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
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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!