W4 - Psychosocial approaches to care in the community

Question 1

What is the DSM-5 definition of mental disorder?

Answer 1

‘A clinically significant disturbance in cognition, emotional regulation, or behaviour

that indicates dysfunction in mental functioning and

are usually associated with significant distress or disability in work, relationships, or other areas of functioning. ‘

Question 2

What is the definition of the psychoanalytic model?

Answer 2

Psychoanalytic theory is the theory of personality organization and the dynamics of personality development relating to the practice of psychoanalysis, a clinical method for treating psychopathology.

Also, the theory of development and organisation of personality that guides psychoanalysis.

Question 3

Explain the evolution of the psychoanalytic model.

Answer 3

First laid out by Freud in the late 19th century.

It adopts a deterministic view of human nature and argues that human beings are actually driven by

irrational forces,

biological and instinctual drives,

and unconscious motivations.

The model focuses and really emphasises the need to explore the unconscious.

The validity of this view is now disputed and rejected by some, for the lack of empirical evidence.

Question 4

Explain Freud theory.

Answer 4

Human beings are dominated by two basic instincts:

Eros (the sexual drive or creative life force)

Eros represents life, creativity and growth.

Thanatos (death force or destructiveness force)

Thanatos represents destruction and death.

Such forces are in a constant battle for balance.

Question 5

Explain the psychoanalytic stance on aetiology of mental illness. (What causes mental illness)

Answer 5

We must consider Freud’s approach to the development of personalities, which he argued that it is shaped through sexual stages.

During each stage, a child is presented with a conflict between biological drives and social expectations.

The mastery of every developmental phase will depend on how the child navigates through until he becomes fully mature and healthy. (his personality).

When an individual fails to navigate or becomes fixated at a stage, unhelpful behaviour can develop and give rise to psychological distress.

Question 6

What are the psychosexual stages in the psychoanalytic model?

Answer 6

Oral stage / from birth to 1 y / mouth is the erogenous zone

Consequences of psychological fixation:

Orally aggressive or passive. May result in manipulative personality. (chewing gum, smoking, sexual practices)

Anal stage / from 1 to 3 y / bowel and bladder elimination

Consequences of psychological fixation:

Anal retentive or expulsive (OCD or ADHD)

Phallic stage / from 3 to 6 y / genitalia

Consequences of psychological fixation:

Oedipus complex in boys
Electra complex in girls

Latency / from 6 to puberty / dormant sexual feelings

Consequences of psychological fixation:

Sexual unfulfillment if fixation occurs in this stage

Genital / Puberty to death / sexual interest matures

Consequences of psychological fixation:

Frigidity, impotence, unsatisfactory relationships.

Question 7

What is the Oedipus complex?

Answer 7

The Oedipus complex is an idea in psychoanalytic theory. The complex is an ostensibly universal phase in the life of a young boy in which, to try to immediately satisfy basic desires, he unconsciously wishes to have sex with his mother and disdains his father for having sex and being satisfied before him

Question 8

What is the Electra complex?

Answer 8

The Electra complex is a term used to describe the female version of the Oedipus complex. It involves a girl, aged between 3 and 6, becoming subconsciously sexually attached to her father and increasingly hostile toward her mother.

Question 9

Explain Freud’s psychosocial theory of development of personality.

Answer 9

This theory sets the ground for how personality develops and what could be the causes for psychological distress.

The personality consists of three elements:

Id, ego and superego.

Question 10

Explain the Id (the pleasure principle)

Answer 10

It is the personality element driven by internal basic drives and needs.

Instinct: hunger, thirst, sex.

It acts in accordance to the pleasure principle as it completely avoids pain.

It is always seeking pleasure and has no consideration for others.

The id is impulsive and unaware of the implications of its actions.

Example:

When the baby is hungry it will seek pleasure (food) and will cry as an instinct, no matter how much his mother tries to calm him down, he wants to be fed.

Phase develpment:

As the infant interacts more with the external world, the next stage of personality starts to develop, meaning, the Ego.

Question 11

Explain Ego (the reality principle)

Answer 11

The ego develops with the interaction with the external world.

It understands that other people have needs and desires, so it works to achieve or grant the id (childish) wishes without causing consequences.

It compromises.

In a healthy person Ego is the strongest. Trying to not upset the Superego and sees reality and understands it.

Question 12

Explain Superego (the moral principle)

Answer 12

By the age of five the superego develops.

It appears due to the moral and ethical restraints that are placed on us by our family and society.

It can be called: the conscience, as it dictates right from wrong.

Question 13

What is the dynamic of the three personality forces?

Answer 13

They must be in equilibrium.

Lack of balance will cause conflict and psychological difficulties.

If Id is too strong the person can be impulsive and out of control.

Of superego is too strong the person can be overcritical and rigid, may develop depression.

When the ego is not in control through direct methods, it can operate at an unconscious level by distorting reality through ego defences.

Question 14

Explain the three parts of consciousness according to Freud. (the iceberg theory)

Answer 14

Ego work in the conscious level of our mind.

Superego and id work within the unconscious level.

The conscious level is just a small part of our personality and the majority of our inner feelings (beliefs, impulses) are not available at this level.

Most of what drives us is buried in the unconscious and is mostly inaccessible.

However, there is also a part between the conscience and unconscious that has information that is not readily available but that we can retrieve.

It is call the preconscious level.

Question 15

Explain the object-relations theory.

Answer 15

The object-relations theory is a branch of psychoanalytic theory, however, it places less importance on biological drives.

It emphasises interpersonal relationships, primarily in family and mother and child.

Object means ‘other’ and relations means ‘interpersonal relations’.

While Freud is more paternalistic (Oedipus complex), the ORT emphasises the mother.

Question 16

Name two contributors to the object-relations theory.

Answer 16

Melanie Klein (1882-1960)

Donald Winnicott (1886-1971)

Question 17

Explain Melanie Klein’s contribution to ORT?

Answer 17

Post-freudian

She is the mother of the ORT.

Particularly interested in early causes of psychosis.

Her theory:

first six months are crucial for the healthy development of the infant’s ego.

infants suffer from anxiety, because of its innate aggressive and destructive instincts.

Question 18

Explain Klein’s two positions for infant’s development?

Answer 18

1. Paranoid-schizoid position (0 to 3 months)

The infants projects out his loving hating feelings onto separate parts of the mother. (life and death instincts)

Baby is only able to relate to the mother and external in part objects.

Maternal object is divided into bad (hated) or good (loved).

There is a clear separation between goo and bad, they cannot coexist together.

2. Depressive position (3 to 6 months)

Infant can now relate to objects as whole objects.

There is ambivalence and good and bad, love and hate can coexist.

Question 19

Explain Donald Winnicott’s contribution to ORT?

Answer 19

Winnicott emphasises

the vulnerability of the infant,

the importance of a good holding environment provided by the care giver,

he also introduced the good-enough mother concept.

Question 20

Explain the good-enough mother concept.

Answer 20

The good-enough mother concept

develops a heightened state of sensitivity during pregnancy

when it passes, the mother has a ‘flight insanity’ (awareness of what exists outside of maternity)

No matter what, the good enough mother continues to provide a safe and consistent holding environment

hence, meeting the baby’s needs on a physical and emotional level, also protecting the baby from her bad parts.

Question 21

Explain the symbiosis process by Winnicott.

Answer 21

Winnicott emphasises the state of complete symbiosis between mother and child (infant and caregiver) in the early stages of the baby’s life.

Initially, the carer supports this ‘illusion of symbiosis’, and then gradually and carefully allows ‘disillusionment’ by failing to adapt to the baby’s needs.

This process allows the child to be aware of the separateness between his individuality and the mother’s.

All processes happen through play and the use of transitional objects.

Question 22

When do psychological difficulties develop in the good-enough mother concept?

Answer 22

Psychological difficulties develop when the environment is not holding,

when the mother fails to meet the baby’s needs (at least reasonable care),

when the carer fails to protect the baby from experiencing overwhelming distress (emotional or physical).

Question 23

Name the main figure behind the attachment theory.

Answer 23

John Bowlby (1907-1990)

His work was shaped by his early life experiences. From grieving a nanny at 4 to going to boarding school alone.

Question 24

Explain John Bowlby’s attachment theory.

Answer 24

He studied children who had been separated from their primary caregivers through hospital admission and children who had been institutionalised.

The result of these observations made him argue that

in order to grow up mentally healthy a child must experience a warm, intimate and continuous relationship with his mother.

This relationship (carer/mother) is crucial in the development of healthy individuals.

He coined the term ‘attachment’ to describe the bond between child and carer.

Question 25

How does John Bowlby describe attachment?

Answer 25

Attachment according to Bowlby is a strong disposition to seek proximity to a specific figure, particularly when tired, frightened or ill.

He argued that attachment is an innate primary drive, and the nature of this bond is crucial for social, cognitive and emotional development as well as future capacity to build relationships, sort of an internal working model.

Question 26

Explain the internal working model in the attachment theory.

Answer 26

The internal working model is a bit like a cognitive framework, the child learns from the quality of the bond he creates with his carer.

How a child is cared for in their early life will become sort of a prototype for future relations, expectations, how they relate to other and vice versa.

Now depending on the primary carer’s behaviours towards the child he will create an internal working model.

If the initial experience is positive and loving his attachment style will be secure.

E.g., other people are loving and so am I. I can have a confident approach to relationships.

If the initial experience is unloved and rejected or even abused, his attachment style will be avoidant and insecure.

E.g., I am unlovable and unlikable. I can’t be emotionally available.

If the initial experience is inconsistent (sometimes available, sometimes not) his attachment style will be ambivalent and resistant.

E.g., I love you today but tomorrow I don’t know.

Question 27

What is behaviourists most important argument?

Answer 27

Behaviourists took a different approach to the aetiology of good and bad behaviour.

They argue that psychology should be the science of behaviour, not the science of the mind.

For them, human behaviour has nothing to do with with the internal, unconscious conflict or repression or problems with object representation.

They use principles of learning theory to explain human behaviour.

Sources of behaviour are external, in the outer world or the environment.

Question 28

Explain the behavioural model.

Answer 28

Humans learn through conditioning.

Human beings are born a blank slate and are all equal at birth.

Environmental factors determine our behaviour, rather than genetics or biological differences.

Dysfunctional and unhelpful behaviours are learned (phobias, depression, etc)

What can be learned can be unlearned. Faulty learning is the base for abnormal behaviour to develop.

There are no references to internal psychological processes.

Question 29

Explain the classical conditioning and the operant conditioning from the behavioural model.

Answer 29

1. Classical conditioning

A naturally occurring stimulus is placed with a neutral stimulus allowing the neutral stimulus to evoke a natural reflex.

e.g, when a child hears a very loud noise when playing with a rabbit, hence, becomes scared to rabbits and furry animals.

2. Operant conditioning

Learner makes a connection with the consequences associated with his/her behaviour through positive and negative reinforcement and punishment.

e.g, depression is caused by the environment and lack of skills to cope. The person receives negative reinforcement and starts a depressive behaviour.

Question 30

Explain the cognitive-behavioural model.

Answer 30

Some theorists emphasised that behaviour does play a role in unhealthy behaviours, however, what really matter is how we interpret the event.

In the cognitive model the emphasis is on the process by which individuals engage in cognitive distortions (interpretations) and biases. This is the cause of psychological distress.

Question 31

What is the CBT’s ‘Hot Cross Bun’ ?

Answer 31

A classic example of person walking down the street and seeing a neighbour. The persona waves and the person doesn’t wave back.

The person interpretation’s to that attitude will impact his thoughts, emotions, physical sensations and behaviour.

If the person feels rejected or unnoticed, this will have a negative impact.

If the person just says: ‘he did not see me’ this will have a different connotation.

Thoughts,

emotions,

physical sensations
and

behaviour

are aspects of the cognitive cycle and each element has impact on the other and are interconnected in a hot cross, vicious cycle.

In summary, what matter is our interpretation/ evaluation of the event and not the event itself.

Question 32

Explain the cognitive-behavioural model’s ABC.

Answer 32

A stands for Activating event

• an event that we interpret as wrong from default, with little flexibility for change.

B stands for Belief

-negative thoughts
-cognitive biases/thinking errors/cognitive distortion.

C stands for Consequence

-emotionally drained
-negative thoughts of self and the world
-isolation
-interpersonal struggles.

Psychological difficulties are the result of cognitive distortions and biases.

Question 33

What are some common cognitive distortions?

Answer 33

1. Mental filter

Focus exclusively on the negative aspects of the situation.

2. Mind-reading

Thinks that knows what the other person is thinking, and that is probably bad.

3. Catastrophising

Infers catastrophe from a mildly negative or neutral situation. (e.g., panic attacks)

4. Black and white thinking

Thinks in extremes: all or nothing, good and bad, right or wrong.

CBT therapists argue that when an individual engages in these cognitive distortion patters on a regular basis, this can lead to psychological distress.

Question 34

Explain CBT’s layers of cognition.

Answer 34

The deeper the layer, the more deeply rooted the cognition and the more entrenched the psychological distress. Distortions can happen at all levels.

1. Early learning experiences
   (parental criticism and rejection)
2. Life events
   (romantic breakups)
3. Core beliefs
   (I am unlikable)
4. Intermediate beliefs
   (If I am perfect, then I will be loved)
5. Negative automatic thought - situation specific, thought that happen on a daily basis.
   (I’ll never be good enough)
6. Depression
   (low mood, social withdraw)

Question 35

What did first and second CBT wave had in common?

Answer 35

They shared the assumption that certain cognitions, emotions, and physiological states can leas to mental distress, and the four therapeutic interventions should aim at eliminating or at least changing/reducing them.

Question 36

Explain the third wave of CBT.

Answer 36

Moves away from much content oriented cognitive intervention, and emphasises in other forms of behaviourism.

It comprises heterogeneous groups of treatments.

Question 37

Name some third wave psychotherapy treatments.

Answer 37

1. Acceptance and commitment therapy (ACT).
2. Behavioural activation (BA).
3. Dialectical behavioural therapy (DBT).
4. Mindfulness-based cognitive therapy.
5. Schema therapy.

Question 38

Explain Dialectical behavioural therapy (DBT).

Answer 38

It is a cognitive behavioural approach treatment.

It emphasises the SOCIAL aspect of treatment and was created by Dr. Masha Linehan.

DBT is a package of treatments:

a. team based interventions
b. group work
c. telephone support
d. one-to-one therapy.

Question 39

What is DBT approach to mental distress?

Answer 39

The Diathesis-stress model or vulnerabilty-stress model

A theory that attempts to explain the trajectory of a disorder as a result of the interaction between the predispositional (biological) vulnerability (diathesis) and life-stress factors.

Psychological disorder is the result of a disorder-specific predisposition that lies dormant until it is activated by and environmental stressor.

Question 40

What does the term dialectical means for DBT?

Answer 40

The term dialectical means integration of opposites or a synthesis.

The primary dialectical within DBT is between acceptance and change, meaning the therapist accepts the patient or client is suffering, and accept them as they are, acknowledging as well that change is needed in order to reach their goals.

Question 41

Explain the biological diathesis of DBT on borderline personality disorder (BPD)

Answer 41

The child suffers from emotional dysregulation

This has a great demand from the family

Parents invalidate such feelings by ignoring or punishing

Child would have an emotional outburst which the parents would attend to.

This feed the cycle.

Question 42

Explain Schema therapy.

Answer 42

Developed by Dr. Jeffrey Young

It is a combination of cognitive therapy, behavioural therapy, object-relations therapy that combine into one unified systematic approach to treatment.

According to Young:

• Primary attachment is very important for the development of unconditional abstract concepts ‘about reality’.
• Humans strive for connection, understanding and growth.

Question 43

What are the core emotional needs of Schema therapy:

Answer 43

1. Secure attachment,
2. the need for autonomy and competence,
3. a sense of identity,
4. freedom of expression,
5. spontaneity and play,
6. limits and self control.

Question 44

What is a schema according to Dr. Young?

Answer 44

A schema is defined as a broad, pervasive theme regarding oneself’s relationship with others. It develops through lifetime and it is dysfunctional to a certain degree.

There are up to 18 maladaptative schemas.

Schemas are deeply entrenched and familiar.