Chapter 3

Theories and Model of

Contemporary Mental Health
Diathesis-stress Paradigm

 The diathesis–stress model serves to explore how

biological or genetic traits (diatheses) interact with
environmental influences (stressors) to produce disorders,
such as depression, anxiety, or schizophrenia
Diathesis-stress Paradigm

The term diathesis derives from the

Greek term (διάθεσις) for
disposition, or vulnerability, and it
can take the form of genetic,
psychological, biological, cognitive,
situational or personality-related
factors.
Cont…Diathesis-stress Paradigm

Stress refers to a life event or

series of events that disrupt a
person’s psychological
equilibrium and potentially
serves as a catalyst to the
development of a disorder.
Cont…Diathesis-stress Paradigm

The model asserts that if the

combination of the
predisposition and the stress
exceeds a threshold, the
person will develop a disorder.
Diathesis-stress Paradigm

 The model is used in many fields of

psychology, specifically for studying the
development of psychopathology.
 It is useful for the purposes of understanding
the interplay of nature and nurture in the
susceptibility to psychological disorders
throughout the lifespan.
Cont..Diathesis-stress Paradigm

 Diathesis–stress models can also assist in

determining who will develop a disorder and who
will not.[7] For example, in the context of
depression, the diathesis–stress model can help
explain why Person A may become depressed
while Person B does not, even when exposed to
the same stressors. More recently, the diathesis–
stress model has been used to explain why some
individuals are more at risk for developing a
disorder than others.
Cont…Diathesis-stress Paradigm

 For example, children who have a family history

of depression are generally more vulnerable to
developing a depressive disorder themselves. A
child who has a family history of depression and
who has been exposed to a particular stressor,
such as exclusion or rejection by his or her peers,
would be more likely to develop depression than
a child with a family history of depression that
has an otherwise positive social network of peers
Cognitive Theory

 In the 1950's, a psychologist named Albert

Ellis, and a psychiatrist named Aaron Beck,
independently developed two very similar
theories. Both of these theories resulted in
effective forms of cognitive therapy. These
therapies continue to be widely practiced
today.
Cont..Cognitive Theory

 While behavioral learning theory

emphasizes the role of the environment,
cognitive theory emphasizes the key
role of the mind's cognitions in
determining behavior. These cognitions
include a person's thoughts, feelings,
beliefs, and perceptions.
Cont..Cognitive Theory
 According to cognitive theory, our dysfunctional
thoughts lead to extreme emotions. These extreme
emotions in turn, lead to maladaptive behaviors.
 To illustrate the powerful effect of these thoughts,
consider the following example. Suppose I am preparing
to take a difficult test.
 While doing so I think to myself "I can't do anything
right, I'll probably fail this test." This thought will likely
cause me to feel apprehensive. When I eventually take
the test, this degree of anxiety will affect my ability to
concentrate and earn a good grade.
 In addition, these negative thoughts will affect the amount of effort I put forth when
studying for the test. When I incorrectly believe that I will certainly fail, it seems rather
futile to invest a great deal of energy in attempting to succeed.

 As a result, I may indeed fail, simply because I didn't invest much time and energy in
preparation for the exam. Ironically, this failure will serve to strengthen my faulty
belief; i.e., my poor test score "proves" my belief is correct- I am a failure.

 However, the true reason for my failure was due to my lack of effort and preparation,
and not because I am inherently a failure. Quite a different outcome would occur if I
were to think to myself, "Yes, this test is going to be quite difficult but I have succeeded
before. I will study hard and put forth my best effort. Besides, I am just as competent
as any of the other students in the class." These thoughts would cause me to feel
confident and ready to face the challenge. I would put forth the extra effort needed to
succeed. Clearly, these two different ways to think about the same event result in very
different behaviors and outcomes.
Cont..Cognitive Theory
 Albert Ellis's cognitive therapy is called Rational Emotive
Behavior Therapy (REBT). He believed peoples' intense
suffering from negative emotions was caused by their
irrational core beliefs.

 Core beliefs refer to the basic beliefs people have about

themselves and the world around them. For instance, in the
previous example my thought "I'll probably fail this test" may
stem from a core belief "I must always achieve complete
success or else I am a complete failure." Irrational core
beliefs cause the negative emotions that lead to
dysfunctional behaviors.
 Albert Ellis focused on irrational core beliefs by identifying beliefs for
which there was no evidence. Thus, they are irrational. According to
REBT, teaching therapy participants to think in a more rational,
balanced manner eliminates the extreme emotions that result from
these irrational beliefs. In so doing, this rational thinking eliminates
dysfunctional behavior.

 Ellis identified common, irrational, core beliefs such as: 1) I must do well
and win the approval of others or else I am no good. 2) Everybody
should treat me kindly. (3) Life must be fair. Ellis noticed that irrational
beliefs often contained words like "must," "should," and "can't." REBT
has a systematic and direct way of teaching therapy participants to
identify, challenge, and replace these irrational core beliefs with more
rational and balanced ones.
Cont..Cognitive Theory
 Around this same (1950's), Aaron Beck was practicing as a
psychoanalyst.
 He realized that people's internal thoughts and perceptions
had a large influence on their emotions.
 He also believed that a more active and directive approach
to modify thoughts would positively influence behavioral
change.
 His theory takes a slightly different approach than REBT, and
the terminology is somewhat different.
 Nonetheless, both Beck and Ellis sought to modify an
individual's dysfunctional thoughts, in order to produce a
change in emotions and behavior.
 According to Beck, problems occur when distorted thinking patterns
influence our interpretation of environmental events.

 In other words, our behavior is not really determined by what is actually

happening in the environment. Instead, our behavior is determined by our
thoughts about what is happening.

 Therefore, behavior is significantly influenced by our perceptions and

interpretations of the environment. Let's illustrate this important
distinction. Suppose someone walks past me and steps on my foot. I could
interpret this as an accidental, clumsy act.

 Alternatively, I could interpret it as an intentional, hostile act. Each

interpretation would likely elicit a very different emotional and behavioral
response.
 According to Beck, the way we interpret environmental events is a
function of our core schema. A core schema is a central
assumption about oneself, others, and the world. These
assumptions influence our feelings and behavior. Examples of core
schema include:
 1) The world is a dangerous place.
 2) I am unlovable.
 3) I am inadequate.
 Notice how similar Ellis's concept of core beliefs is to Beck's
concept of core schema. According to cognitive theory, when
cognitive distortions and core beliefs are modified, behavioral
change naturally follows. This principle forms the foundation for
cognitive therapy techniques.
Biopsychosocial Integration

 The biopsychosocial model (abbreviated

"BPS") is a general model or approach stating
that biological, psychological (which entails
thoughts, emotions, and behaviors), and
social (socio-economical, socio-
environmental, and cultural) factors, all play a
significant role in human functioning in the
context of disease or illness.
 The biological component of the biopsychosocial model seeks to
understand how the cause of the illness stems from the
functioning of the individual's body.
 The psychological component of the biopsychosocial model looks
for potential psychological causes for a health problem such as
lack of self-control, emotional turmoil, and negative thinking.
 The social part of the biopsychosocial model investigates how
different social factors such as socioeconomic status, culture,
poverty, technology, and religion can influence health.
 However a closer reading of Engel's seminal paper in the American
Journal of Psychiatry (1980) embeds the biopsychosocial model
far more closely into patient care.
 The model was theorized by psychiatrist George L. Engel at the
University of Rochester, and putatively discussed in a 1977 article
in Science, where he posited "the need for a new medical model."

 He discusses his model in detail in his paper in the American

Journal of Psychiatry where he discusses the fate of a hypothetical
patient, a 55 year old man who has a second heart attack six
months after his first.

 Engel elegantly indicates that the patient's personality helps to

interpret his chest pain, that he is in some degree of denial and
that it is only the intervention of his employer that gives him
permission to seek help.
 Whereas reductionistically his heart attack can be understood as a clot in a
coronary artery, the wider personal perspective helps to understand that
different outcomes may be possible depending on how the person responds
to his condition.

 Subsequently, the patient in the emergency room develops a cardiac arrest

as a result of an incompetent arterial puncture.

 Once again systems theory can analyse this event in wider terms than just a
cardiac arrhythmia. It sees the event as due to inadequate training and
supervision of junior staff in an emergency room.

 Thus while there may be "no single definitive, irreducible model has been
published," [5] Engel's elegant exposition of his model in this paper gives
plenty of scope for this broader understanding of clinical practice.
 The biopsychosocial model of health is based in part on
social cognitive theory. The biopsychosocial model implies that treatment of
disease processes, for example type two diabetes and cancer, requires that
the health care team address biological, psychological and social influences
upon a patient's functioning. In a philosophical sense, the biopsychosocial
model states that the workings of the body can affect the mind, and the
workings of the mind can affect the body. [6] This means both a direct
interaction between mind and body as well as indirect effects through
intermediate factors.
 The biopsychosocial model presumes that it is important to handle the three
together as a growing body of empirical literature suggests that patient
perceptions of health and threat of disease, as well as barriers in a patient's
social or cultural environment, appear to influence the likelihood that a
patient will engage in health-promoting or treatment behaviors, such as
medication taking, proper diet or nutrition, and engaging in physical activity.[7]
Family System Theory
 Created in the middle of the 20th century

 People live in families and social groupings, and depend

upon one another for the means that insure their mutual
survival, including (as Maslow has taught us) food clothing
and shelter, but also safety, belonging and social support.

 Family members are interconnected: Every person within a

family has a role to play within the life of the family as a
whole. Alteration or damage to one family member affects
the entire family, for all are interconnected.
 Family Systems theory takes an ecological approach, viewing problems as
things that occur between people.

 They tend to see individual problems as instances of larger relationship

problems occurring within families (or within communities or society).

 This means that when a family member becomes depressed, the effect of
that depression are not localized within the depressed person, but rather
affect all family members. It is thus a family problem, not an individual one.

 The depression may even be a consequence of some other family problem.

For example, a mother's "empty nest" depression (occurring when her last
child leaves home) may result as much from the radical alteration of her day
to day family life as from any chemical problem she may have.
 Family Systems theorists pay careful attention to the boundaries between family
members, because such boundaries are exactly where problems tend to manifest.

 A boundary is a sort of psychological perimeter and definition that people draw

around themselves, and around particular relationships they are involved in.

 Boundaries mark off where one person or group ends and another begins. Healthy
boundaries act as containers that keep things apart that need to stay apart, and also
as roles that help people to know how to act.

 The boundary around the family as a whole helps family members know who is a
member and who is not, for instance. The boundary around the parents helps them
keep their adult sexuality and communication apart from their children.

 The boundary around each child and adult within the family helps each family
member keep some secrets that are theirs alone.
 Family problems occur when boundaries become strained or break and members are put
into situations that may harm them.

 Incest situations are probably the worst sorts of boundary violations, but others are also
worth pointing out as examples.

 Families dealing with spousal abuse often fail to protect their children from that abuse
(as well as vulnerable spouses from abuse), resulting in traumatized children and adults.
Alcoholic parents may be incapable of taking care of themselves, influencing their
children to become "parentified" (e.g., responsible before their time).

 Angry divorced parents may start fighting through their children (a situation known as
"Triangulation because of the shape of the communication communication)", in essence
making them into unwilling messengers, filling them with venom and forcing them to
choose between parents. Family systems therapists look for patterns of boundary
violation in the families they work with, and then work with family members to try to
correct what is bent or broken.
 For all that family members are bonded, they are frequently blind to how much they
are ecologically interdependent with one another.

 It is very disturbing to most people to think that they might be contributing to a

problem.

 For this reason, dysfunctional families are often quick to blame individuals within the
family for their woes, falsely localizing the cause of their pain into a scapegoated
member.

 The family that has created an "identified patient" through this process may still be
quite dysfunctional, but this fact becomes conveniently less apparent to the members.

 A family systems oriented therapist who might work with such a family would look to
see whether any identified patients had been created, and then work to educate them
as to the truer ecological nature of their family issues.