Lecture 16 Models of Psychopathology Lecture Outline I. Introduction II. Medical Model A. Criticisms III.Biopsychosocial Model A. Characteristics 1. Hierarchical Organization 2. Reverberating System B. Implications IV. Discussion: A Deficit Model? A. Blaming the Victim B. Meta-messages and Self-fulfilling Prophecies V. Difference Model VI. Conclusion ------------------------------------------- I. Introduction We have looked at numerous factors that are associated with the etiology of various psychological disorders. We've examined biology, physiology, genetics, learning, social factors, cognitions, communication, emotions, and so on. The question is, how do we put all these various factors together? Are certain factors more important than others in determining the etiology of psychological disorders? Is there one factor that is primary; all the others being secondary outcomes of the one primary factor? So far we've really only looked at these various etiological factors in isolation - a catalog of hypotheses if you will. We need to see if there is a way to organize these factors into an overarching model of psychopathology. Without such a unifying model, a comprehensive understanding of psychopathology will continue to elude us. Today we will examine some attempts at providing this overarching framework. We will look at various models of psychopathology. Each model attempts to answer (at least some of) the questions we have posed. This discussion is a starting place: it is not an exhaustive list of models, nor is it the last time we will confront these issues. II. The Medical Model The dominant model today (at least within psychiatry) is the medical model of psychopathology (Carpenter, 1987; Engel, 1980). The basic assumption is that psychological disorders are diseases. The nature of onset, distribution of cases, development and course, treatment response, and associated features seen in psychological disorders are seen to be parallel to what occurs in physical diseases (Carpenter, 1987). This model assumes diseases of any sort to be fully understood in terms of abnormal biological variables (Engel, 1977). Thus, a "psychological" disorder can be explained in terms of (and actually is) a disorder of underlying physical mechanisms (e.g.: biochemical and physiological processes). Of the etiological factors that we have examined, the biological realm is primary. To understand psychopathology, we need not look beyond the biological level. This approach embraces reductionism: a philosophical view that complex phenomena (such as thoughts, behaviors, emotions) can be completely understood and explained in terms of a more basic level. That is, in this case, thoughts, behaviors and emotions can be "reduced to" the more basic level of biological processes. A thought is a neurological event in the brain. Psychopathology is a biological phenomenon. Implications: Research and treatment will focus on searching for and altering biological variables. A. Criticisms This model has been criticized (e.g: Carpenter, 1987; Engel, 1980) as being insufficient for truly understanding psychopathology. "The crippling flaw of the (medical) model is that it...can make provision neither for the person as a whole nor for data of a psychological or social nature" (Engel, 1980). Biology simply can't account for psychological disorders. A model of psychological phenomena must be based on other levels of data, levels that involve psychological processes; for example: cognitive and social levels. At the very least, to truly understand a psychological disorder, we need to integrate knowledge from these various levels with the biological level. We need to recognize that each level has its own strengths, but also its own limitations. Biological levels do pretty good at providing explanations of "form", that is, it answers "how" questions: how a particular disease process occurs, what its mechanisms are, etc. Biological explanations do not, however, provide explanations of the "function" of the disorder. That is, biology does not address the "why" questions: why did this disorder occur, what is its meaning, purpose, or function? Both sets of questions are important in understanding a phenomenon. Both approaches need to be assimilated. An everyday example This will illustrate the necessity of integrating various levels of analysis to fully understand a phenomenon. Let's look at blushing (Carpenter, 1987). We could reduce a blush to the biological level: vascular changes in the body. But this certainly is not the whole story. At best, we know the physiological mechanism of how the blush occurs. But we also need to look at why it occurs. We need to recognize the role that psychological variables play: a person blushes when they experience shame, for example; and we need to look at sociological variables: the blush occurs in response to shame when the person is in a public setting. No single level (biology, psychology or social) is sufficient in providing an explanation of blushing. Another Example In 1982, a group of Danish doctors reported that five previously healthy and skilled men who were severely tortured six years before the doctors had examined them had experienced various forms of brain atrophy (Stover & Nelson, 1985). For example: enlarged cerebral ventricular structures (Carpenter, 1987). Such a phenomenon can not be explained at just one level. A comprehensive explanation requires that we look at physiological mechanisms that induce structural changes in response to psychological processes, such as pain, associated with torture. In other words, we must integrate biological, psychological and social factors. III. The Biopsychosocial Model An alternative model, the biopsychosocial model, attempts to recognize the shortcomings of the medical model (Engel, 1977, 1980). A basic assumption remains: the "disease model" is the essential frame of reference (Carpenter, 1987). However, the biopsychosocial model, in contrast to the medical model, conceptualizes disease as a multilevel phenomenon. It rejects the reductionistic bias of the medical model. To embrace reductionism means important data will be excluded. For example, let us look at Schizophrenia (Carpenter, 1987). To fully understand Schizophrenia, we must understand the nature of the disorder at multiple levels. It is the interaction between these levels that account for the manifestations of Schizophrenia. It is not at all a priori evident which level is primary. For example: Social changes may lead to brain changes, but so too will brain changes lead to social changes. Is one always the cause of the other? Which one? Or are there different independent causes for changes of the brain and changes at the social level? Or do they both have a common causative factor? The biopsychosocial level identifies numerous levels that may be relevant in understanding psychopathology, including social, psychological, biological, and physical variables (Carpenter, 1987). Figure 16-1 provides a more detailed list of the various levels. A. Characteristics There are two basic characteristics of the biopsychosocial model: 1. Hierarchical Organization: The levels listed in Figure 16- 1 can be organized in a hierarchical continuum. The more complex, larger units can be seen as superordinate to the less complex, smaller units. In this way, each level of the hierarchy represents an organized system with distinct properties and characteristics. And each level will thus requires its own methods of study unique to that level (Engel, 1980). 2. Reverberating System: The hierarchically arranged levels can also be seen as part of an overarching system, where activity at one level influences other levels - the activity at one level reverberates to other levels (Carpenter, 1987). This can be seen in Figure 16-2 where each level is at the same time a component of higher levels. Thus, every level is at the very same time "both a whole and a part". "Nothing exists in isolation". For example, we can look at the level of red blood cells, study them and explain them. But in so doing we are also implying the existence of the larger systems without which the red blood cell has no existence (Engel, 1980). B. Implications The comprehensive study of psychological disorders will require research in many areas. Hopes for finding the single, unitary hypothesis for a disorder will be futile. This does not negate the importance of doing narrow, specific experiments. Such studies are necessary for exploring specific associations and processes and for examining predicted relationships. Such experiments can provide a foundation upon which to build. The problem arises when investigators stop at that level and do not integrate their knowledge with other levels of investigation. Psychopathology is very complex. So too, then, will be the methods of study and the theories we build. It has been argued my various scientists that the medical model presents an overly simplistic picture of psychopathology: The boundaries between health and disease are not at all clear: they are wrapped up in cultural, social and psychological considerations as well as biological considerations (eg: Engel, 1977). IV. Discussion: A Deficit Model? The biopsychosocial model has much to offer. It sees the person as a whole; it recognizes the complexity inherent in psychological disorders. Nevertheless, the biopsychosocial model is open to criticisms as well. One of the strongest criticisms of the biopsychosocial model has been that it is a deficit model of psychopathology. That is, it sees as the core factor in psychological "illness" a problem with the person. There is something about the person that is amiss, whether it is "under his/her skin" or in his/her relation to the world. So, to understand a disorder, we search for abnormalities in subjects' biology, relationships, and the like. On the face of it, such an approach seems logical. Of course there is something wrong with the person. A. Blaming the Victim However, such a deficit orientation has been challenged as being actually a case of blaming the victim (Ryan, 1976). Critics claim that people suffering from "mental illness" are actually the victims of an environment that is hostile to them. For example: The economy is in terrible shape, the person is a woman and a minority in a prejudiced community, and she is unemployed with 3 children to take care of. She becomes depressed, and eventually suicidal. The biopsychosocial model certainly will take into account all these factors, but (and here's the point) it will still place the locus of the problem within the woman. She is suffering from a psychological disorder. This, claim some, is blaming the victim, which only serves to hurt the person we label as ill. B. Meta-messages and Self-Fulfilling Prophecies Critics of this deficit-model orientation claim that it communicates certain things to people who are diagnosed with psychological disorders and to people in general. Such an orientation communicates messages of weakness. It is telling the mental health patient that he/she has deficits and defects, that other people without them are healthy, and the more he/she can be like them the better he/she will be. The message is one of inferiority. Not only does the person come to believe this (after all, experts are saying so), so too does the community in general. The person so labelled, as well as others, will overgeneralize from the label - the label ends up doing more harm than what ever problems the person might originally have actually had. The outcome, critics continue, is that mental illness becomes associated with stigma. To be diagnosed is to be labelled. That label has a lot of stigma attached to it. People misunderstand it. We can see such stigma in action: Presidential candidate Mike Dukakis had all sorts of problems when it was suspected that he might have been treated for depression. The stigma communicated to patients produces a self-fulfilling prophecy: the message of inferiority is internalized by the patients, so they come to believe in their inferiority and act accordingly. There is a long history of research that stresses the importance of others' expectations, attitudes, and appraisals about an individual for that individual's identity formation and self- esteem (e.g.: Cooley, 1964; Mead, 1962; Rosenberg, 1965). V. A Difference Model What critics claim is that the shift from the medical model to the biopsychosocial model really made no fundamental change in orientation. The underlying nature of these two models is the same: the deficit model. The victim blaming, meta-messages and self-fulfilling prophecies that the two imply are just the same. They both are models that conceptualize the "patient" as defective or deficient in some way. So what do the critics offer as an alternative? One alternative orientation is to use a difference model (Rappaport, 1977). The basic assumptions are changed. The question is no longer what is wrong with the person, but what are the strengths of this person and how can they be used. The goal changes from rehabilitating the person, to finding a setting into which the person can fit and use his/her abilities, and where he/she can develop new abilities. These critics are calling for "a psychology of strengths rather than weaknesses" (Rappaport, 1977, p.125). From this perspective, we would approach the schizophrenic person, for example, in a very different manner than we did in the other models. The focus now (Rappaport, 1977): emphasize an "individual" rather than a "patient" status treat person as responsible human being (eg: expected to participate in their own self-care: work, recreational, social activities) rather than providing "treatment" (so person can fit back into society), restructure society so their are more opportunities and resources available for the person and what skills s/he does have it's as much other people's responsibility to change as it is the "patient's" - cannot merely remove "patients" form society and place them in hospitals all people ("patients" and "nonpatients") should live in mutually supportive ways, in the community if possible VI. Conclusion We began by examining two of the major approaches to psychopathology research and theory: the medical model and the biopsychosocial model. The latter has clear advantages over the former: a more sophisticated and comprehensive understanding of psychological disorder is possible. Such a biopsychosocial is really a call for interdisciplinary cooperation in the study of psychopathology, a cooperation that has not historically been a reality. Nevertheless, as we have seen, there are some criticisms that can be leveled at both the medical and biopsychosocial models. If they do indeed embody assumptions of weakness and deficits, then there may be undesirable implications for how we conceptualize and treat people with (so called?) psychological disorders. Some scientists thus advocate a difference model for understanding psychopathology. Once again, we seem to have run into: "just exactly what do we mean by Psychopathology?" I am certainly not advocating one of these models as The Best or The Correct model...But I am saying this: Again, I urge you not to be lulled into the belief that everything is clear-cut and simple. Stay sharp! Look for assumptions! And question them! No science advances with blind acceptance of what's, "of course", common- sense. By comparing and contrasting these various models, we have learned about some of their strengths and weaknesses; their uses and potential misuses. This is always a useful exercise!