mental health problems by religious methods is based in demonology, the view that these problems are the caused by forces of evil. Through-out the Middle Ages in Europe, the church was responsible for explaining the causes of psychological disturbance and providing treatment for it (most often in the form of punishment). For example, disturbed and disordered behavior that today is considered evidence of psychosis (e.g.. hallucinations, delusions) used to be interpreted as evidence of possession by the devil and was treated through exorcisms, torture, or death by burning at the stake. An alternative to demonology emerged in the form of medical explanations of psychological problems the somato-genic perspective, during the Greek period.
THE RENIASSANCE
During the renaissance, renewed interest in the physical and medical worlds emerged, overshadowing previously supernatural and religious viewpoints. Interest in the mind and soul were considered unscientific.
Morgagni discovered through autopsy that a diseased organ in the body could cause illness and
death. Andreas Vesalius emphasized scientific observation and experimentation rather than
reason, mythology, religious beliefs, and dogma. Rene' Descartes argued that the mind and
body were separate. This dualism of mind and body then became the basis for Western medicine until recently. As biological explanations for psychological problems emerged, medical professionals became involved in the identification and treatment of such disorders. Unfortunately, from the 1500s through 1800s, medical treatment of psychological problems primarily took the form of placement of individuals in psychiatric hospitals and asylums that offered little if anything in the way of treatment. Patients were held as prisoners in horrible conditions, little care or treatment was available, and even humane treatment was often lacking. In contrast to these early approaches, more recent developments in biological explanations of psychopathology have led to major advances in diagnosis and treatment.
THE NINETEENTH CENTURY
The nineteenth century experienced numerous advances in understanding mental and physical illness, and allowed for a more sophisticated understanding of the relationship between body and mind in both health and illness.
1.3 THE SKILLS & ACTIVITIES OF A CLINICAL PSYCHOLOGIST
The fundamental skill areas that is essential for competent functioning as a clinical psychologist within the areas of mental health include the following:
- Assessment & Diagnosis 2. Intervention & Therapy 3. Teaching 4. Clinical Supervision
- Research 6. Consultation 7. Program Development 8. Administration 1. ASSESSMENT & DIAGNOSIS Assessment has long been a critical part of the clinical psychologist’s role. Clinical psychologists most commonly administer psychological tests for the purposes of assessing a person's mental health. Assessment, whether through observation, testing or interviewing, is a way of gathering
information so that an important question can be solved. Assessment of an individual's development, behavior, intellect, interests, personality, cognitive processes, emotional functioning, and social functioning are performed by clinical psychologists, as are assessment activities directed toward couples, families, and groups. Interpretation of assessment results, and integration of these results with other information available, in a way that is sensitive to the client, and particularly clients of special populations, is an essential skill of clinical psychologists. The process of assessment is very important as it leads to the diagnosis of the client’s problem(s). All practicing clinicians engage in assessment of one form or another. Take, for example, the following cases:A child who is failing the fourth grade is administered an intelligence test to check if there is an intellectual deficit; a student with an undesirable behavior in class is administered a personality test to check the presence of anti-social personality traits. DIAGNOSIS To formulate an effective method of treatment, clinical psychologists must not only determine that there is a problem but also must make a specific diagnosis. That is, they must identify the specific disorder or problem affecting the patient. Clinical psychologists are trained to assess, and make functional diagnoses regarding intellectual level, cognitive, emotional, social, and behavioral functioning, as well as mental and psychological disorders. For this purpose, the most widely used diagnostic scheme in the United States is the Diagnostic and Statistical Manual of Mental Disorders, a reference book published by the American Psychiatric Association. This manual contains a complete list of psychological disorders classified into 16 broad categories. For example, panic disorder, post-traumatic stress disorder, obsessive-compulsive disorder, and phobias are grouped under the category of anxiety disorders. The manual describes the main symptoms for each disorder in concrete behavioral terms. It also gives the prevalence rates for men and women in the population; a list of predisposing factors; the normal age of onset; and the prognosis, or expected outcome. In clinical settings, diagnoses may be made formally, using widely accepted criteria, such as the DSM IV, or informally, such as diagnosis of family dynamics using a particular theoretical model.
2. INTERVENTION & THERAPY A major activity of clinical psychologists is intervention or treatment. Many clinical psychologists work directly with people who have a mental illness or psychological disorder. By choosing an appropriate treatment, clinical psychologists can help such people overcome their problem or, at minimum, manage their symptoms. All psychological intervention rests on the ability to develop and maintain functional therapeutic relationships with clients. 5
adopted. This meant that in contrast to other mental health workers such as psychiatrist or social worker, all clinicians were to be trained both as scientist and as practitioner. Although this research emphasis may not be as prominent in some training programs as it once was, the fact remains that clinical psychologists are in a unique position both to evaluate research conducted by others and to conduct their own research. Clinical psychology research can be both basic and applied. Among the health care professions, clinical psychology is one of the few to provide extensive research training. Thus, clinical psychologists are well suited to design, implement, and evaluate research and conduct program evaluation/quality assurance programs as part of their activities.
6. CONSULTATION Consultation, regardless of the setting in which it occurs, or the particular purpose it has, is a significant activity of many clinical psychologists. A growing number of clinical psychologists serve as consultants. In consultation, the goal is to increase the effectiveness of those to whom one’s efforts are directed by imparting to them some degree of expertise. Consultation might involve an informal discussion, a brief report, or a more ongoing and formal consultation arrangement. It takes innumerable forms, in many different settings. For example, companies might consult with a clinical psychologist to help reduce co-worker conflicts or provide stress management strategies for high stress employees such as business executives, fire fighters, police officers, or prison guards. Consultation might involve helping a physician to better manage patient non-compliance with unpleasant medical procedures. Consultation might also include assessment, teaching, research, and brief psychotherapy activities.
1.4 CLINICAL PSYCHOLOGY EMPLOYMENT SETTINGS
Clinical psychologists are found in a number of service settings, including the following: Ψ General Hospitals and Medical Clinics; Ψ Mental Health Clinics and Psychiatric Hospitals; Rehabilitation Hospitals and Clinics; Ψ Community Service Agencies; Ψ Private Practice; Ψ Schools, Universities and Colleges; Ψ Industry and the military Ψ Prisons and Correctional Facilities; Ψ Private and Government Research Agencies; and 7
Research on the employment settings of clinical psychologists reveals that the most frequent employment setting for clinical psychologists is private practice, while the university settings are the second most common employment sites. PRIVATE PRACTICE About 40% of clinical psychologists work in solo or group private practices. As a private practitioner, the clinical psychologist offers certain services to the public, as much as a dentist or general medical doctor does. Office hours are established and patients (i.e. clients) are seen for assessment, diagnosis and psychotherapy. Fees are charged for services rendered. Many psychologists are drawn to independently providing direct clinical, consultation and other professional services to their clients and enjoy being their own boss and setting their own hours and policies. Research supports that, private practitioners report more job satisfaction (Norcross& Prochaska, 1983; Norcross, Karg & Prochaska 1997a) and less job stress than other psychologists. COLLEGES AND UNIVERSITIES About 20% of clinical psychologists are employed in academic environments (American Psychological Association, 1993a). Most of these psychologists work as Professors. They generally teach psychology courses, supervise the clinical and or research work of psychology students and conduct both independent and collaborative research. They also typically serve on various college or university committees, providing leadership and assistance with the academic community. Some clinical psychologists work in academic clinical settings, such as student counseling centers, providing direct clinical services to students. HOSPITALS Many clinical psychologists work in hospital settings. They may conduct psychological testing, provide individual, family or group psychotherapy act as a consultant to other mental health or medical professionals on psychiatric or general medical hospital units, and may serve in administrative roles such as unit chief on a psychiatric ward. Many states now allow psychologists to become full members of the medical staff of hospitals. In California, for example, psychologists are allowed to have full admitting, discharge and treatment privileges which allow them to treat their patients when they are hospitalized and to participate in hospital committees. MEDICAL SCHOOLS Clinical psychologists serve on the faculties of many medical schools. They typically act as “clinical faculty”, which generally involves several hours (i.e., two to four) per week of pro bono time contributed to the training of medical center trainees. These trainees might include psychiatry residents, other medical residents (e.g., pediatric residents), medical students, nursing students or
initiatives or group program developments, e.g. exploring probation 'drop-out' rates or evaluating a group program; d) Participating in the delivery of, or acting as coordinating 'Treatment Manager' for, nationally recognized cognitive-behavioral group programs, e.g. Enhanced Thinking Skills or Sex Offender Treatment Program; e) Overseeing the training of prison/probation service staff. f) Dedicating time to the preparation of court reports. OTHER LOCATIONS ..This category includes • Professional schools
- Correctional facilities • Managed care organizations
- Nursing homes • Child and family services
- Rehabilitation centers • School systems
- Health maintenance organizations and so on.
1.5 MENTAL HEALTH PROFESSIONS THAT ARE CLOSELY RELATED TO
CLINICAL PSYCHOLOGY
Many people are unaware of the similarities and differences between clinical psychology and related Fields, e.g. a popular question is: what is the difference between a psychologist and a psychiatrist, or between a clinical psychologist and a counseling psychologist? Since almost all of the mental health ddisciplines share certain activities such as conducting psychotherapy, understanding differences between these fields can be very challenging. Major professions in the mental health field other than Clinical Psychology include the following:
- PSYCHIATRISTS 5. SCHOOL PSYCHOLOGISTS
- COUNSELING PSYCHOLOGISTS 6. HEALTH PSYCHOLOGISTS
- PSYCHIATRIC SOCIAL WORKERS 7. PSYCHIATRIC NURSES
- REHABILITATION PSYCHOLOGISTS 8. PARAPROFESSIONALS
- THE PSYCHIATRISTS The psychiatrics are physicians. Psychiatry is rooted in the medical tradition and exists within the framework of organized medicine. Because of the medical training, they may prescribe medications, treat physical ailments and give physical examination. In addition to their concentration on psychotherapy and psychiatric diagnosis, they make extensive use of a variety of medications in treating their patients' psychological difficulties. Furthermore, their medical training makes them potentially better able to recognize medical problems that may be contributing to the patient’s psychological distress.
Specific training in psychiatry begins only after a physician receive his/her MBBS or MD degree and takes the 4 years residency training in psychiatry with further specialized training following the completion of residency. DIFFERENCE BETWEEN A CLINICAL PSYCHOLOGIST AND PSYCHIATRIST Before receiving psychiatric training, a psychiatrist complete four years of the medical degree and the general medical internship. In contrast to psychiatrists, a clinical psychologist typically receives no training in medicine, receives more extensive training in human behavior and formal assessment of psychological functioning and receives extensive training in scientific research methods. Psychiatrists often come from an authoritarian tradition. The psychiatrist is an expert who tells patients what is wrong with them and then may prescribe medication to make things right. In contrast, clinical psychologist frequently emphasizes to troubled clients their autonomy and the necessity that they, as clients, collaborate with the therapist in the change process. Usually psychiatrists give emphasis on the use of medication in the treatment of problems. In contrast, clinical psychologist stress that client must learn to come to grips psychologically with their problems in living. Traditionally, clinical psychologists have been committed to the power of words (the talking cure) and to the process of thought and social learning. They do not subscribe to the credo of “better living through chemistry” when applied to psychological problems.
- COUNSELING PSYCHOLOGIST The activities of counseling psychologists overlap with those of clinical psychologist. Although both fields generally differ in philosophy, training, emphasis, and curriculum, but counseling psychology is perhaps the most similar to clinical psychology in actual practice. Like clinical psychologist, counseling psychologists generally major in psychology as undergraduates, attend a four-year graduate training program, one-year clinical internship and complete postdoctoral training prior to obtaining their license as a psychologist. Their principle method of assessment is usually the interview but they also do testing. Historically they have a great deal of educational and occupational counseling. More recently, many have begin to employ cognitive- behavioral techniques and even biofeedback HOW CLINICAL PSYCHOLOGY DIFFERS FROM COUNSELING PSYCHOLOGY The field of clinical psychology is much larger in terms of the number of doctoral- level professionals as well as the number of accredited doctoral training programs. There are approximately three times as many accredited doctoral program, producing four times as many graduates in clinical rather than in counseling, whereas counseling psychology is less large in the number of doctoral level professions and training programs. 11
6. PSYCHIATRIC NURSES
Psychiatric nurses receive their basic training in nursing as part of two-year program to be a registered nurse. Because psychiatric nurses spend many hours in close contact with patients, they are not only in a position to provide information about patients' hospital adjustment, but they can also play a crucial and sensitive role in fostering an appropriate therapeutic environment. They work in close collaboration with the psychiatrists or clinical psychologists, and they (along with those they supervise - attendants, nurse's aides, volunteers, and so on) implement therapeutic recommendations. They, cannot conduct psychotherapeutic sessions by themselves, but provide help to professionals.
- PARA-PROFESSIONALS .. People who are trained to assist professional mental health workers are called Paraprofessionals. They, just like psychiatric nurses, cannot conduct psychotherapeutic sessions by themselves, but provide help to professionals.
1.6 THE ROLE OF RESEARCH IN CLINICAL PSYCHOLOGY
Research lays a foundation of knowledge for understanding the phenomena of interest to clinical psychologists, including psychopathology, mental health, and the relationship between psychological factors and physical disease. Research also provides a body of evidence to guide clinical practice, including empirically validated methods to assess people and their problems and empirically supported methods of prevention and treatment. Psychological tests and other assessment methods used in clinical practice should be based on research that has established their reliability and validity. Research findings should also identify those interventions that have been shown to be more effective than no treatment or alternative forms of treatment. Just as research informs clinical practice, clinical experiences provide a source of ideas and hypotheses for research. Research also provides ideas for new directions and applications for the field of clinical psychology, including links between clinical psychology and research in other behavioral, biological, and social sciences. Because of the wide range of questions that confront researchers in clinical psychology, a variety of methods are used in research in this field. Research designs used by clinical psychologists range from single-case designs that study one individual at a time to large -scale, multisided studies involving hundreds or even thousands of participants. Clinical psychologists conduct research in many different settings including experimentally controlled laboratories as well as naturalistic settings such as hospitals, clinics, schools, and the community. Clinical researchers utilize various methods of data analysis, ranging from complex multivariate statistics used with large samples to 13
non-statistical methods in single-case studies. The methods that are chosen by researchers shape the types of questions that are asked; reflect the hypotheses that are being tested; and influence the interpretation of findings.
CHAPTER TWO
2.1 THE CONCEPT OF ABNORMAL BEHAVIOR & MENTAL ILLNESS
Clinical psychology is usually thought of as an applied field. Clinicians attempt to apply empirically supported psychological principles to problems of adjustment and abnormal behavior. Typically this involves finding successful ways of changing the behavior, thoughts, and feelings of clients. In this way, clinical psychologists lessen their clients' maladjustment or dysfunction or increase their levels of adjustment. Before clinicians can formulate and administer interventions, however, they must first assess their clients' symptoms of psychopathology and levels of maladjustment. Interestingly, the precise definitions of these and related terms can be elusive. Further, the manner in which the terms are applied to clients is sometimes quite unsystematic. Clinical psychology has moved beyond the primitive views that defined mental illness as possession by demons or spirits. Maladjustment is no longer considered a state of sin. The eighteenth and nineteenth centuries ushered in the notion that "insane" individuals are sick and require humane treatment. Even then, however, mental health practices could be bizarre, to say the least. Clearly, clinical psychologists' contemporary views are considerably more sophisticated than those of their forebears. Yet many view current treatments such as electroconvulsive therapy (ECT) with some skepticism and concern. Still others may see the popularity of treatments using psychotropic medications (such as antipsychotic, antidepressant, anti-manic, or anti-anxiety medications) as less than enlightened. Finally, many forms of "psychological treatment" (for example, primal scream therapy, age regression therapy) are questionable at best. All of these treatment approaches and views are linked to the ways clinical psychologists decide who needs assessment, treatment, or intervention, as well as the rationale for providing these services. These judgments are influenced by the labels or diagnoses often applied to people. WHAT IS ABNORMAL BEHAVIOR? Ask ten different people for a definition of abnormal behavior and you may get ten different answers. Some of the reasons that abnormal behavior is so difficult to define are (1) no single descriptive feature is shared by all forms of abnormal behavior, and no one criterion for "abnormality" is sufficient; and (2) no discrete boundary exists between normal and abnormal
although we must systematically seek the determinants of the individual's nonconformity or deviance, should resist the reflexive tendency to categorize every nonconformist behavior as evidence of mental health problems. Conformity criteria, in fact, have a number of problems.
Choice of Cutoff Points: Conformity oriented definitions are limited by the difficulty of establishing agreed-upon cutoff points. As noted previously, a cutoff is very easy to use once it is established. However, very few guidelines are available for choosing the cutoff point. For example, in the case of Billy, is there some thing magical about an of 64? Traditional practice sets the cutoff point at 70. Get an IQ below 70 and you may be diagnosed with mental retardation. But is a score of 69 all that different from a score of 72? Rationally justifying such arbitrary IQ cutoff points is difficult. This problem is equally salient in Martha's case. Are five crucifixes on the wall too many? Is attendance at three church services per week acceptable?
The Number of Deviations: Another difficulty with nonconformity standards is the number of behaviors that one must evidence in order to earn the label "deviant." In Martha's case, was it just the crucifixes, or was it the total behavioral configuration-crucifixes, clothes, makeup, withdrawal, fasting, and so on? Had Martha manifested only three categories of unusual behavior, would we still classify her as deviant?
Cultural Relativity: Martha's case, in particular, illustrates an additional point. Her behavior was not deviant in some absolute sense. Had she been a member of an exceptionally religious family that subscribed to radical religious beliefs and practices, she might never have been classified as maladjusted. In short, what is deviant for one group is not necessarily so for another. Thus, the notion of cultural relativity is important. Likewise, judgments can vary, depending on whether family, school authorities or peers are making them. Such variability may contribute to considerable diagnostic unreliability, because even clinicians' judgments may be relative to those of the group or groups to which they belong. Two other points about cultural relativity are also relevant. First, carrying cultural relativity notions to the extreme can place nearly every reference group beyond reproach. Cultures can be reduced to subcultures and subcultures to mini-cultures. If we are not careful, this reduction process can result in our judging nearly every behavior as healthy. Second, the elevation of conformity to a position of preeminence can be alarming. One is reminded that so-called nonconformists have made some of the most beneficial social contributions. It can also become very easy to remove those whose different or unusual behavior bothers society. Some years ago in Russia, political dissidents were often placed in mental hospitals. In America, it sometimes happens that 70-year-old Uncle Arthur's family is successful in hospitalizing him largely to obtain his power of attorney. His deviation is that, at age 70, he is spending too much of the money that will eventually be inherited by the
family. Finally, if all these points are not enough, excessive conformity has itself sometimes been the basis for judging persons abnormal. B. SUBJECTIVE DISTRESS We now shift the focus from the perceptions of the observer to the perceptions of the affected individual. Here the basic data are not observable deviations of behavior, but the subjective feelings and sense of well-being of the individual. Whether a person feels happy or sad, tranquil or troubled, and fulfilled or barren are the crucial considerations. If the person is anxiety-ridden, then he or she is maladjusted, regard-less of whether the anxiety seems to produce overt behaviors that are deviant in some way. ADVANTAGES OF THIS DEFINITION Defining abnormal behavior in terms of subjective distress has some appeal. It seems reasonable to expect that individuals can assess whether they are experiencing emotional or behavioral problems andcan share this information when asked to do so. Indeed, many methods of clinical assessment (for example, self-report inventories, clinical interviews) assume that the respondent is aware of his or her internal state and will respond to inquiries about personal distress in an honest manner. In some ways, this relieves the clinician of the burden of making an absolute judgment as to the respondent's degree of maladjustment. C. DISABILITY OR DYSFUNCTION A third definition of abnormal behavior invokes the concept of disability or dysfunction. For behavior to be considered abnormal, it must create some degree of social (interpersonal) or occupational problems for the individual. Dysfunction in these two spheres is often quite apparent to both the individual and the clinician. For example, a lack of friendships or of relationships because of a lack of interpersonal contact would be considered indicative of social dysfunction, whereas the loss of one's job because of emotional problems (such as depression) would suggest occupational dysfunction. ADVANTAGES OF THIS DEFINITION Perhaps the greatest advantage to adopting this definition of abnormal behavior is that relatively little inference is required. Problems in both the social and occupational sphere often prompt individuals to seek out treatment. It is often the case that individuals come to realize the extent of their emotional problems when these problems affect their family or social relationships as well as significantly affect their performance at either work or school. PROBLEMS WITH THIS DEFINITION Who should establish the standards for social or occupational dysfunction, the patient, the therapist, 17
MENTAL ILLNESS
Like abnormal behavior, the term mental illness or mental disorder is difficult to define. For any definition, exceptions come to mind. Nevertheless, it seems important to actually define mental illness rather than to assume that we all share the same implicit idea of what mental illness is. The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994), known as DSM-IV the official diagnostic system for mental disorders in the United States, states that a mental disorder is conceptualized as :“a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering, death, pain, disability, or an important loss of freedom ”. In addition, this syndrome or pattern must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one. Whatever its original causes, it must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual. Neither deviant behavior (e.g., religious, political, or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of the dysfunction in the individual as described above. CAUSES OF MENTAL ILLNESOVERVIEW OF ETIOLOGY The precise causes (etiology) of most mental disorders are not known. But the key word in this statement is precise. The precise causes of most mental disorders—or, indeed, of mental health— may not be known, but the broad forces that shape them are known: these are biological, psychological, and social/cultural factors. What is most important to go over is that the causes of health and disease are generally viewed as a product of the interplay or interaction between biological, psychological, and sociocultural factors. This is true for all health and illness, including mental health and mental illness. For instance, diabetes and schizophrenia alike are viewed as the result of interactions between biological, psychological, and sociocultural influences. With these disorders, a biological predisposition is necessary but not sufficient to explain their occurrence (Barondes, 1993). For other disorders, a psychological or sociocultural cause may be necessary, but again not sufficient. The brain and behavior are inextricably linked by the plasticity of the nervous system. The brain is the organ of mental function; psychological phenomena have their origin in that complex organ. 19
Psychological and sociocultural phenomena are represented in the brain through memories and learning, which involve structural changes in the neurons and neuronal circuits. Yet neuroscience does not intend to reduce all phenomena to neurotransmission or to reinterpret them in a new language of synapses, receptors, and circuits. Psychological and sociocultural events and phenomena continue to have meaning for mental health and mental illness. It is still meaningful to speak of the interaction of biological and psychological and sociocultural factors in health and illness. BIOPSYCHOSOCIAL MODEL OF DISEASE The modern view that many factors interact to produce disease may be attributed to the seminal work of George L. Engel, who in 1977 put forward the Biopsychosocial Model of Disease (Engel, 1977). Engel’s model is a framework, rather than a set of detailed hypotheses, for understanding health and disease. To many scientists, the model lacks sufficient specificity to make predictions about the given cause or causes of any one disorder. Scientists want to find out what is the specifically contribution of different factors (e.g., genes, parenting, culture, stressful events) and how they operate. But the purpose of the biopsychosocial model is to take a broad view, to assert that simply looking at biological factors alone—which had been the prevailing view of disease at the time Engel was writing—is not sufficient to explain health and illness. According to Engel’s model, biopsychosocial factors are involved in the causes, manifestation, course, and outcome of health and disease, including mental disorders. The model certainly fits with common experience. Few people with a condition such as heart disease or diabetes, for instance, would dispute the role of stress in aggravating their condition. Research bears this out and reveals many other relationships between stress and disease (Cohen & Herbert, 1996; Baum & Posluszny, 1999). One single factor in isolation—biological, psychological, or social—may weigh heavily or hardly at all, depending on the behavioral trait or mental disorder. That is, the relative importance or role of any one factor in causation often varies. For example, a personality trait like extroversion is linked strongly to genetic factors, according to identical twin studies (Plomin et al., 1994). Similarly, schizophrenia is linked strongly to genetic factors, also according to twin studies. But this does not mean that genetic factors completely preordain or fix the nature of the disorder and that psychological and social factors are unimportant. These social factors modify expression and outcome of disorders. Likewise, some mental disorders, such as post-traumatic stress disorder (PTSD), are clearly caused by exposure to an extremely stressful event, such as rape, combat, natural disaster etc.
