43 Psychiatry and Clinical Psychology
Life is complicated – A Lot Can Go Wrong
Eat, survive, reproduce, and think about the meaning of life. Every human addresses these concerns. We have seen how our genes and experiences interact to enable us to survive, perceive, learn, think, develop, and adapt to the current physical and social environment. Humans have attained varying degrees of success in achieving their potential under extraordinarily different conditions throughout their history on the planet. This is the fourth and final chapter in the nature/nurture section of the book. We have seen how nature and nurture interact during different developmental stages to influence our individual personalities and interpersonal relationships.
Tragically, some fetuses inherit genes or encounter environmental conditions resulting in their not surviving till birth. For most of our history, the birth process itself was extremeley dangerous and many infants did not survive. Until recently, humans lived under harsh geographic and climatic conditions including life-threatening predators. Many perished during childhood and early adulthood. Thankfully, a sufficient number managed to survive long enough to reproduce and sustain our species.
The Nukak survived for thousands of years under some of the least habitable conditions on earth. Over the millennia, it is likely that some of the Nukak inherited characteristics that made it difficult for them to learn to eat, survive, or reproduce. Some children may have exhibited unusual, or annoying, or disturbing behaviors. Such children were dependent upon caretakers for greater investments in time and energy. As mentioned earlier, some Stone-Age nomadic tribes abandoned unwanted children. If caretakers were unsuccessful in efforts to modify problematic behaviors, these children might be subject to shunning, abandonment, or worse. These natural and social selection processes probably resulted in extremely hardy, low-maintenance tribe members.
With the advent of agriculture and animal domestication, human communities increased in size, from dozens, to hundreds, to thousands, to millions. Different social arrangements and institutions became necessary. Governments were formed to create and enforce consensually agreed upon norms for behavior. As a species, we became increasingly tolerant of individual differences and implemented laws to protect infants and children inheriting or developing medical and behavioral problems.
Psychiatry and Clinical Psychology
Some medical and behavioral problems are sufficiently serious to be considered illnesses or disorders. I have described psychology as the science of human potential. Achieving one’s potential is an adaptive process taking place within a specific environmental context. A mental illness or a psychological disorder is usually inferred when a person’s thoughts, emotions, or behavior appear to interfere with or prevent adapting to the current environment and fulfilling one’s potential.
Two different professions emerged to address the wide spectrum of problems that can interfere with adaptation or self-fulfillment. Because of the very different histories, traditions, explanatory models, and professional organizations, there has frequently been confusion and sometimes controversy concerning the appropriate boundaries and relationships between these two professions. Fortunately, both professions have evolved to the point that these boundaries are becoming increasingly clarified and the relationships increasingly collaborative and synergistic.
The medical profession applies the findings of the basic biological sciences to conditions that threaten the health or vitality of individual animals. Veterinarians treat animals other than humans. As disciplines, including sciences, advance and acquire more knowledge, they typically fragment into specialized sub-disciplines. There are a number of such specializations for the medical treatment of humans. Some address problems with specific parts of human structure, such as nephrology (kidneys), ophthalmology (eyes), orthopedics (muscles and bones), and otolaryngology (ear, nose, and throat). Other medical specializations address problems with specific biological functions such as cardiology (circulation), endocrinology (glandular functions), gastroenterology (digestion), and neurology (the nervous system). Some specializations are specific to certain times of one’s life; obstetrics for birth, pediatrics for childhood, and gerontology for the aged. Speaking of the aged, Dr. Seuss (Geisel, 1986) wrote a book for adults entitled You’re Only Old Once! It describes the types of medical doctors one acquires as they get older. I used to think the book was funny! Similar to medicine, professional psychology has evolved and developed specialized, applied, sub-disciplines. The practices of some of these professions will be described in Chapter 12.
Psychiatry and clinical psychology are the specializations within professional medicine and psychology that address problems related to adaptation and personal fulfillment. Although both disciplines recognize the importance of nature and nurture in the understanding of human behavior, they have different emphases. Each specialization employs the schematic framework of its parent discipline. Psychiatry assumes the causes and treatment for adaptive problems are based on biological mechanisms. Clinical psychology assumes that although problems may be based on nature/nurture interactions, effective treatment can be entirely experiential. One would expect that each discipline would employ treatment methods exclusively based upon its underlying science. This has not always been the case in the past, which is part of the reason for the confusion regarding the roles and boundaries of the two professions.
The Separate Histories of Psychiatry and Clinical Psychology
Although it is commonly understood that biology and psychology are separate disciplines, the separation between psychiatry and clinical psychology is less familiar. The contributions of the early schools of psychology (structuralism, functionalism, Gestalt psychology, and behaviorism) were reviewed in Chapter 1. Over time, the basic content areas comprising most of the chapters in this book developed and evolved. Contemporary approaches to clinical psychology apply the research findings from these content areas, particularly the principles of direct and indirect learning (Chapters 5 and 6). In general, psychological approaches involve assessing and providing experiences to improve an individual’s ability to adapt to their environmental conditions and realize their potential.
The word psychiatry, initially defined as “medical treatment of the soul”, was introduced by the physician Johann Reil in 1808 (Shorter, 1997). At that time, when families could not provide the necessary care or individuals displayed unusual, self-destructive, or dangerous behaviors, they were often placed in monasteries or jailed. As communities increased in size and the numbers of such individuals overwhelmed existing facilities, asylums were created to house them. The negligent, frequently abusive treatment of individuals in asylums, led to this approach eventually being abandoned. Asylums were replaced in the latter half of the 19th century, for those who could afford them, by more fashionable spas (Shorter, 1997). Over the next century, two distinct psychiatric approaches emerged, one based on advances in the biological sciences; the other on Freud’s personality theory (see Chapters 9 and 12). Advances in the biological sciences and controversies regarding the scientific basis for Freudian theory and treatment led to the emergence of anti-psychiatry initiatives in the 1960s (Cooper, 1967; Szasz, 1960). The development of effective pharmacological treatments and the reluctance of insurance companies to pay for frequent “talk therapy” sessions resulted in eventual rejection of the Freudian model in favor of a purely biological model of psychiatry (Shorter, 1997). A benefit of these developments has been increased clarity concerning the complimentary roles played by psychiatry and clinical psychology. It is necessary to assess the appropriate balance of biological and experiential approaches to treatment for every client. We will now consider the historical, disease-model approach to diagnosis of disorders implemented by the American Psychiatric Association. Toward the end of the chapter, an alternative, psychological approach to assessment of maladaptive behavior will be described.
The Medical Model and DSM 5
Is psychiatry a medical enterprise concerned with treating diseases, or a humanistic enterprise concerned with helping persons with their personal problems? Psychiatry could be one or the other, but it cannot–despite the pretensions and protestations of psychiatrists–be both
Thomas Szasz
A medical model treats adaptive disorders as though they are diseases; thus, the term “mental illness.” The medical model has been enormously successful in the treatment of biological disorders ranging from broken bones, to common colds, to infectious diseases, to heart disease, and cancer. Thomas Szasz (1960), a psychiatrist, wrote an extremely controversial, provocative, and influential book entitled The Myth of Mental Illness. He argued that illnesses result from biological malfunctions but that behavioral disorders do not. Szasz considered the labels for different mental illnesses to be pseudo-explanations; labels for the behaviors they purport to explain. That is, the different labels used for mental illnesses are defined exclusively by a constellation of behaviors as opposed to an underlying biological pathology. Recalling the example from Chapter 1, the disease term “influenza” stands for the relationship between a specific pathogen (virus or bacteria) and a syndrome of symptoms. In comparison, the disease term “schizophrenia” is defined exclusively as a constellation of behaviors (i.e., on the dependent variable side). No cause (i.e., independent variable) is specified. Remember the opening line of this book. There are things I think I know, things I think I might know, and things I know I do not know. Szasz is telling us that we know less than we think when we are given a mental illness label.
If one approaches a disorder as an illness, the function of assessment is to determine a medical diagnosis . A useful diagnosis provides information concerning the etiology (i.e., initial cause and/or maintaining conditions), prognosis (i.e., course of the disorder in the absence of treatment), and treatment of a biological syndrome (i.e., collection of symptoms occurring together). Many disease names (e.g., influenza, malaria, polio, etc.) provide information about the underlying mechanisms that cause and sustain a syndrome of specific symptoms. However, this is not always the case, even for biological disorders. For example, hypertension is exclusively defined by the magnitude of one’s blood pressure readings. Despite the fact that the term does not explain the elevated pressure, it is still useful since it provides information concerning prognosis and treatment. If hypertension is left untreated, blood pressure remains elevated. Treatment usually follows a course from least to increasing levels of invasiveness. It might begin with the recommendation to decrease sodium (e.g., salt) in your diet and to increase exercise. Psychiatric illness labels are also defined exclusively on the dependent variable (in this instance, behavioral) side. One might be diagnosed as schizophrenic based on the report of hallucinations (see below). Even though the term “schizophrenia” provides no information about the cause(s) of hallucinations, it does provide information about prognosis and treatment. Hallucinations will continue in the absence of treatment; anti-psychotic medications will probably help.
The American Psychiatric Association (2013) compiles a comprehensive listing of mental illness disease labels and definitions (i.e., behavioral criteria) in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM, published initially in 1952, has undergone periodic revision; DSM-II in 1968, DSM-III in 1980, DSM-III-R (revised) in 1987, DSM-IV in 1994, DSM-IV-TR (text revision) in 2000, and DSM-V in 2013. Starting with DSM-III, the Freudian psychoanalytic influence was reduced and the attempt made to establish consistency with the World Health Organization publication, International Statistical Classification of Diseases and Related Health Problems. Recognition of the overlap between psychiatry and psychology and the limitations of the illness labels are indicated in the DSM-III Task Force quote, “Each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome.” Some considered DSM-III to represent a significant advance from the prior DSMs (Mayes & Horwitz, 2005; Wilson, 1993). It became the international standard for psychiatric classification and for such practical concerns as informing legal decisions (e.g., whether an individual was competent to stand trial) and the determination of health insurance payments.
DSM-5 (American Psychiatric Association, 2013) lists the following types of psychiatric disorders:
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- Neurodevelopmental disorders
- Schizophrenia spectrum and other psychotic disorders
- Bipolar and related disorders
- Depressive disorders
- Anxiety disorders
- Obsessive-compulsive and related disorders
- Trauma- and stressor-related disorders
- Dissociative disorders
- Somatic symptom and related disorders
- Feeding and eating disorders
- Sleep–wake disorders
- Sexual dysfunctions
- Gender dysphoria
- Disruptive, impulse-control, and conduct disorders
- Substance-related and addictive disorders
- Neurocognitive disorders
- Paraphilic disorders
- Personality disorders
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The next sections provide summaries of these major DSM-5 listings, including suspected causes and current treatment approaches.
specializations within professional medicine and psychology that address problems related to adaptation and personal fulfillment
an institution for the maintenance and care of individuals requiring specialized assistance
treats adaptive disorders as though they are diseases
provides information concerning the etiology (i.e., initial cause and/or maintaining conditions), prognosis (i.e., course of the disorder in the absence of treatment), and treatment of a biological syndrome (i.e., collection of symptoms occurring together)
comprehensive listing of mental illness disease labels and definitions (i.e., behavioral criteria)