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The Efficacy Of Contemporary Western Psychology In The Formation Of Diagnoses, In Explaining The Etiology, And In The Treatment Of Psychological Abnormalities.
Psychology’s efficacy in diagnosing, in explaining the etiology, and in the treatment of psychological abnormalities is assessed. Four abnormalities are assessed; Dementia, Autism, Attention-deficit hyperactivity disorder, and Depression. The difficulty of assessing efficacy is also noted. Future prospects for psychology are outlined, particularly in regard to psychology as a more coherent and effective science. The diverse spectrum of psychological approaches is suggested as the greatest obstacle to further scientific progress. In conclusion, it will be argued that psychology is effective in many areas, although many fundamental mental processes remain unexplained. It is suggested that the most serious problem that psychology faces today, is the lack of a coherent integration between psychologists from different theoretical approaches.
The coming dawn of the twenty first century brings with it an opportunity to reflect upon how we have progressed, where we are now, and what the future may hold. As we approach this calendrical milestone, psychology, as one of the more recently formulated branches of science, deserves such a moment of reflection and assessment. As an empirically based science, psychology is indeed very young, and has made great progress since Wundt opened the first psychological laboratory a century ago (Shiffman, 1996). Psychology has developed at a prodigious rate this century, due in part to a mutually enhancing dyad. First, advances in technology have allowed psychologists to view the workings of the human mind in greater detail. Brain scanning technology, such as Magnetic Resonance Imaging (MRI) and Positron-Emission tomography (PET) have allowed researchers to view live images of the electrical activity of the human nervous system. Second, the psychologists themselves. Great figures such as Luria, Rogers, and Hebb, have launched psychology into an era of great progress. Together, psychologists’ usage of sophisticated technology have greatly enhanced our understanding of the human mind.
This article will provide an overview of psychology’s efficacy in the domain of abnormalities. For each of the four abnormalities, three key aspects will each be evaluated. First to be assessed, the ability of psychology to diagnose an abnormality. Second, psychology’s explanatory effectiveness in delineating the etiology for a given abnormality. Third, I will reflect upon the efficacy of psychological treatments in alleviating, or even curing an abnormality. One important point needs to be made at this stage. Diagnoses, theoretical explanations, and treatments should not each be dealt with in isolation. To do so, would be making a fundamental error. All three aspects are very much intertwined, each having important consequences for the other. For example, the method and criteria used in forming a diagnosis will determine whether a behaviour or thought is deemed ‘abnormal’, and whether ‘treatment’ is necessary. Also to be discussed is the problematic nature of assessing the efficacy of psychological applications. Finally, a brief look into the future of psychology. In particular, the degree of integration between psychologists from different psychological approaches.
Psychology : So many approaches, which is right ?
To anyone unfamiliar with the field of psychology, one of the initial understandings the inquirer might make, are the diversity of approaches that exist. Psychology could be thought of as a broad church, comprised of various factions, each unique, yet often sharing some characteristic beliefs. There are five main divisions, neurological/physiological, behavioural, cognitive, psychoanalytic, and humanistic/existential. These five are themselves divisible, making the number of distinct approaches well in excess of a dozen.
With so many different opinions and styles, the obvious question is which one is the correct (or most correct) approach to adopt and follow ? Does one take a behavioural view of people, or a psychoanalytical opinion ? Such questions are of paramount importance since each approach differs (often in extreme ways) in theory, method of diagnosis, and style of treatment. One unfortunate problem in the training of psychologists - especially at undergraduate level, is of academic institutions tending to be heavily weighted toward one particular approach. Thus, a student will often only be informed adequately in one approach.
In illuminating how different psychologists of different theoretical orientations frequently are, I will present a mythical case example, and then briefly look at how a psychologist from each of the five main orientations might typically approach, and deal with our case subject.
Mara, thirty years old, has lived in Norway for five years, she is an art student, with a part-time job in a shop. She complains to have been suffering from a deep depression for a number of years. Mara adds that her depression appears to be worse in winter months, and feels her depression to be seriously affecting her ability to function normally. She has been married for three years, has one child of four years. Mara has had no contact with her family for just over four years, who remain in Spain.
First, a clinical psychologist who works within a psychiatric unit. A summary of Mara’s life history would be taken, along with physical details such as weight. This psychologist would be focused primarily on finding a cause for Mara’s depression on a neurochemical level. For the clinician, two diagnostic measures commonly used to measure depression are, the Beck Depression Inventory (BDI), and the Hamilton Rating Scale for depression.
The life history information might explain Mara’s depression. For example, the fact that Mara has experienced many life changes in the previous five years will probably have been very stressful on Mara. One useful tool to measure such stress is the Social Readjustment Rating Scale (SRRS) developed by Holmes and Rahe (1967). Although limited in its application, this measure can provide the psychologist with some understanding of the stress, that a person has been subjected to, in the recent past. The clinical psychologist would also look at Mara’s family, for factors such as alcoholism, psychiatric disorders, which can be hereditary factors. There is a fair amount of evidence to support a genetic link for mental illness (e.g. Torgensen, 1986). For the clinical psychologist, the tools of treatment are quite varied. The main treatments are drug therapy, psychotherapy, and electro-convulsive therapy (ECT).
For the psychologist working from a behavioural perspective, Mara’s depression is seen as a result of maladaptive behaviour. This approach looks no further than the actual depression, assuming that the symptoms themselves are the disorder (Tyrer & Steinberg, 1998). For Mara, the behavioural psychologist would analyse her behaviour patterns, and attempt to trace back in time how such unproductive learning developed. The task of the therapist would be to retrain Mara, a process of counter-conditioning (Tyrer & Steinberg, 1998).
A cognitive therapist would look at Mara’s way of thinking. Beck’s (1976) theory of depression asserted that a depressed person is biased (incorrectly) toward negative interpretations. The therapist would therefore want to discern which of Mara’s interpretations have caused her to become depressed. Once the faulty interpretations are identified – through regular sessions of therapy, the therapist would aim to help Mara form more accurate thoughts. This is done through a variety of different exercises, such as analysing the client’s internal thoughts and discussing their validity.
For the psychoanalyst, depression in adult life is seen as dependent upon early childhood experiences. Factors such as early relationship to parents, and attachment style are important in how the child deals with the end of a relationship in later life. Therapy would typically consist of an hour long session each weekday, which could continue for some years. Therapeutic techniques employed include, dream analysis, and the transference that might arise in the patient-analysis relationship.
The therapist with a humanistic orientation would stand apart from the aforementioned four approaches. The humanist – in the purest form, would not directly attempt to change the client’s state of mind, whether it be depression or any other disorder. Instead of attempted change, the typical humanistic therapist would seek to provide the three core conditions of a helping relationship. These conditions, empathy, genuineness, and unconditional positive regard (to the client) are aimed to provide the client with an opportunity to ‘experiment’ (Rogers, 1951). This experimentation can include the discussing of one’s childhood, expressing oneself in ways not tried before, and consideration of new ways to ‘be’. For Mara, therapy will usually consist of an hour long ‘one to one’ session each week, typically lasting 3-6 months.
In forming a diagnosis about Mara’s reported depression, the problem most apparent to an independent observer is which approach to take. Psychologists of different approaches are understandably ardent that their way is the ‘right way’. It seems likely that most approaches offer something of value, in explaining and treating Mara’s problem. This makes choosing one approach above another, the more difficult. How can one be certain that one is adopting the correct, ( or best ) approach in tackling the perceived abnormality ? This is a real concern, and one that seems unlikely to be resolved for many decades to come. One supplementary aspect to this concern is that science is always developing. This progress is apparently relentless, but also reassuring - in the respect that psychological theory is being refined to ever higher standards, yet these developments are often radical. What may have been a generally accepted diagnosis and related treatment, may be quickly dropped a few years later. For instance, autism is now generally believed ( but certainly not universally ), to be a result of physiological problems, not a behavioural disorder as once thought (e.g. Frith, 1997). We will return to this ‘problem of choice’ later.
Dementia : the disease of age.
The human brain is an astounding evolutionary design, yet it does have the potential to fail. Such failure can range from temporary retrieval problems in memory, to catastrophic long term breakdown such as schizophrenia. This section will look at Dementia, in particular Dementia of the Alzheimer type (DAT). DAT is a devastating failure, and its prevalence is increasing, due in part to increasing longevity ( see Simon, 1999).
The symptoms of Alzheimer’s are complex and diverse, causing cognitive dysfunction, changes in behaviour, and dementia. Alzheimer’s is a very prevalent disorder, although at retirement age (65-74) the occurrence is still below five per cent. However, it climbs to a disturbing 40-50 percent for those aged over 85 (Evans et al, 1989). Death usually occurs 10-12 years after onset as a result of extensive neural destruction (Davison & Neale, 1998). The first symptoms of the disease are forgetfulness, progressing in a few years to include such problems as severe confusion, and frequent memory failure (Cummings & Victoroff, 1990).
One unfortunate problem is that the breakdown of the ‘neural net’ may have been in progress for some 20 to 40 years without any detectable symptoms. Clearly, the clinician is at a real disadvantage from the moment the afflicted person is discovered to be ill. This delay in detection is one which psychology will need to address. Early warning of the onset of dementia might provide the opportunity to reduce, halt, or even reverse any existing damage.
It is clear that two physical changes occur in Alzheimer’s. First, neurons die, along with their associated dendrites and axons, forming the characteristic neurofibrillary tangles (Kalat, 1998). Second, the formation of neuritic plaques are apparent amongst the dying neurons (Davison, 1992). The reason for such degeneration might well include a genetic component. It is extensively documented that people with Down’s syndrome almost always develop Alzheimer’s (Lott, 1982). An analysis of chromosome 21 ( for which Down’s people have one extra copy ), resulted in a gene linked to early onset Alzheimer’s (Murrell, Farlow, Ghettis, & Benson, 1991). An assured diagnosis of any type of dementia is presently lacking. It remains the case that a definite diagnosis is only possible at a post-mortem (Jacques, 1992). A positive can only be confirmed once the illness has progressed beyond the early stage (Jacques, 1992). Once this stage is reached, test such as the Mini Mental State Examination (MMSE) can be used to assess cognitive ability – a key component that progressively degenerates as DAT develops.
Another possible cause for DAT is the environment. Aluminium is known to induce lesions in the brains of animal subjects (see Heston & White, 1991), although the link is still dubious.
A treatment (especially a preventative one) is needed to combat the demographic time bomb of western society. According to Khachaturian (1998) by 2030 there will be some nine million people over 85 in America alone. The implications of such a vast number of elderly people requiring 24 hour care are a nightmare that western governments need to address.
Treatment at present is very limited. Drug therapy remains in the early stage of development, Donepezil hydrochloride ( trade-name – ‘Aricept’ ) is one of the first drugs to receive FDA approval. The aim of Aricept is to restore the homeostatic neurochemical balance of the cholinergic system. One symptom of Dementia is a depletion of acetylcholine – a key neurotransmitter of the cholinergic system. Aricept’s aim is to restore this balance. Allen (1999) noted how the difficulties in memory and cognition in general are associated with significant losses in cholinergic function. Allen (1999) argued that the benefits of the drug are small, although interestingly, some 25 per cent of those treated displayed a noticeable reduction in symptoms. It is thus vital that further research looks how to identify those people who respond most favourably to specific drugs.
Ross and Shau-Haim (1998) brought to light the case of how two patients thought to be suffering from ‘probable’ Alzheimer’s reacted to treatment. The two people both in late old age were prescribed Aricept, taken just before sleep. Both reported frequent awakening and nightmares, not present before treatment. The daily dosage was then changed to be administered first thing in the morning. The disturbing sleep problems soon dissipated after this change was implemented. This case, although only a sample of two, illustrates the great difficulty that the psychologist usually faces when a treatment is applied. The complexity of the human body, and its effects on the ‘conscious mind’ of the person concerned, make it near impossible to predict with much precision, the possible unpleasant side-effects. Yet the tragic nature of abnormalities like dementia, make it necessary for a treatment to at least be tried.
One therapy being tested is estrogen replacement therapy (ERT). A number of trials are already running, comprised of post-menopausal women, and women already with Alzheimer’s. Estrogen has been shown to improve learning and memory, the main effect being to maintain and build synapses (Khachaturian, 1998). In one study, estrogen ‘patches’ were seen to improve both memory and concentration (Asthana et al, 1996).
In summary, psychology has provided considerable detail on the widespread cerebral damage that is apparent in patients with Alzheimer’s. Diagnosis is only possible in the later stages of the disease. The actual cause of DAT is still uncertain, except for the confirmed data on the aluminum link. Effective treatment to halt or reverse the disease is yet to be developed, although drug therapy is perhaps one way to at least partially alleviate the effects of Alzheimer’s.
Autism : being alone among others.
One abnormality which psychology has made some considerable progress is Autism. Autism was simultaneously first defined by Kanner (1943) and Asperger (1944). Before this time, autistics were not a group in their own right, but were mixed in amongst the mentally retarded and the psychotic (Sacks, 1995). The frequency of autism is approximately 1-2 per thousand of the general population (Frith, 1997). It is noteworthy that 2-4 times as many boys as girls are diagnosed as autistic. Autism is very variable, some autistics are fluent speakers, whilst others fail to ever speak a single word. The case of Grandin (see Sacks, 1995) is an interesting case. Grandin displayed many characteristics of autism, however she has achieved a high level of academic/professional success, and is very much self-sufficient.
Psychology has made great progress in narrowing down the list of possible causes of autism. Originally, autism was believed to be a result of disturbing experiences in early childhood. This ‘psychogenic’ model has now been all but abandoned due to a lack of any substantial evidence. Frith (1997) highlighted the occurrence of people who were rejected and endured a deprived childhood, yet who did not develop autism. This realisation has lead psychologists to a concerted effort to instead find a physiological cause. A number of interesting findings have recently come to light. Wing (1997) argued that the different symptoms associated with autism do not occur by coincidence. Wing and Gould (1979) focused on three core cognitive features of the autistic person that are impaired, communication, imagination, and socialisation. Frith (1997) proposed that a deficit in a single cognitive component was responsible for this triad of impairments.
Forming a diagnosis is often difficult. The strange situation (see Ainsworth et al, 1978), is a frequently used measure of attachment style of a child. In one study involving autistic children, Capps, Sigman, and Mundy (1994) observed that all the children displayed ‘disorganised attachment’, yet using the criteria of the strange situation, forty percent were subclassified as securely attached ! In short, autistic children were not well captured by any of the categories (Capps et al, 1994). This example clearly displayed the limited usefulness of the ‘strange situation’ as a diagnostic tool. For if it can not detect children who have the more severe kinds of psychological problems, then it can hardly be relied upon to discriminate more subtle instances of behaviour or emotional difficulties. Rutter (1980) suggested that it was uncertain if such broad categories were adequate to cover all the variations of attachment relationships. Further, Rutter (1995) argued that psychologists should use a wide range of interview and observational data to give an accurate picture. This point makes sense, for example, if a variety of diagnostic tools are employed, and all (or a majority) suggests a similar abnormal condition, then the analyst can be secure with the data, and form a more accurate diagnosis.
Diagnosing autism is not easy, but a wide array of behavioural patterns are known to be integral to the autistic individual. Kanner’s (1943) definition of autism consists of four main behavioural traits. A child who prefers to be alone, who insist on sameness, who likes elaborate routines, and who can possess remarkable abilities relative to deficits (Kanner, 1943). Amongst others aspects, DSM-IV (American Psychiatric Association, 1994) features the autistic as having a preoccupation with parts of objects, and a restricted field of interests.
Two important theories have recently been proposed that take account of the many facets of autism. First, the executive dysfunction hypothesis (Ozonoff, Pennington, & Rogers, 1991). This theory is based on the assumption that autistics have a deficit in executive functions, such as planning, impulse control, initiation, and monitoring of action. Processing of these cognitive functions is believed to be located in the pre-frontal cortex – an area of the brain where ‘high level’ cognition takes place (see Kalat. 1998). Poor performance of these functions is directly related to repetitive thought, stereotyped and rigid behaviour as seen in autistic people.
The second theory is weak central coherence proposed by Frith and Happé (1994). This hypothesis attempted to explain the exceptional talents and very restricted interests, that a significant proportion of autistic individuals display. Weak central coherence refers to the preference of autistic people for segmental over holistic information processing. Frith and Happé (1994) suggested autistic people process information in a ‘piecemeal fashion’. This theory would certainly explain how gifted autistics like Stephen Wiltshire and ‘Blind Tom’ (see Sacks, 1995) capture – in a ‘photographic’ manner, a visual or auditory ‘scene’, and are then able to reproduce it with apparently little effort, and in such intricate detail.
Another suggested cause for autism is a faulty immune system. One study by Comi et al (1999) displayed a strong link between the occurrence of autism and auto-immune disease within a family. Boyce (1999, p. 17) noted how “In 46 percent of the families of autistic children, two or more [family members] had an auto-immune disease (. . .) [This compared to ] (. . .) 26 per cent of normal children’s families.” One further factor that supports the autism-immune deficit theory was the result that “(. . .) 39 per cent of normal children had allergies, while only 11 per cent of the autistic children had them.” (Boyce, 1999, p . 17). So, it would appear that a weak immune system results in fewer allergies, and this lack of a normal allergic reaction in a person, could be one indicator of many, that a person is possibly autistic. Naturally, as with all ‘links’, the immune problem could be symptomatic of other biological effects resulting from autism, and not an actual causal factor.
Treatment for autism is aimed to “(. . .) reduce their unusual behaviour and improve their communication and social skills” (Davison & Neale, 1998, p. 445). A number of programmes have appeared successful in this aim. From a behavioural perspective, Lovaas (1987) instituted an operant programme with autistic children. The main aspect of the programme was the ‘mainstreaming’ of autistic children with normal children. I.Q. ratings were much higher after two years of the intensive therapy, autistics in the programme scored 83 contrasted to 55 in the control group. A follow up of the children some four years later found that improvements were maintained in I.Q., behaviour, and academic progression (McEachin, Smith, & Lovaas, 1993).
Treatment from a psychodynamic perspective lacks any empirical support. Bettelheim (1967) argued that autism was due to a lack of a warm and loving home environment, and claimed some success in his programme. However, Gardner (1997) argued that Bettelheim’s methodological procedures were unreliable.
For correcting autism, Davison and Neale (1998) argued that it would be necessary to approach the condition from both a psychological and biological perspective. It would appear that autism can be managed, although Temple Grandin is content to be autistic, “If I could snap my fingers and be non-autistic, I would not (. . .) Autism is part of who I am ”(Sacks, 1995, p. 278). Sacks (1995, p. 277) argued that autism can be pathologised, but it can be viewed as a “mode of being (. . .) one that needs to be conscious (and proud) of itself.” With such a view, the ethical implications of labeling autism as an illness are still questionable. Even though the disorder is increasingly well understood, does not necessarily mean that psychologists should aim to ‘cure it’.
In summary, psychology has made some progress in narrowing down the number of possible causes of autism. Diagnosis is well refined and reliable. Treatment is still a long way off, although evidence for a specific neural deficit provides optimism for a treatment in the next century.
ADHD : A case of overlabeling behaviour, or a real epidemic ?
Attention-deficit hyperactivity disorder (ADHD) is a problem which affects approximately 1.3 million children in the U.S. (Beardsley, 1999b). A fierce debate continues, regarding the current methods of treatment which psychiatry is prescribing en masse to the western worlds youth.
Sachdev (1999) questioned the validity of ADHD as a disorder, in particular highlighting the fact that presently there is a lack of longitudinal data. The term ADHD has now become part of the public’s awareness. Public concern (or should that be ‘hysteria’?) regarding children who have been diagnosed with ADHD, is understandable, as the disorder is not yet conclusively supported. Certainly, as Sachdev (1999) noted, there is a great deal of evidence to support the existence of ADHD, but until children with supposed ADHD are tracked well into their adult lives, it may just be a case of over-labelling.
The number of diagnoses of ADHD have risen, quite extraordinarily in the last decade. In the United States diagnoses of ADHD increased from over 900,000 in 1990 to a little above 2.3 million in 1995 (Robison, Sclar, Skaer, & Galin, 1999).This in itself raises a few questions. First, why the massive increase ? Second, are the employed methods of diagnoses valid ? Diagnostic criteria for DSM- IV demand that for ADHD to be diagnosed, a suspected case must display persistently at least six or more symptoms of inattention or six or more symptoms of hyperactivity and impulsivity (American Psychiatric Association, 1994). Despite the great increase in diagnoses of ADHD, some still argue that under-diagnosis remains a real problem (Wender, 1998).
There exist a problem in forming any diagnosis. Barkley (1999) noted how psychiatry has had a problem in clarifying what ADHD is. The classification of ADHD has changed radically, even in the last few years. Searight and McLaren (1998) argued that some reasons for the great increase in ADHD diagnoses are more social, cultural, and economic, rather than based on a real illness. It is perhaps true that as the mass lay media of the western world seem intent on raising fear, behaviour that was once perceived as natural for a child, is now medicalised as an illness, one which ought to be treated.
There is the threat psychology will provide society with the means to shape children into less disruptive and more obedient people. Douglas (cited in Beardsley, 1999b, p. 93) believed “There is a tendency to start using [stimulants] when ever people have difficulties with a child.” This is an important admission, one which calls into question the ethics and legitimacy of trying to reshape children’s behaviour using pharmocotherapy. Another real problem in diagnosis of ADHD is that general practitioners often fail to use structured questionnaires, and instead rely upon the parents opinion of the child (Beardsley, 1999b). A parent can hardly be relied upon to give an accurate, and truly unbiased behavioural summary of their own child. It is therefore important that for any suspected case of ADHD, they be referred to a professional psychologist for an objective analysis.
Wender (1998) characterised the ADHD sufferer as inattentive, restless, a ‘quicktemper’, overacting and impulsive. It is worth taking a moment to really consider the preceding characteristics. Who is not ‘restless’ or ‘impulsive’ from time to time ? For such rigid labels are central to forming a diagnosis, yet do not explore the situational reasons why the person is restless. It is at this point that anti-labelling extremist clearly have a point that we should seriously consider. Let us consider the case of a child in a typical ‘western world’ educational setting. The child is disinterested in what the teacher is saying, and is understandably wishing to be some place else. The child’s behaviour may be accurately assessed as inattentive, restless, and distractible. Were the child in a class where the lesson was of personal interest, then such behaviour and associated diagnostic labels would no longer be applied, as the child resides in a place where they are happy to be. The fact that a significant percentage of children at school are being labeled with ADHD is hardly surprising when reasons like this are considered. The very fact that education is ‘forced’ invariably means that many children are in a place – for usually more than a decade, where they’d rather not be, resulting in behaviour labeled as an illness. Something to consider, perhaps.
The etiology of ADHD is very much disputed, as is the disorder itself. As follows are some of the main theories on the matter. Chervin (1999) noted that in experiments of sleep deprivation, subjects display symptoms that are similar to those of ADHD. It remains to be seen whether any type of sleep disturbance is responsible for any cases of ADHD, although it is certainly an interesting avenue of possible research.
One explanation often cited for behavioural disorders is nutrition. It is logical to assume that any deficiency (or more unusually, an excess) in physiological requirements will result in physiological and/or psychological problems. Zinc deficiencies have received particular attention. Bekaroglu, Aslan, Gedik, and Orhan (1996) tested 48 children with ADHD and 45 ‘normals’. Results of the mean serum zinc level were significantly lower in the ADHD group. The difficulty with studies of this nature, is that the zinc deficiency may be a symptom of ADHD and not a causal factor.
A genetic basis for ADHD is increasingly supported from twins studies. One very strong piece of evidence by Gjone, Stevenson, Sundet, and Eiletsen, (1996) employed 526 identical and 389 fraternal twins. It was found that ADHD is almost 80 percent heritable, “(. . .) meaning that up to 80 percent of the differences in attention, hyperactivity and impulsivity between people with ADHD, and those without the disorder can be explained by genetic factors” (Barkley, 1998, p. 46). Which particular genes are responsible for the symptoms of ADHD is the more difficult task. Barkley (1998) suggest those genes which specify how the brain uses dopamine. Initial evidence by Cook et al (1995) displayed children with ADHD as more likely to possess a variation in a dopamine transporter gene – DAT1.
In a study by Jensen et al (1999) the effects of several treatments were monitored for 14 months. The results of the study supported the use of medication (stimulants) above all other therapies. Other treatments, such as restricted diets, and psychotherapy were not shown to have any benefits (Beardsley, 1999b).
Since the 1960’s drugs commonly used to treat ADHD, such as Methylphenidate (trade-name Ritalin) - a mild stimulant, Adderell and dextroamphetamine - both types of amphetamine (Sprague & Gadow, 1976). The use of amphetamines is particularly troublesome, because of the tolerance that quickly develops to the drug (see Davison & Neale, 1998)
The worry that prescribing such potent drugs to children will make them the drug users of tomorrow is not shared by all. The situation may be quite the opposite in fact. Wilens (1999) surveyed two groups, both who had been diagnosed with ADHD. In the medicated group only 38 per cent had gone on to experiment with illegal drugs, this compared to 58 per cent in a control group. No data exist on whether this ‘protective effect’ will last (Wilens, 1999). The implications of long-term drug treatment with stimulants are worrying, although much research suggest that medication is more beneficial than either cognitive or behavioural therapies (Garland, 1998). Zametkin (cited in Beardsley, 1999b) of the National Institute of Mental Health (NIMH) noted the mass of evidence which does suggest the use of stimulants – like Ritalin, are quite safe and pose no dependency problem. Beardsley (1999b, p. 93) concluded that “For some children [prescribed stimulants] (. . .) may spell the difference between a measure of calm at school and at home and an existence of unrelenting chaos.” This view appears balanced and practical in the ‘real world’, but it is still subject to the social norms of western society, norms which demand children to spend years in an environment such as school, where they are sometimes unhappy and disinterested.
In summary, at present there is no cure for ADHD, but the use of pharmocotherapy appears to be effective in improving attention, reducing activity, and impulsiveness. Whilst a ‘cure’ is being sought, the intervening question which psychologists and health care professionals need to ask, is whether such behaviour modification is necessary, and whether the benefits of treatment outweigh the possible risks.
Depression: Living under a cloak of darkness.
It seems likely that at some time in every person’s life, depression is a feature – if a brief one. There are times when people are euphoric, and times when people are in despair, both can be normal responses to life events. Yet it is when the despair persist, when it breeds a variety of symptoms “(. . .) that the condition can be considered pathological, and to form part of a clinical syndrome (Silverstone & Turner, 1995).
Depression is perhaps the most common psychological problem, one which most people can empathise with on some level. DSM-IV classifies depression as a major mood disorder, and splits the disorder into major depression and bipolar depression (Davison & Neale, 1998). At some time in life major depression is reported to affect about 17 per cent of the population (Blazer, Kessler, & McGonagle, 1994). There are significant differences in prevalence of depression by gender. Leutwyler (1997, p. 33) noted “(. . .) major depression is twice as common among women as it is among men.”
Diagnosing depression is problematic though, in the sense that depression is very variable, and the behaviour changes of the depressed vary enormously from person to person. For a major depression diagnosis to be made, DSM-IV requires at least four of nine symptoms to be displayed. The symptoms which must be present for at least two weeks include, loss of appetite, negative self-concept, and thoughts of death/suicide (American Psychiatric Association , 1994).
There are a wide variety of opinions as to the etiology of clinical depression. It is worth keeping in mind that more than one approach is likely valid for some cases of depression. Any blanket view to depression, such as solely taking a biochemical viewpoint would appear to be quite misguided given the wealth of evidence that most approaches have to support their own theory. Attempts to find the cause of depression are fraught with problems. For example, another illness such as dementia may be producing depressive symptoms.
There are two categories of anti-depressant drugs, the monoamine reuptake inhibitors (MARI), and the selective serotonin reuptake inhibitors (SSRI). In general, about 60-70 per cent of patients respond to one of these two drug types (Paykel, 1985; Paykel, 1988).
Fisher and Greenberg (1989) analysed studies of antidepressant trials across the 1960’s to the 1980’s. They concluded that about “(. . .) two thirds of the patients placed on medication either showed no improvement or responded equally well to a placebo (. . .) the effects of medication wane for many patients after the first several months, and those who discontinue treatment have high relapse rates” (Horgan, 1996, p.78). In a meta-analysis of 475 therapy studies, Smith, Glass, and Miller (1980) concluded that for most therapies, the patient did better, than those without treatment. Interestingly, Smith et al noted that the effect size did not vary much across the different therapies.
The continuation of mental health benefits after a course of therapy is of great importance. Lambert, Shapiro, and Bergin (1986) cited evidence in a study by Nicholson and Berman (1983), that the positive effects of psychotherapy lasted for many months.
Cognitive therapy has been shown to be far more effective than pharmocotherapy in the treatment of major depression (Rush, Beck, Kovacs, & Hollon, 1977). There was a significantly higher dropout rate for those receiving pharmocotherapy compared to cognitive therapy. Similarly, in a study of 87 psychiatric outpatients, the 70 who completed the 12 week course of treatment displayed significant improvement in both cognitive therapy and pharmacotherapy (Murphy, Simons, Wetzel & Lustman, 1984). Further, and somewhat unfortunate, the combination of both therapies failed to provide any added benefit (Murphy et al, 1984). Psychotherapy has been shown to be more effective than cognitive therapy, for the most severely diagnosed patients (e.g. Elkin et al, 1996).
The problem of side-effects with medication – even with the new SSRI’s, is one of psychiatry’s most serious hindrances to successful treatment. For our case of Mara, let us assume she is prescribed the anti-depressant Prozac, one of the SSRI group. Prozac is known to have some adverse effects on sexual functioning. Problems such as reduced interest and difficulty in achieving orgasm have been reported to be a significant effect (Persaud, 1997). For Mara, who has already suffered, her depression may well be lessened due to treatment, but she could quite conceivably lose one of life’s great pleasures. Understandably people in Mara’s situation often view the side-effects as actually worse than the depression, and discontinue treatment. These types of secondary problems make it the more difficult to convince the depressed person that medication is worthwhile. However, Persaud (1997) noted the frequent observation that it can be difficult to assess whether sexual problems are a result of the medication, or due to other reasons, such as the depression itself.
The difficulty of assessing efficacy.
This assessment has presented evidence which illustrated psychological applications to be both effective, as well as quite disastrous in others. However, assessing the efficacy of any given treatment is at best difficult, and often beyond reasonable methods of assessment. There are four main problems.
First, in determining the etiology of an abnormality, it is difficult to ascertain a cause, due to large number of variables involved. Second, the level of technology, particularly in brain scanning, is still very simplistic. Only broad phenomena are currently studied. It is yet to be seen how synapses form and how dendrites form connections. Third, determining whether a treatment has been successful is not as straightforward as might initially appear. Fourth, how can a counsellor be qualitatively rated in their efficacy ? This is perhaps the most difficult task of all.
Returning to our case of Mara, assuming she has had six months of psychotherapy, how might a ‘success’ or ‘failure’ be judged ? The criteria of DSM-IV could be applied once more, to see if Mara was still officially ‘depressed’, yet there is probably more to the situation than mere rigid labels.
Our case of Mara was a simplified one, yet just a few pieces of information can lead to a variety of causes being considered. It is quite understandable that a person is sometimes misdiagnosed, and even given the wrong treatment.
In summary, any assessment is fraught with a whole range of problems, although some idea can be achieved of how effective a treatment is.
Forceful Psychology
At the time of writing the United Kingdom home secretary (Jack Straw) has issued a new proposal relating to this discussion. The proposal concerns people who have untreatable personality disorders. Currently, unless the condition is treatable - dependent upon psychiatry’s view, the mentally ill person retains the same liberties as all ‘normal’ individuals. The new proposal overturns this philosophy, and for those psychiatry deems as ‘a threat to others or oneself’, the person can be forcibly locked away, for life is necessary (see Ford, 1999). This dramatic change in policy, would if implemented, be unique in the western world. The idea of innocent people being sectioned for crimes that might be committed, has understandably concerned many psychologists -from all approaches. The ethics of such a policy is worrying indeed, and places psychology in a difficult position. It would seem that when mixed with legal enforcement, psychology becomes unscientific, and open to abuse. Once a political dimension is brought into the arena of diagnoses, theory, and treatment, psychology’s efficacy appears no longer as secure.
In any mention of the ethics of a treatment, it is difficult not to take note of what the anti-psychiatry extremists have to say. The effect of the books of the infamous Thomas Szasz still echo amongst all those who work in the psychiatric profession worldwide. Szasz’s arguments were simple, that “(. . .) mental illness is a myth” (Szasz, 1973, p. 262). Szasz’s view that psychiatry is just another means of social control is somewhat enticing. In closing this argument I will end with one of Szasz’s (1973, p. 261) most powerful beliefs “I am opposed, on moral and political grounds, to all psychiatric interventions which are involuntary; and, on personal grounds, to all such interventions which curtail the client’s autonomy.” Clare (1980) argued that psychiatry has many problems, but added that there is too much scientific evidence to consider Szasz’s view credible.
Psychology in the twenty-first century.
The nature-nurture argument which has plagued psychology since time immorial seems to be reaching a resolution. Instead of the “(. . .) traditional either/or approach to learning and instinct [ will be] (. . .) a more integrated perspective” (De Waal, 1999, p. 61). This mature attitude once fully adopted by psychologists from all, or the majority of approaches, will surely enhance the efficacy of psychology in explaining, diagnosing, and treating abnormalities. Although it will for instance, be far more difficult to establish the etiology for a given abnormality, theorectical accuracy will probably improve beyond current imagination.
The quality of diagnoses seem likely to improve, although some problems need to be dealt with. First, is the issue of forced intervention. Psychology as a young science is far from complete in terms of it’s empirical underpinnings. Basic processes such as how the synapse form are still to be fully determined and observed directly.
The future of psychology in treating abnormalities, appears very promising. Psychotrophic drugs seem likely to become more refined, with fewer side effects, and specific to each patient. Perhaps the most exciting recent development, are findings by Ronald Mckay of the National Institute of Neurological Disorders and Stroke. Beardsley (1999c, p. 13) notes that “Mckay’s experiments indicate that neural stem cells placed in a rodent brain can form neurons and make synapses (. . .) appropriate to their location, an indication they are functional.” The obvious benefits of new neural cells can not be overstated. Devastating disorders such as Parkinson’s and Alzheimer’s might be moderated, perhaps totally reversed using the patient’s own dormant stem cells. Most people would do well to have a ‘top-up’ of new neural cells in later life, and this dream of neurology, could become a reality within decades, and if research maintains its current rate of progress. Observational technology is also improving. The finer workings of the human brain are yet to be seen, but the latest microscopy has provided a limited glimpse of how synapses originate (Beardsley, 1999a).
Psychology has journeyed a long way since the time when treatments were applied without any understanding of what their effects on the body and mind might be.
One final point to inspire hope in those who fear psychology will remain a fragmented science, is the great progress being made in exploring how the physical structure of the brain creates a human ‘mind’. Since Hubel and Wiesel (1959) found that neurons are directly and selectively responsive to a preferred stimulus, efforts have increased in mapping neural activity with associated cognitive processes. It appears that a thorough understanding of how the ‘physical’ creates the ‘mental’ will be available by 2050 (Damasio, 1999).
The four abnormalities assessed in this article, have illuminated some key issues.
First, for diagnosis of psychological illness. Rating scales are widely used as a quick and cheap way to identify how a patient might be feeling. Yet the reliability of such measures is dubious. For example, the BDI scale has been shown as very erratic, being based on college students (Hammen, 1980). Jacques (1992, p. 271) made the point that perhaps “We should question the use of expensive diagnostic tests if they lead to diagnosis but no treatment.” This is precisely the case with Dementia. There is no real treatment for the disease, yet much effort has been applied to diagnosing dementia in the elderly.
Second, the etiology of some behavioural abnormalities is yet to be understood, even at the most fundamental level. For instance, autism and ADHD are well documented, with clear diagnoses, yet their cause is simply not yet apparent.
For ADHD, one task urgently required is to improve the understanding of “(. . .) the links between ADHD and other coexisting conditions”, such as depression and oppositional defiant disorder (ODD) (Beardsley, 1999, p. 93).
Third, treatment needs to be more specific and refined. At present, treatment is blunt and unfocused. It is analogous to demolishing a brick wall using a large nuclear device. The wall is removed, but so is the rest of the town ! For example, a child with ADHD is prescribed a stimulant, the dosage is a rough estimate of what is required, and the side-effects are highly variable for each patient.
For Alzheimer’s sufferers, no treatment exist to reverse, or even halt the progressive decline, although pharmocotherapy might at least improve or retain some level of cognitive ability.
Treatment for depression has met with some success, although medication can often have adverse effects as bad as the depression itself.
As was detailed in the case of Mara, each of the approaches appear to offer a solution to Mara’s depression. Yet, the question still remains, which approach does one choose ?
One proposed solution to this problem of which approach to choose, is to take a constructivist view of science. This view suggested there is no one reality (Mischel, 1993). Scarr’s (1985) support for this view makes sense in many respects, especially in regard to the development, or even abandonment of once established theories. Each person’s perception and experience of the world is unique. Yet can science be treated in such an imprecise way ? Either the universe is governable and explainable by a series of rules, or it is not. It will be for each psychologist to decide where they sit on this paramount philosophical fence. Either psychology is viewed as seeking ‘the truth’, or it seeks some variable truth, dependent upon particular ‘point of view’. I conclude this (possibly unsolvable) debate, and argue that it is time for the traditional empiricist to make their viewpoint heard. Only ‘true science’ is responsible for the progress which psychology has made. The ‘many truths’ way is unfocused and holds little hope for those suffering with real psychological abnormalities. It is all well and good for a humanistic counsellor to accept unconditionally a persons depressed thoughts, yet the client’s quality of life is arguably poor, and for some people, only a scientist can offer a way forward to improve the depressed persons life. An open-minded and multi-model approach to mental health is possibly the most productive and ‘right’ way to proceed. Tyrer and Steinberg concluded (1998, p. 138) “(. . .) those who imprison themselves within the confines of one model only have the perspective of the keyhole, a perspective that is stimulating at first but which without the wider view is seriously limiting.” This view is perhaps one that the psychologist of the next century will come to follow.
In consideration of all the earlier evidence, I would like to outline four recommendations, changes that ought to improve the efficacy of psychology. First, the training of psychologists. Training needs to be more broad in the variety of approaches that are covered, this would seem to be especially necessary at undergraduate level. Specialisation and a dedication to ‘one view’ should at least be forestalled until graduate level. Second, a greater degree of communication between advocates of different approaches. More communication between psychologists of different approaches may open minds to other possibilities. Third, an end to either/or thinking. The human mind and body are complex systems, and it would appear from all the evidence so far, that there exist many causal factors for most psychological phenomena. Fourth, more research into less conventional methods of treatment. Acupuncture has just about gained official acceptance in the western medical profession, many more ‘alternatives’ are probably likely to have great potential for alleviating illness.
Despite the great difficulty in diagnosing psychological problems, psychiatry has more than proved itself. The fierce opponents to psychiatry such as Szasz are clearly wrong on a general level, although the issue of ‘forced treatment’ has understandably swayed many to Szasz’s side of this sharp divide.
In consideration of the preceding argument ( surely an endless one ), is this suggestion. The psychologists – as scientists, can classify, define, explain, and offer a corrective procedure for any abnormality. Yet, it is not the task of any scientist to become embroiled in such arguments. It is instead society’s job to decide mental health policy, such as whether ‘forced intervention’ should be legally enforced.
As this discussion comes to a close, I would like to outline the reason for this particular line of inquiry. I have assessed the efficacy of psychology as a scientist, but have viewed the effects of psychology from more of a ‘humanistic’ perspective. In my experience (no doubt biased ) psychiatry remains firmly closed to ‘other ways of seeing’ - such as other viewpoints of what constitute ‘normal thoughts’. However, as shown earlier in this discussion, psychiatry has undoubtedly alleviated much suffering, despite some terrible mistakes. At the other end of the spectrum, and in stark contrast, I have found the humanistic profession to be openly dismissive of scientifically documented mental disorders such as depression and ADHD. I have encountered counsellors who have refused to read scientific literature, and who are psychologically closed to the possible existence of neurological deficits or biochemical imbalances. Both camps appear ignorant of each other, and far from being scientific (as any psychiatrist ought to aspire) or open-minded (as the humanists preach so regularly), psychiatry and the counselling profession fail the society they serve. I would like to believe there is a middle-ground between such polar opposites, forming a productive collaboration. Such a collaboration can only be achieved with greater communication between devotees of all the many varied approaches. At present it would appear that very little is being done to build bridges to aid such valuable communication. A brief scan through publications of both sides are littered with authors trying to ‘score a point’ at the other side’s expense. This war of words is a primary issue of importance, which psychology needs to address, if progress is to continue as well as it has this past hundred years. As I have presented, the many different psychological approaches usually have something useful to offer the society they attempt to explain and serve. Therefore, the future psychologist might be more aware of, and draw upon, a number of approaches. Working from a variety of perspectives is surely more productive, than working from just one approach, however much evidence exist for a given approach.
With less than a year to the new century, psychology is arguably on the right path to further the astounding progress seen this century, forming better diagnoses, providing more detailed theorectical explanations of the etiology of abnormalities, and in more focused effective treatments. What is required though, is a greater degree of communication across the whole spectrum of theorectical approaches. Only with further theorectical integration can psychology claim to be a coherent and effective science.
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