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Foundations for a Contemporary Understanding

James E Maddux, Barbara A Winstead, James E. Maddux, Barbara A. Winstead, James E. Maddux, Barbara A. Winstead, James E. Maddux, Barbara A. Winstead

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eBook - ePub


Foundations for a Contemporary Understanding

James E Maddux, Barbara A Winstead, James E. Maddux, Barbara A. Winstead, James E. Maddux, Barbara A. Winstead, James E. Maddux, Barbara A. Winstead

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About This Book

Psychopathology, Fifth Edition is the most up-to-date text about the etiology and treatment of the most important psychological disorders.

The chapters are written by leading experts in the field of psychopathology who provide up-to-date information on theory, research, and clinical practice. The book is unique in its strong emphasis on critical thinking about psychopathology as represented by chapters on such topics as culture, race, gender, class, clinical judgment and decision-making, and alternatives to traditional categorical approaches to understanding psychopathology. The contributors have incorporated information about and from the World Health Organization's International Classification of Diseases along with information about and from the DSM-5.

As with the previous editions, this book remains a true textbook in psychopathology. Unlike the many weighty volumes that are intended as reference books, Psychopathology, Fifth Edition has been designed specifically to serve as a textbook on psychopathology for graduate students in clinical and counseling psychology programs and related programs such as social work. It will also serve as an extremely useful reference source for practitioners and researchers.

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Part I
Thinking About Psychopathology

Chapter 1
Conceptions of Psychopathology

A Social Constructionist Perspective

James E. Maddux, Jennifer T. Gosselin, and Barbara A. Winstead
Chapter contents
Conceptions of Psychopathology
Categories Versus Dimensions
Social Constructionism and Conceptions of Psychopathology
Summary and Conclusions
A textbook about a topic should begin with a clear definition of the topic. Unfortunately, for a textbook on psychopathology, this is a difficult if not impossible task. The definitions or conceptions of psychopathology and such related terms as mental disorder have been the subject of heated debate throughout the history of psychology and psychiatry, and the debate is not over (e.g., Gorenstein, 1984; Horwitz, 2002; Widiger, Chapter 6 in this volume). Despite its many variations, this debate has centered on a single overriding question: Are psychopathology and related terms such as mental disorder and mental illness scientific terms that can be defined objectively and by scientific criteria, or are they social constructions (Gergen, 1985) that are defined largely or entirely by societal and cultural values? Addressing these perspectives in this opening chapter is important because the reader’s view of everything in the rest of this book will be influenced by his or her view on this issue.
This chapter deals with conceptions of psychopathology. A conception of psychopathology is not a theory of psychopathology (Wakefield, 1992a). A conception of psychopathology attempts to define the term – to delineate which human experiences are considered psychopathological and which are not. A conception of psychopathology does not try to explain the psychological phenomena that are considered pathological, but instead tells us which psychological phenomena are considered pathological and thus need to be explained. A theory of psychopathology, however, is an attempt to explain those psychological phenomena and experiences that have been identified by the conception as pathological. Theories and explanations for what is currently considered to be psychopathological human experience can be found in a number of other chapters, including all of those in Part II.
Understanding various conceptions of psychopathology is important for a number of reasons. As explained by medical philosopher Lawrie Reznek (1987), “Concepts carry consequences – classifying things one way rather than another has important implications for the way we behave towards such things” (p. 1). In speaking of the importance of the conception of disease, Reznek wrote:
The classification of a condition as a disease carries many important consequences. We inform medical scientists that they should try to discover a cure for the condition. We inform benefactors that they should support such research. We direct medical care towards the condition, making it appropriate to treat the condition by medical means such as drug therapy, surgery, and so on. We inform our courts that it is inappropriate to hold people responsible for the manifestations of the condition. We set up early warning detection services aimed at detecting the condition in its early stages when it is still amenable to successful treatment. We serve notice to health insurance companies and national health services that they are liable to pay for the treatment of such a condition. Classifying a condition as a disease is no idle matter (p. 1).
If we substitute psychopathology or mental disorder for the word disease in this paragraph, its message still holds true. How we conceive of psychopathology and related terms has wide-ranging implications for individuals, medical and mental health professionals, government agencies and programs, legal proceedings, and society at large.

Conceptions of Psychopathology

A variety of conceptions of psychopathology have been offered over the years. Each has its merits and its deficiencies, but none suffices as a truly scientific definition.

Psychopathology as Statistical Deviance

A commonly used and “common sense” conception of psychopathology is that pathological psychological phenomena are those that are abnormal – statistically deviant or infrequent. Abnormal literally means “away from the norm.” The word “norm” refers to what is typical or average. Thus, this conception views psychopathology as deviation from statistical psychological normality.
One of the merits of this conception is its common sense appeal. It makes sense to most people to use words such as psychopathology and mental disorder to refer only to behaviors or experiences that are infrequent (e.g., paranoid delusions, hearing voices) and not to those that are relatively common (e.g., shyness, a stressful day at work, grief following the death of a loved one).
A second merit to this conception is that it lends itself to accepted methods of measurement that give it at least a semblance of scientific respectability. The first step in employing this conception scientifically is to determine what is statistically normal (typical, average). The second step is to determine how far a particular psychological phenomenon or condition deviates from statistical normality. This is often done by developing an instrument or measure that attempts to quantify the phenomenon and then assigns numbers or scores to people’s experiences or manifestations of the phenomenon. Once the measure is developed, norms are typically established so that an individual’s score can be compared to the mean or average score of some group of people. Scores that are sufficiently far from average are considered to be indicative of “abnormal” or “pathological” psychological phenomena. This process describes most tests of intelligence and cognitive ability and many commonly used measures of personality and emotion (e.g., the Minnesota Multiphasic Personality Inventory).
Despite its common sense appeal and its scientific merits, this conception presents problems. Perhaps the most obvious issue is that we generally consider only one “side” of the deviation to be problematic (see “Psychopathology as Maladaptive Behavior” later in this chapter). In other words, Intellectual Disability is pathological, intellectual genius is not. Major Depressive Disorder is pathological, unconstrained optimism is not. Another concern is that, despite its reliance on scientific and well-established psychometric methods for developing measures of psychological phenomena and developing norms, this approach still leaves room for subjectivity.
The first point at which subjectivity comes into play is in the conceptual definition of the construct for which a measure is developed. A measure of any psychological construct, such as intelligence, must begin with a conceptual definition. We have to answer the question “What is ‘intelligence’?” before we can attempt to measure or study its causes and consequences. Of course, different people (including different psychologists) will come up with different answers to this question. How then can we scientifically and objectively determine which definition or conception is “true” or “correct”? The answer is that we cannot. Although we have tried-and-true methods for developing a reliable and valid (i.e., it consistently predicts what we want to predict) measure of a psychological construct once we have agreed on its conception or definition, we cannot use these same methods to determine which conception or definition is true or correct. The bottom line is that there is not a “true” definition of intelligence and no objective, scientific way of determining one. Intelligence is not a thing that exists inside of people and makes them behave in certain ways and that awaits our discovery of its “true” nature. Instead, it is an abstract idea that is defined by people as they use the words “intelligence” and “intelligent” to describe certain kinds of human behavior and the covert mental processes that supposedly precede or are at least concurrent with the behavior.
We usually can observe and describe patterns in the way most people use the words intelligence and intelligent to describe the behavior of themselves and others. The descriptions of the patterns then comprise the definitions of the words. If we examine the patterns of the use of intelligence and intelligent, we find that at the most basic level, they describe a variety of specific behaviors and abilities that society values and thus encourages; unintelligent behavior includes a variety of behaviors that society does not value and thus discourages. The fact that the definition of intelligence is grounded in societal values explains the recent expansion of the concept to include good interpersonal skills (e.g., social and emotional intelligence), self-regulatory skills, artistic and musical abilities, creativity, and other abilities not measured by traditional tests of intelligence. The meaning of intelligence has broadened because society has come to place increasing value on these other attributes and abilities, and this change in societal values has been the result of a dialogue or discourse among the people in society, both professionals and laypersons. One measure of intelligence may prove more reliable than another and more useful than another measure in predicting what we want to predict (e.g., academic achievement, income), but what we want to predict reflects what we value, and values are not derived scientifically.
Another point for the influence of subjectivity is in the determination of how deviant a psychological phenomenon must be from the norm to be considered abnormal or pathological. We can use objective, scientific methods to construct a measure such as an intelligence test and develop norms for the measure, but we are still left with the question of how far from normal an individual’s score must be to be considered abnormal. This question cannot be answered by the science of psychometrics because the distance from the average that a person’s score must be to be considered “abnormal” is a matter of debate, not a matter of fact. It is true that we often answer this question by relying on statistical conventions such as using one or two standard deviations from the average score as the line of division between normal and abnormal. Yet the decision to use that convention is itself subjective because a convention (from the Latin convenire, meaning “to come together”), is an agreement or contract made by people, not a truth or fact about the world. Why should one standard deviation from the norm designate “abnormality”? Why not two standard deviations? Why not half a standard deviation? Why not use percentages? The lines between normal and abnormal can be drawn at many different points using many different strategies. Each line of demarcation may be more or less useful for certain purposes, such as determining the criteria for eligibility for limited services and resources. Where the line is set also determines the prevalence of “abnormality” or “mental disorder” among the general population (Kutchins & Kirk, 1997; Frances, 2013), so it has great practical significance. But no such line is more or less “true” than the others, even when those others are based on statistical conventions.
We cannot use the procedures and methods of science to draw a definitive line of demarcation between normal and abnormal psychological functioning, just as we cannot use them to draw definitive lines of demarcation between “short” and “tall” people or “hot” and “cold” on a thermometer. No such lines exist in nature awaiting our discovery.

Psychopathology as Maladaptive (Dysfunctional) Behavior

Most of us think of psychopathology as behaviors and experiences that are not just statistically abnormal but also maladaptive (dysfunctional). Normal and abnormal are statistical terms, but adaptive and maladaptive refer not to statistical norms and deviations but to the effectiveness or ineffectiveness of a person’s behavior. If a behavior “works” for the person – if the behavior helps the person deal with challenges, cope with stress, and accomplish his or her goals – then we say the behavior is more or less effective and adaptive. If the behavior does not “work” for the person in these ways, or if the behavior makes the problem or situation worse, we say it is more or less ineffective and maladaptive. The Diagnostic and Statistical Manual of Mental Disorders (5th ed.) (DSM-5) incorporates this notion in its definition of mental disorder by stating that mental disorders “are usually associated with significant distress or disability in social, occupational, or other important activities” (American Psychiatric Association [APA], 2013, p. 20).
Like the statistical deviance conception, this conception has common sense appeal and is consistent with the way most laypersons use words such as pathology, disorder, and illness. As we noted earlier, most people would find it odd to use these words to describe statistically infrequent high levels of intelligence, happiness, or psychological well-being. To say that someone is “pathologically intelligent” or “pathologically well-adjusted” seems contradictory because it flies in the face of the common sense use of these words.
The major problem with the conception of psychopathology as maladaptive behavior is its inherent subjectivity. Like the distinction between normal and abnormal, the distinction between adaptive and maladaptive is fuzzy and arbitrary. We have no objective, scientific way of making a clear distinction. Very few human behaviors are in and of themselves either adaptive or maladaptive; instead, their adaptiveness and maladaptiveness depend on the situations in which they are enacted and on the judgment and values of the actor and the observers. Even behaviors that are statistically rare and therefore abnormal will be more or less adaptive under different conditions and more or less adaptive in the opinion of different observers and relative to different cultural norms. The extent to which a behavior or behavior pattern is viewed as more or less adaptive or maladaptive depends on a number of factors, such as the goals the person is trying to accomplish and the social norms and expectations in a given situation. What works in one situation might not work in another. What appears adaptive to one person might not appear so to another. What is usually adaptive in one culture might not be so in another (see López & Guarnaccia, Chapter 4 in this volume). Even so-called “normal” personality involves a good deal of occasionally maladaptive behavior, which you can find evidence for in your own life and the lives of friends and relatives. In addition, people given official “personality disorder” diagnoses by clinical psychologists and psychiatrists often can manage their lives effectively and do not always behave in maladaptive ways.
Another problem with the “psychopathological = maladaptive” conception is that judgments of adaptiveness and maladaptiveness are logically unrelated to measures of statistical deviation. Of course, often we do find a strong relationship between the statistical abnormality of a behavior and its maladaptiveness. Many of the problems described in the DSM-5 and in this textbook are both maladaptive and statistically rare. There are, h...

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