It is a course of mental illness related to sociology.Please read the attached files and watch the video (link below) to understand the task properly. Its one page writing with any of the following--

CHAPTER 79 4 T his chapter provides further background on the characteristics of mental disorders by reviewing the major theoretical models explaining the causes. This literature is often interdisciplinary and provides models developed by psychiatrists, psychologists, sociol- ogists, and others. Models are abstractions organized to place facts and theories into an orderly framework for analysis and scientific verifica- tion; they provide directions for research. And for the applied disci- plines of psychiatry and clinical psychology they are invariably a basis for therapy because they have been found to obtain positive results for certain patients. While no single concept is able to provide a definitive Mental Disorder Concepts of Causes and Cures Cockerham, William C.. Sociology of Mental Disorder, Taylor & Francis Group, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/umanitoba/detail.action?docID=4710761.

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80 Chapter 4 • Concepts of Causes and Cures explanation of all cases of insanity, several models are discussed in the litera- ture. These models are (1) medical, (2) psychoanalytic, (3) behavior modifica- tion, (4) social stress, and (5) antipsychiatric.

THE MEDICAL MODEL The medical model views mental disorder as a disease or a disease-like entity that can be treated through medical means. That is, it attributes mental abnor- malities to physiological, biochemical, or genetic causes and attempts t\ o treat these abnormalities by way of medically grounded procedures such as psycho- pharmacology (drug therapy), electroshock therapy (EST), or psycho-surgery (brain surgery). In this particular context, a person who is mentally ill is regarded as sick in much the same manner as if that person were physically\ ill.

The medical model holds that abnormal behavior is symptomatic of an under- lying psychic disturbance; therefore, its approach is to discover and treat the cause of that disturbance with a strategy similar to that of finding and curing a bacteriological infection.

As discussed in Chapter 1 , the origins of this approach stem from the efforts of physicians during the Renaissance and post-Renaissance to comba\ t the notion, prevalent during the Middle Ages, that mental disorder was caused by demons, spirits, and other supernatural forces. By the end of the seventeenth century, the medical profession had generally been successful in separating the\ social responsibility for treating mental disorder from theology and pla\ cing it within the field of medicine. Physicians thus looked to the study of human anatomy for evidence that madness was caused by pathological organic pro- cesses within the body, but, with a few exceptions (e.g., syphilis of the brain), such evidence was not forthcoming. Nevertheless, by the end of the nineteenth century, the idea had become widely accepted by both the medical profession and the lay public that mental disorders were caused by mental diseases.\ In the twentieth century, however, it became clear that most mental disorders could not be attributed to observable anatomical abnormalities. As Robert Spitzer and Paul Wilson (1975: 826–7) observe, most psychiatric conditions do not meet the four presumed criteria for a physiological dysfunction—these are:\ (1) hav- ing a specific etiology or cause (such as a virus); (2) being qualitatively differ- ent from some aspect of normal functioning; (3) showing a demonstrable physical change; and (4) being internal processes that, once initiated\ , proceed somewhat independently of environmental conditions outside the body. Yet the medical model not only has persisted in psychiatry, it has become dominant. It guides most of the present-day search for solutions to ment\ al dis- order. Why? Basically there are three reasons. First, all psychiatrists are tra\ ined as medical doctors and are thereby socialized into adopting a medical pe\ rspec- tive. The medical profession, not surprisingly, regards medical training as the optimal preparation for working with mentally disturbed people. Hence, the medical model is able to maintain a pervasive influence upon the practice of psychiatry because psychiatrists are trained to view health problems as medical Cockerham, William C.. Sociology of Mental Disorder, Taylor & Francis Group, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/umanitoba/detail.action?docID=4710761.

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81 Chapter 4 • Concepts of Causes and Cures problems and often see themselves as first a physician and then a psychiatrist (Smith 2014).

Second, as Spitzer and Wilson point out, critics of the medical model often fail to realize that some physical disorders, such as essential hyperten-\ sion, endocrine disorders, and vitamin deficiencies, likewise do not meet all the criteria for physiological dysfunctions. But these disorders are sti\ ll treat- able through medical means and unquestionably fall within the purview of a medical problem. Consequently, Spitzer and Wilson argue that the appropri- ateness of the medical model cannot always be derived from the requirements of logic but should be based upon how well the model works in actual practice.

Even if it works poorly, they insist that it should not be abandoned until another model is developed that can be shown to work more effectively in treating patients. Their solution is to extend the definition of mental disorder to include those conditions of human suffering and disability that respond to medical treatments. In this context, psychiatric problems are not necessarily “diseases”; instead, they are “disorders” treatable in a medical mode. This broader defini- tion thus allows the medical practitioner to assume responsibility for a greater range of problems, providing that suffering or disability is present and a medi- cal treatment is available. The danger inherent in such an approach, however, is that the definition of suitable disorders becomes too broad and extends beyond medicine’s demonstrable capacity to “cure.” Nevertheless, this situation under- lies the medicalization of social problems (Conrad 2007; Conrad and Ber\ gey 2014; Conrad and Slodden 2013; Smith 2014). Such a trend is indicative of the medical model’s strength. Third, there is enthusiasm among many psychiatrists concerning the effec- tiveness of psychoactive drugs in treating certain mental disorders and signifi- cantly reducing the inmate population of American mental hospitals. This outlook has intensified, as a majority of psychiatrists appear to want to “get back to medi- cine” as full-fledged partners with other medical specialists in the search for drugs as “magic bullets” to eliminate or control mental health dysfunctions. As Dena Smith (2014:79) points out, psychiatrists trained in Freudian psy\ choanaly- sis were skeptical of treating mental disorders with psychoactive drugs, but as the decline in their numbers continued into the twenty-first century, little opposition to the medical model is left in psychiatry. Bolstered by biochemical discoveries and advances in genetics, the cur- rent view is that psychiatry is entering a new era, possibly making it one of the most scientifically precise of all medical specialties and ending its traditional dependence upon subjective judgments of and insights into the human mind.

Whether this new psychiatric era will arrive to the extent that some anticipate remains speculative at this time, but the research has been impressive enough to provoke among psychiatrists tremendous interest in psychopharmacology and recognition of the potential of genetics. While genetic research is in its infancy, it is no exaggeration to state that the community mental health move- ment would not be able to function without the drug treatments that allow Cockerham, William C.. Sociology of Mental Disorder, Taylor & Francis Group, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/umanitoba/detail.action?docID=4710761.

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82 Chapter 4 • Concepts of Causes and Cures patients to sustain themselves outside of hospitals. Besides psychopharmacol- ogy, the remainder of this section on the medical model will briefly discus\ s behavioral genetics, electroshock therapy, and psychosurgery to provide an overview of those approaches based upon procedures that are strictly medical.

Psychopharmacology The concept of a biochemical cause of insanity goes back to the time of \ the ancient Greeks and is historically derived from a belief that “poisons” gener- ated within the body are somehow able to affect the mind. At the beginning of the twentieth century, this idea was strengthened by findings demonstrating how syphilis was able to produce infection in the brain and cause manifestly bizarre behavior. Subsequent strategies to locate abnormal biochemical substances in the blood and urine of schizophrenic patients were generally unsucces\ sful, but there was a major breakthrough in 1952. Two French psychiatrists, Jean Delay and Pierre Deniker, injected chlorpromazine into their patients and soon found that it would activate withdrawn schizophrenics and bring their charac- teristically flat personal manner into a relatively normal state. Later, in large BOX 4.1 The Dominance of the Medical Model Dena Smith’s (2014) study of psychoanalysts provides insight into the perva- siveness of the medical model in psychiatry. She finds that for most psychia- trists, institutional forces outside their control structure their practice. First, pharmaceutical corporations control testing and research on psychotropic drugs and make enormous profits in the process. And through the medical model, they also influence medical training, as their drugs are linked to diag- noses. Moreover, drug companies advertise in the media directly to consumers, which promotes demand for their products from patients who seek psychiat- ric treatment (Payton and Thoits 2011).

Second, Smith notes that the insurance industry is also highly influenti\ al since it likewise is driven by the profit motive and seeks to control its costs by the most efficient and cheapest means possible. Insurance companies rely heavily on the DSM to decide which disorders they will cover and which ones they will not, requiring psychiatrists to use its codes for reimbursement. Smith asks what makes it so likely that psychiatrists will rely on the medical model?

Even the psychoanalysts in her study thought and practiced medically, despite their greater interest in “in-depth explorations of the human psyche.” She (Smith 2014:88) concludes:

I contend that teaching the medicalized model of mental illness in medic\ al schools creates a situation in which doctors, patients, the medical industry, and insurance reinforce (both consciously or not) the medicalized notion of mental illness and prevent the emergence of viable challenges to medicalization. Cockerham, William C.. Sociology of Mental Disorder, Taylor & Francis Group, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/umanitoba/detail.action?docID=4710761.

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83 Chapter 4 • Concepts of Causes and Cures controlled studies conducted in the United States, it was confirmed that chlor- promazine produced significant improvements in thought disorder, withdrawal, blunted affect, and autistic behavior.

The focus of biochemical research dealing with behavioral abnormalities has been on the neuronal activity in the central nervous system. This activity consists of signals carried via chemical agents (neurotransmitters) be\ tween one neuron and another. How such activity affects behavior is not entirely certain, but the assumption is that the action of the neurotransmitters is very important in mental disorder. It may be that too much or too little of these chemical sub- stances at particular receptor sites produces or fails to produce certain chemical responses that shape behavior. Neurotransmitters may work like keys in a lock; some fit correctly into receptor sites specifically designed to accept them, and others prevent insertion of the correct key. Or receptor sites may have a selective affinity for some compounds of a given type and a similar affinity for antagonis- tic compounds, which leads to the displacement of one or another substan\ ce. Or perhaps some other process is involved, as in the case of genetic research show- ing fewer neural connections in schizophrenics due to the hyperactivity of the C4-A protein (Sekar et al. 2016). At any rate, chlorpromazine and other drugs of the phenothiazine group are apparently able to block the action of dopam\ ine, a neurotransmitter whose hyperactivity is thought to be significant in the produc- tion of paranoid delusions and auditory hallucinations. An excessive amount of dopamine in brain receptor sites may also be involved in mania, and a deficiency in norepinephrine, another neurotransmitter, might produce depression. Even though the biochemical mechanisms that cause the effects brought on by psychotropic drugs are not fully understood, the effects of these drugs are of sufficient clarity that they can be prescribed for certain disorders. In other words, physicians may not know exactly how they work, but they do know that in certain cases they are effective. Thus, specific psychoactive drugs can be used for specific disorders. For example, benzodiazepine compounds such as chlordiazepoxide (Librium) and diazepam (Valium), propanediols such as meprobamate (Miltown, Equanil), or perhaps barbiturates (phenobarbital) or antihistamines (hydroxyzine) all belong to the so-called minor tranqui\ lizer class of psychoactive drugs and are used in the treatment of anxiety. The major tranquilizers used in the treatment of schizophrenia are the phenothiazi\ nes such as chlorpromazine (Thorazine) or the butyrophenones such as haloperidol (Haldol). For the treatment of bipolar and depressive disorders, calling for either antidepressants or antimania drugs, tricyclic antidepressants such as imipramine (Tofranil, Presamine) and amitriptyline (Elavil) are widely used.

Other mood-elevating drugs are the monoamine oxidase (MAO) inhibitors such as tranylcypromine (Parnate). Among the antidepressant drugs is fluoxe- tine (Prozac), which has more specific biochemical effects than most other medications for depression. Prozac brightens mood and lessens anxiety an\ d has been a highly popular drug since the 1990s—although there are side ef\ fects for some patients, such as sexual problems, drowsiness, and weight gain (Cascade, Kalali, and Kennedy 2009).

Cockerham, William C.. Sociology of Mental Disorder, Taylor & Francis Group, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/umanitoba/detail.action?docID=4710761.

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84 Chapter 4 • Concepts of Causes and Cures Several studies attest to the effectiveness of psychotropic drugs in con- trolling mental disorders (Leucht et al. 2012; Schatzberg and Nemeroff 2004).

There is, however, important criticism both within and outside psychiatry about overreliance on drugs for therapy. Valium, for example, although widely prescribed for anxiety, may do little more than help people sleep and can be habit forming; Thorazine, on the other hand, can control the hallucinations and agitati\ on in schizo- phrenics, but not apathy. Clozaril (clozapine) helps reduce apathy and improve motivation in schizophrenics and does not produce the long-term effects found in Thorazine, such as muscle stiffening and spasms. Yet Clozaril is expensive—it requires continual blood testing and monitoring of patients as it causes\ a blood abnormality that can be fatal in about 1 percent of all patients who take it. Reviews show, in fact, that psychotropic drugs commonly have adverse side effects, including risks for obesity, endocrine and metabolic functioning, bone density, thyroid problems, and sexual dysfunctions (Bhuvaneswar et al.

2009). Nevertheless, psychiatrists have shifted toward the increased use of drugs to treat schizophrenia, as well as anxiety and depressive disorders—with generally effective results. In regard to the effectiveness of drug therapy, it should be kept in mind that drugs do not cure mental disorder—they ameliorate symptoms. They help mental patients act in a reasonably normal manner when they would act bizarrely otherwise. The past few years have seen a large increase in new drugs introduced to treat mental disorder. These new drugs have become increasingly sophisticated owing to advances in neuroscience and molecular biology that have allowed enhanced manipulation of their chemical structures. The goal has been to create more effective drugs with fewer side effects that are specifically targeted to correct the biochemical alterations in the brain that accompany mental disorders. PHOTO 4.2 Filling a Prescription for a Psychotropic Drug at a Pharmacy Cockerham, William C.. Sociology of Mental Disorder, Taylor & Francis Group, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/umanitoba/detail.action?docID=4710761.

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85 Chapter 4 • Concepts of Causes and Cures Behavioral Genetics Another component of the medical model is genetics. Research in the area\ of behavioral genetics has produced strong evidence that genetic factors are important in the transmission of certain mental disorders, notably schiz\ o- phrenia, bipolar, and depressive disorders, from parent to child (Craddock, O’Donovan, and Owen 2012; Landecker and Panofsky 2013; Schwartz and Corcoran 2010; Sekar et al. 2016). This would explain why certain people are prone, for example, to schizophrenia and why schizophrenia tends to be preva- lent in certain families and not in others (Schwartz and Corcoran 2010). In the late nineteenth century, almost as soon as schizophrenia was defined as a spe- cific type of mental disorder, it was noticed that it “ran in families.” Under the scientific standards of the time, this was taken as “proof” that schizophrenia was inherited or at least involved genetics.

Indeed, a number of family studies conducted since the early decades of the twentieth century supported this assumption by showing that the closer an individual’s genetic relationship was to a known schizophrenic, the greater his or her chance of developing the disorder (Craddock, O’Donovan, and Owens 2012; Landecker and Panofsky 2013). Among identical (monozygotic) twins, if one twin is schizophrenic, the other twin has about a 50 percent chan\ ce of likewise becoming (or being) schizophrenic. Fraternal (dizygotic) twins,\ ordi- nary siblings, and parents show a lower degree of genetic affinity (concor- dance) for schizophrenia, nieces and nephews still lower, and so on. The lowest degree of concordance is, of course, for people who are unrelated. The child of two severely affected schizophrenics would have a 50 percent or greater chance of developing the disorder, but the risk would drop to 25 percent for the child of two mildly schizophrenic parents. If one parent is schizophrenic and the other is not, the chances of avoiding schizophrenia altogether are the same as for the general population. Then, of course, there is the genetic research previously discussed in Chapter 2 of Aswin Sekar et al. (2016) on the adverse effects of the C4-A protein in reducing (“pruning”) the number of neurotransmitters in the p\ refrontal lobe of schizophrenics that likely affect perception and the recognition of reality.

This finding provides a target for developing intervention drugs and a basis for the construction of a genetic profile of schizophrenics, providing the findings can lead to further research and more answers. As for depressive disorders, the concordance for monozygotic twins is even higher—around 70 percent; so if one twin has a depressive disorder, there are seven chances in ten that the other twin will suffer similarly. This is the highest concordance rate for any mental disorder. For first-degree relatives such as dizygotic twins, siblings, and so forth, the concordance rate drops s\ ignifi- cantly to about 15 percent and continues to decline accordingly. The exact genetic factors involved in mental disorder are not known at present; some hypotheses favor the notion that abnormal behavior is related to a single domi- nant gene, and another view is that several predisposing genes are implicated.

Cockerham, William C.. Sociology of Mental Disorder, Taylor & Francis Group, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/umanitoba/detail.action?docID=4710761.

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86 Chapter 4 • Concepts of Causes and Cures What apparently is not in dispute is that the mechanism of transmission \ is biochemical. What passes from parents to offspring are probably compounds (nucleic acid sequences) that control the biosynthesis of other compou\ nds (pro- teins); consequently, inherited abnormalities of either physiology or behavior imply an abnormality in the body’s protein complement.

Another unanswered question pertains to the relative contributions of heredity and the social environment. There is growing evidence that genetic influences on mental disorder can be modified by the environment, but the exact extent to which this is the case is still being determined (Landecker and Panofsky 2013; Pescosolido et al. 2009; Schwartz and Corcoran 2010; Toyokawa et al.

2012). According to Ronald Simons and his colleagues (2011), some individu- als are programmed by their genes to be especially sensitive to the context of their environment, which influences the probability of certain behaviors on their part. As Simons et al. (2011:883) state:

Genetic determinism has died a quiet death. Evidence is overwhelm- ing that human beings are never simply instructed by their genes to show a particular trait or behavior. Rather, genes are turned on (i.e., expressed) and messages they translate vary depending on environ- mental circumstances. This emerging perspective on genetics underscores the importance of the environmental context and formulating models of human behavior that take into account the interplay of sociocultural and genetic variables. Some people therefore appear to be genetically “primed” for schizo\ phre- nia and other mental disorders as a result of heredity; whether the diso\ rder actu- ally develops is most likely contingent upon environmental factors that “trigger” the predisposition. While it is not known what environmental factors activate a mental disorder in a genetically susceptible person, a highly plausible \ theory of schizophrenia is that given a genetic predisposition, stressful life events or circumstances elicit the disorder (Os, Rutten, and Poulton 2008; Schwartz and Corcoran 2010). Similar evidence has been found for depressive disorders and other types of mental illness (Mandelli and Serretti 2013; Uddin et al.\ 2013).

The need to study the social environment, especially in relation to stressful life events, forecasts a closer association between geneticists and sociologist\ s in researching this problem. A considerable proportion of the research on the social environmental causes of stress has been carried out by sociologists. In sum, it is generally believed that genetics play a significant role in the onset of mental disorder for some people—although there is much we ye\ t do not know, such as exactly how it works and what proportion of mentally ill people become that way because of the interaction between heredity and the environment. However, the completion of the Human Genome Project’s map- ping of the entire human genetic structure significantly improves the capability of researchers to answer these questions in the future and helps better \ explain the heredity–environment relationship. Cockerham, William C.. Sociology of Mental Disorder, Taylor & Francis Group, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/umanitoba/detail.action?docID=4710761.

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87 Chapter 4 • Concepts of Causes and Cures Electroconvulsive Therapy Electroconvulsive therapy (ECT) is a controversial method of therapeutic treatment—in fact, there is probably no procedure in medicine that is more surrounded by myths. Developed in Italy in 1938, ECT gained a reputation in the mass media, and among some psychiatrists as well, for being a partic\ ularly harsh form of punishment for unruly mental patients, and perhaps even damag- ing to the brain. The procedure, greatly improved since the 1940s, consists of placing electrodes around the brain and administering an electric curren\ t (rang- ing from 70 to 170 volts) for 0.75 to 1.25 seconds. The immediate effect on the brain is to produce a condition similar to a seizure. The most likely locus of action is the hypothalamus, the origin of the autonomic nervous system, which is thought to be involved in the expression of emotion. What actually happens in the central nervous system is not known, but it appears that electroshock causes the release of norepinephrine in the brain, which acts as an anti\ depres- sant. The most immediate feature of the experience for the patient, however, is a loss of memory, which eventually returns. Yet the therapeutic value of ECT reportedly lies not in memory loss, causing the patient temporarily to “\ forget his or her problems,” but in the organic changes in brain chemistry induced by the treatment.

Despite our lack of knowledge about the exact brain processes affected by ECT, advocates of the method point to the striking success it has with certain patients suffering from depression and suicidal tendencies (Singhal 2011). The effect of ECT on endogenous depression, a type of depression that is associated with physiological dysfunctions (e.g., loss of weight, in\ somnia, decreased bodily secretions) and that develops without relation to a specific life event (e.g., death of a loved one), was hailed decades ago as “one of the most spectacular therapeutic responses in medicine” (Kalinowsky 1975:1973).

The response is very rapid and is suggested for patients who are potentially suicidal, thus needing prompt treatment. ECT is likewise regarded as the most effective method of treating catatonic schizophrenia because of the dif- ficulty in breaching the patient’s catatonic state through the use of psycho- therapy or drugs. It is also thought to be generally effective for psychotic depression, bipolar, and depressive disorders. It is not considered particularly effective for depression brought on by anxiety or for drug-induced psychoses or personality disorders. Unfortunately, there has been a lack of controlled studies in the past that demonstrate how ECT affects the mind, and it is this lack of information that con- tributed significantly to the myths about electroshock. We now know that the procedure produces a significant improvement in certain patients, especially those who require emergency treatment for depression when a rapid recovery is needed, or have a high risk of suicide, physical deterioration due to refusal to eat or drink, severe psychomotor retardation, and extreme adverse reaction to medication for depressive disorders (Singhal 2011). However, there are also findings that ECT causes brain damage in the form of memory dysfunction f\ or Cockerham, William C.. Sociology of Mental Disorder, Taylor & Francis Group, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/umanitoba/detail.action?docID=4710761.

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88 Chapter 4 • Concepts of Causes and Cures some patients that is associated with the procedure itself and not depre\ ssion (Read and Bentall 2010). John Read and Richard Bentall (2010) conclu\ de that ECT’s effects last only a few days, that it does not prevent suicide, and argue that the short-term benefit does not justify the potential risks. Therefore, the place of ECT in psychiatry remains controversial, although some psychiatrists believe it has a role in the treatment of mental disorder when other methods have failed and rapid, short-term improvement is needed so the patient can be more responsive to other forms of therapy (Singhal 2011). Psychosurgery A treatment even more controversial than ECT is psychosurgery, which is seldom employed and is generally considered a last resort for seemingly desper- ate cases. Psychosurgery first achieved prominence in 1936 in Portugal and was used in the United States to treat some 50,000 mental patients during th\ e 1940s and early 1950s. The decline in its use is generally recognized as resulting from the widespread use of psychoactive drugs beginning in the mid-1950s, the per- sistent social stigma attached to recipients of the operation, and adverse public opinion about the procedure. Psychosurgery is usually surgical mutilation of the frontal lobe (prefrontal lobotomy) of the brain, where higher intellec\ tual func- tioning (memory, abstract reasoning, and speech) takes place. The results of the surgery are permanent, and critics have argued that although such surgery has had a “calming” effect on patients and has enabled some of them to be discharged from mental hospitals, they can be left as “semi-vegetables” (Valenstein 2010).

More improved surgical approaches, however, have allegedly been found not to result in any cognitive loss, and the procedure remains a rare alternative therapy for totally incapacitated patients who fail to respond to any of the other cur- rently available forms of treatment. Today, the method is applied most often to patients with an obsessive-compulsive disorder.

Generally, psychosurgery is advocated for only those patients who are chronically violent toward themselves or others, but there is strong controversy over whether physicians have the legal right to perform the operation on a person who may not be able to understand the consequences. There is also seri- ous concern that psychosurgery may be used for the social control of relatively helpless people. Some states, such as California and Oregon, have strict regula- tions pertaining to psychosurgery. Although some psychiatrists maintain that psychosurgery can be beneficial to certain patients, most avoid the practice. Assessment of the Medical Model The purely medical approach to mental disorders has unquestionably resul\ ted in positive gains for many patients, especially those on drug therapy, who are now able to lead relatively normal lives outside a mental hospital. Moreover, research in the areas of brain chemistry and behavioral genetics has produced significant findings enhancing our understanding of the causes and treatment of Cockerham, William C.. Sociology of Mental Disorder, Taylor & Francis Group, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/umanitoba/detail.action?docID=4710761.

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89 Chapter 4 • Concepts of Causes and Cures mental disorders. As previously noted, the medical model is the dominant approach to treatment. It operates to return abnormal behavior—primarily through drugs—to as normal a state as possible and stabilize the beha\ vior at that point. It does not usually eliminate the cause; it attempts to reli\ eve the symptoms so people can better cope with their life situations. What matters most is altering the brain chemistry of the individual.

Despite the efficacy of many psychotropic drugs, the medical model has several shortcomings. First, the model approaches mental disorders as if th\ ey were illnesses, even though most psychiatric conditions cannot be shown to result from a disease. Thus the defining condition is whether the disorder can be treated medically, not whether it has a medical cause. The result, states Allan Horwitz (2002a: 3–4), is that this view locates “the pathological qualities of psychological conditions in the physical properties of brains, not in\ the symbolic systems of minds.” Yet it is through the distortion of these mental symbolic systems that insanity is expressed. Consequently, treating the symp- toms may not necessarily help us to understand the cause—especially i\ f the brain’s biochemical changes are a physiological response to an external cause, not a cause in itself. As the French physician René DuBois (1959) noted many years ago, “While drenching fire with water may help in putting out a blaze, few are the cases in which fire has its origin in a lack of water.” Second, the medical model focuses almost exclusively on controlling symptoms rather than on cures. Unfortunately, the emphasis on control may retard the emphasis on cure, since the model’s major approach is to use drugs as quick remedies for interpersonal problems. This approach also neglects the social situations that may promote the onset and course of the disorder \ in the first place. Third, the medical model has not been able to explain the cause of mental disorder, even though it has formulated treatments for it. The focus on the con- trol of, or relief from, symptoms of mental disorder still leaves unanswered the question of what actually causes insanity. In sum, the medical model needs to develop a more comprehensive approach so it can deal with the wider spectrum of mental disorders represented by factors external to the individual and to do so in such a way that promotes cure as well as relief. However, it should be noted that while the medical model tends to neglect the role of social factors in the study of mental disorder, it does not reject the relevance of such factors altogether. Behavioral genetics, for example, provides a biopsychosocial concept of mental disorder that depicts social variables as the “trigger” setting off genetic predispositions to abnormal behavior. Moreover, the extent to which a person is able to function normally in society while be\ ing treated medically often requires insight on the part of the medical prac\ titioner into the patient’s social environment and relationships if treatment is to be effective. Medical work, in turn, is useful to the sociologists whose task to uncover the social conditions linked to the onset, course, and treatment of men- tal disorders is made easier when biological factors are better defined and mea- sured (Bruce and Rane 2013). So the optimal situation for sociologists\ with Cockerham, William C.. Sociology of Mental Disorder, Taylor & Francis Group, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/umanitoba/detail.action?docID=4710761.

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90 Chapter 4 • Concepts of Causes and Cures respect to the medical model is to contribute their research findings in areas where it makes sense to do so and draw on the model to refine sociological concepts when appropriate. THE PSYCHOANALYTIC MODEL The psychoanalytic model of mental disorder is analogous to the medical \ model in that it also focuses attention on internal factors that affect the mental health of the human being. But there is a notable difference between these two models in that the psychoanalytic approach views abnormal behavior in psychological terms. In its concern with psychic rather than physiologic\ al and biochemical conditions, the psychoanalytic model views human beings as driven by powerful instinctual forces. Not only is the individual unable to con- trol these forces, but he or she is even unaware of their existence.

The psychoanalytic model is based upon the work of Sigmund Freud, who spent most of his life in Vienna, and others whom he influenced, such as Erik Erikson, Carl Jung, and Alfred Adler—to name only a few of the important figures of psychoanalysis. The scope of this chapter does not permit an exten- sive discussion of the wide range of Freud’s many theories, which psychoana- lysts regard as the most comprehensive and profound explanation of human behavior and which many behavioral scientists view as interesting but theoreti- cally incorrect. Moreover, in psychiatry, Freud’s psychoanalytic approach has moved from being the dominant perspective in the mid to late twentieth century, to an increasingly minor role as it succumbs to medicalization and the p\ ervasive use of psychotropic drugs. Yet psychoanalysis survives because some patients prefer its method of verbally exploring the unconscious mind over those of mainstream psychiatry and its reliance on drugs (Smith 2014).

Freud’s Concept of the Personality Briefly stated, Freud viewed the human organism as a complicated energy system, with all the energy needed to perform the work of the personality being obtained from instincts, which Freud defined as mental stimuli arising from within the organism itself. However, instincts are seen as a special type of stim- ulus because they do not have a single or momentary impact but are a constant force within the personality. The id , one of the three major components in Freud’s structure of the personality, functions as the discharger of any energy or tension brought about by internal or external stimulation. It is guided by the primary process, which produces a memory image of the object needed to reduce tension. The id uses its energy for instinctual gratification in fulfilling the pleasure principle (avoiding pain and finding pleasure) through the means of reflex action—eating, having sex, realizing wishes. The failure of the id to obtain satisfaction gives rise to the ego , the second major part of the personality, which represents the energizing of new processes of memory, judgment, perception, and reason that are intended to bring harmony Cockerham, William C.. Sociology of Mental Disorder, Taylor & Francis Group, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/umanitoba/detail.action?docID=4710761.

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91 Chapter 4 • Concepts of Causes and Cures to a person’s psychological system by synchronizing the subjective inner world with the objective outer world of social reality. Freud initially viewed the ego as somewhat weaker than the id, describing it as “a man on horseback,” who has to hold in check the superior strength of the horse (meaning the po\ wer of the id). But he subsequently saw the ego as having great power of its own. The ego is governed by the reality principle, whose function is to postpone the releas\ e of energy until the actual object has been located that will satisfy the need; the ego tolerates or opposes tension until it can be discharged by an appropriate form of behavior. Thus, to the primary process of memory is added the second- ary process of finding the correct solution (reality) through thought and reason.

Sometimes the solution is not found until various realities have been tested and discovered to provide suitable fulfillment. Hence, the ego is primarily a product of interaction with the external environment. The third major aspect of the personality, the superego , can be described as the moral or judicial branch of the personality. Freud hypothesized that the superego evolves from the ego as the child assimilates the moral authority of his or her parents’ own overt behavior or motives and the parents’ aspirations for the child. The internalization of parental values in the child is accomplished through fear of punishment and desire for parental approval, which cause the child to control his or her own behavior in accordance with the wishes of the parents. The superego represents what is ideal rather than what is real, and its aim is to strive for perfection instead of reality (the function of the ego) or pleasure (the function of the id). Through its two subsystems, the ego-ideal and the conscience, the superego has the power to both reward and punish the organism psychologically through feelings of pride (ego-ideal) or guilt and inferiority (conscience). PHOTO 4.3 Sigmund Freud Cockerham, William C.. Sociology of Mental Disorder, Taylor & Francis Group, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/umanitoba/detail.action?docID=4710761.

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92 Chapter 4 • Concepts of Causes and Cures Seen in its basic form, Freud’s concept of the personality is a system of psychic energy consisting of the id striving for pleasure in order to satisfy fun- damental instincts and the superego striving for perfection while leaving the ego to balance the two drives with a sense of reality. Obviously, the personality would be maladjusted should the ego fail and either the id or the superego become dominant. Thus, for Freud, the ego was the focal point of concern. Stages of Psychosexual Development A basic premise of psychoanalytic theory, depicted by Freud (1964:187) in his book Moses and Monotheism , is that “the child is psychologically father to the adult.” What Freud meant by this is that the events of infancy and childhood persist in the personality of a person throughout all subsequent life. The impair- ment of the behavior of adults is therefore systematically related to early child- hood experiences, particularly the fate of sexually oriented urges for bodily pleasure allowed under the method of training selected by the parents. There are five stages in the Freudian concept of psychosexual development: (1) oral, (2) anal, (3) phallic, (4) latency, and (5) genital. The oral stage consists of the oral-erotic and oral-sadistic periods. The oral- erotic period lasts from birth until about the age of eight months and i\ s charac- terized as a time when the mouth, lips, tongue, skin, and sensory organs are the focus of libidinal (sexual) energy. The primary mode of obtaining pleasure is passive incorporation (receiving) and is expressed by sucking and swallowing.

The greatest normal frustration during this period is the lack of contin\ uous and exclusive availability of the mother to satisfy the infant’s demands for oral gratification. The oral-erotic period is followed by the oral-sadistic period, occurring between six and eighteen months of age, in which the center of\ sex- ual energy is found in the jaws, teeth, skin, and related sensory organs. The mode of obtaining pleasure is active incorporation (seizing) and is expressed by biting and chewing. The main normal frustration at this time for the child is the appearance of a new baby in the family who competes for the mother’s attention. As a whole, the oral stage is a time when the infant is confronted with a developmental crisis of trust versus mistrust. During this period, the infant establishes the dispositions toward being more or less trusting or mistrusting of the external world and his or her own capacity to cope with urges (self- trust) and to elicit the appropriate response from others (trust in ot\ hers).

Ego development is reflected in the gradual emergence of the infant’s ability to distinguish between internal and external reality. The infant becomes aware that he or she must develop the capacity to signal needs to the outside world, and by being frustrated the infant learns to try to find the correct solution to meeting his or her own needs. Psychoanalytic theorists claim that excessive or insufficient oral gratification can result in libidinal fixations that cause patho- logical traits in adulthood, such as excessive narcissism, optimism, pessimism, demandingness, or dependency.

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93 Chapter 4 • Concepts of Causes and Cures The anal stage consists of the anal-sadistic and anal-erotic periods.

During the anal-sadistic period, which occurs between eight and twenty-f\ our months of age, the anus and buttocks are the center of libidinal energy. Here the primary mode of obtaining pleasure is eliminative (the discharge of feces), in which elimination is thought to allow for the expression of aggressive wishes.

The anal-erotic period comes next and takes place between the ages of one and three years. The anus and buttocks remain eroticized, but the primary mode of pleasure is retention, in which the emphasis is upon retaining bodily wastes and offering them as a gift to the parents (and such “gifts” are usuall\ y welcomed with approval by the parents if it signifies that the child is becoming toilet trained). The normal frustration during both the anal-sadistic and anal-erotic periods pertains to the conflict with the parents over toilet training and the demand for self-control. The anal stage presents the child with the developmental crisis of auton- omy versus shame and doubt in which the child learns to develop self-control without a loss in self-pride (ego-ideal). Obsessive-compulsive anxieties are most usually described as typical of the anal stage. This applies to people who show excessive orderliness, stubbornness, frugality, possessiveness, and a “tendency to collect things.” For persons whose defense mechanisms are less effective, the traits of excessive ambivalence, hostility, messiness, lewdness, and sadomasochistic tendencies are also thought to be representative of devel- opmental difficulties during the anal stage. The phallic stage of psychosexual development usually begins during the third year of life and continues to about the age of six. The sex organs now become the source of libidinal energy, and the object of that energy becomes the opposite-sexed parent in what Freud called the Oedipus complex. The Oedipus complex is the unconscious tendency of the child to be attracted to the opposite-sexed parent and to develop feelings of hostility toward the same- sexed parent. In this unconscious conflict, the penis is the sex organ of interest to children of both sexes. In normal circumstances, the boy renounces his desire for his mother because of the threat of castration by the father, who is his rival for the mother’s affection. Freud believed that the narcissistic fear of injury to the penis on the part of boys was stronger than the erotic attachment to the mother. In relinquishing his erotic attachment to his mother, the boy begins to identify with his father and a masculine self-image. For girls it is different, according to Freud, in that they, having already been castrated symbolically by virtue of not having a penis, turn their affec- tions from their mother (who is held responsible for bringing the child\ into the world without adequate sexual equipment—the penis) toward their father, who has a penis. The unconscious hatred of the daughter for the mother is supposed to become even more pronounced when the daughter realizes that the mother, too, lacks the all-important penis. The Oedipus complex in the girl is supposed to be resolved when the daughter is gradually disappointed and frustrated by the father’s failure to give her a penis or a child in place of the penis. Also, by lov- ing the father, the daughter may develop an identification with the mother Cockerham, William C.. Sociology of Mental Disorder, Taylor & Francis Group, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/umanitoba/detail.action?docID=4710761.

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94 Chapter 4 • Concepts of Causes and Cures whom the father loves and for whom he does provide children. Typically, the girl will eventually renounce her erotic interest in her father and turn to a non- incestuous, opposite-sexed love object.

The successful resolution of the Oedipal crisis leads to the formation o\ f the superego as the child internalizes the values governing his or her own sex’s adult roles and sex roles. Failure to accomplish this task, according to Freud, leads to a wide variety of anxiety problems in adulthood. The latency stage is a stage of relative inactivity for the sexual drives and lasts from the ages of five or six until about twelve or thirteen. During this stage, notions of sex roles and sex-role identity are further consolidated as the ego continues to mature and exercise greater control over instinctual desires.

The interest of the child becomes directed more toward peers and peer-related activities that occur outside the family. The latency period has been generally regarded as a period that does not give rise to any special forms of emotional problems that, if present, were derived from earlier stages of development. But it has been realized that latency is a very important stage, in that the child learns to obtain a sense of accomplishment and mastery over objects, thus developing a sense of social competency. Finally, there is the genital stage , or adolescent phase, of psychosexual development, which extends from the ages of approximately eleven to thirteen until the adolescent reaches young adulthood at around eighteen to twent\ y. The physiological maturation of the adolescent’s sex organs and his or her corre- sponding hormonal systems produces an intensification of drives, especially sexual, and reopens conflicts from previous stages of psychosexual develop- ment. Thus, the genital stage provides the adolescent with the opportunity to resolve past conflicts as part of achieving a mature adult identity and sexuality.

The primary objectives of this stage are independence from parents and the establishment of a mature, nonincestuous, heterosexual relationship. Failure to achieve this objective thereby introduces a potential multitude of problems because the developmental task of adolescence during the genital stage is a reworking and resolution of past problems. Mechanisms of Ego Defense Freud’s concept of ego defense is based upon the premise that, throughout each stage of psychosexual development, the ego builds up appropriate defense mechanisms to defend against the conflicts, anxieties, and frustrations \ that dis- turb the individual’s normal psychological functioning. The ego is responsible for this defense because, as the personality’s center of narcissism or self-love, it attempts to escape from any situation that threatens its sense of well-being and integrity. Threats to the ego that summon the ego’s defenses come from three sources: (1) the id as it tries to overwhelm the ego with pressure for instinctual gratification, (2) the superego as it attempts to punish the ego through feelings of guilt, and (3) the external danger that is perceived as being directed toward the ego.

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95 Chapter 4 • Concepts of Causes and Cures All ego defense mechanisms operate at an unconscious level and are acti- vated on a more or less automatic basis; therefore, the individual is not even aware of their existence. Some of the most common ego defense mechanisms described by psychoanalysts are as follows: (1) sublimation (a normal defense in which an instinct is turned into a new and more socially acceptable channel of expression, such as aggression being channeled into sports or the strong \ desire for sex being converted into energy for professional achievement); (2) repression (a forgetting of events or internal impulses that would be painful if they became conscious); (3) projection (the denial of objectionable ideas by the individual and the projection of them outward toward other persons or objects in the external environment); (4) introjection (the opposite of projec- tion, a person incorporates into himself or herself the characteristics \ of another person or object); (5) reaction formation (a rigid attitude or character trait that manages objectionable impulses by permitting expression of the impulse in an opposite form, as when someone acts anxious to please but whose attitude is artificial and hides an underlying hostility); (6) denial (a denial of external reality, such as harming someone else and instead seeing only good in the action); (7) isolation (a situation in which a memory and the emotional effect of the memory are separated); (8) regression (a person who returns to an earlier stage of psychosexual development to seek the security of that stage and avoid the anxieties of later stages); (9) rationalization (substitution by the ego of an acceptable reason for an unacceptable one in attempting to justify a par\ ticular idea or action); and (10) displacement (the effect of one object is transferred to another object in the interest of solving a conflict, such as when a per\ son is verbally abused by his or her employer and upon return home verbally attacks a spouse, so the anger toward one object is displaced to another, safer object). Psychoanalysis, Psychoanalytic Therapy, and Group Therapy Freud’s ideas, through his introduction of psychoanalysis, had a profound effect upon the practice of psychiatry. Psychoanalytic theory holds that emo- tional problems are likely to be revealed in one of four ways. The person (1) develops a personality disorder (displaces conflicts toward the external world); (2) becomes neurotic or anxious (develops excessive ego defenses); (3) develops a psychophysiologic disorder (tension is experienced within the body and eventually produces an organic pathology); or (4) becomes psychotic (the ego disintegrates with a loss of the ability to cope with reality). The forms of treatment used for the individual to eliminate or reduce the effects of these unconscious pressures on the personality are psychoanalysis and psychoan\ alytic therapy. PSYCHOANALYSIS. Psychoanalysis is a one-to-one relationship between the therapist and the patient that utilizes free association as its primary \ technique.

In free association, the patient is encouraged to say whatever comes to mind, while the analyst ensures that the sequence of the undirected thought re\ mains Cockerham, William C.. Sociology of Mental Disorder, Taylor & Francis Group, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/umanitoba/detail.action?docID=4710761.

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96 Chapter 4 • Concepts of Causes and Cures unchanged and that the patient does not withhold any information, no matter how trivial or distressing. Psychoanalysis is a lengthy process and can take years to complete, but its proponents believe that sooner or later the patient will direct the underlying disorder toward the therapist in a process known as trans- ference. Once that happens and the unconscious tendencies are revealed, the patient can be made aware of the source of the problem and counseled on ways to deal effectively with it.

Psychoanalysis is used most often with patients who suffer from chronic anxiety but who have some ego strength. Besides being time-consuming, psy- choanalysis is expensive and does not lend itself to the simultaneous treatment of large numbers of patients. Total therapy time can be as long as 1,000 hours spent in hour-long sessions, one to five times each week for five to seven years or even more. Just how effective psychoanalysis is in treating patients is a subject of controversy. There is evidence that long-term psychoanalytic therapy—defined as at least 50 sessions over a one-year period—is moderately or highly effective for a wide range of psychological problems (Maat et al.

2009). Patients with anxiety rooted in childhood experiences may especially benefit from the treatment. Yet whether psychoanalysis is more successful than other psychotherapeutic methods is not known, but it is clear it is not useful with patients who are schizophrenic; have subnormal intelligence; or reject intimate, personal, therapeutic relationships. PSYCHOANALYTIC THERAPY. Psychoanalytic therapy is a modified form of psychoanalysis. The major difference is that psychoanalytic therapies focus on current conflicts instead of attempting to work through the entire history of a person’s psychosexual development; however, before treatment, an extensive psychiatric diagnosis is obtained that is based upon the patient’s history. This therapy also requires a moderately superficial transference reaction and relies more upon interviewing and discussion than upon free association. GROUP THERAPY. Another type of treatment influenced by the psychoana- lytic model is group therapy, which treats several patients at one time. Group therapy is popular in the United States and consists of having selected partici- pants meet with a trained therapist so that the participants may help on\ e another confront problems and achieve personality change. Group therapy emphasizes the values of individualism within the context of a collective approach to prob- lems, while at the same time allowing for the expression of deviant behavior. In traditional psychoanalytic group therapy, identification with the group is stressed, and the process of transference is subsequently utilized in a \ group context to elicit awareness of unconscious personality conflicts. Assessment of the Psychoanalytic Model One of the most striking criticisms of the psychoanalytic model is that \ it is based largely upon speculation. Supporters of the psychoanalytic model are Cockerham, William C.. Sociology of Mental Disorder, Taylor & Francis Group, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/umanitoba/detail.action?docID=4710761.

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97 Chapter 4 • Concepts of Causes and Cures required to accept as dogma the unproven assumptions of Freudian thought in much the same way that persons living in the Middle Ages accepted on faith the idea that mental disorder was caused by the Devil. There is no actual evidence that the human personality has a tripartite structure consisting of an i\ d, an ego, and a superego. A second major criticism of the psychoanalytic model is that it portrays human beings as being propelled by instincts, without taking in\ to account the person’s own free will. Some behavioral scientists argue, for instance, that the mind is not a structure but a process. This concept arises from the unique human ability to engage in reflexive thinking, an ability that makes possible the control and organization of conduct by the individual in relation to the environment. Third, most research does not support the view that “the child is psychologically father to the adult.” No conclusive evidence links personal- ity problems of adults with specific experiences of pleasure or frustration during a particular developmental stage of childhood. Fourth, the psychoana- lytic approach has been accused of underemphasizing the importance of co\ gni- tive development and overemphasizing emotional development. Yet learning and experience can influence emotions. Education, for example, has been shown to affect the perceived appropriateness of anger and its display (Schieman 2000).

And the fifth major criticism of psychoanalytic theory is that it is vague, is difficult to test empirically, and does not lend itself to predictive assessments.

For example, it offers little guidance to parents about what they can do in advance to protect their children from experiencing an inadequate psychosex- ual development.

Why, then, has the psychoanalytic perspective been influential? Two major reasons account for its success. First, no other theoretical approach ha\ s provided so many insights into the development and functioning of the human personality. 1 Even though the central propositions of psychoanalytic theory are not empi\ ri- cally verifiable, neither are many of the theories of the classic masters of socio- logical thought—Émile Durkheim, George Herbert Mead, Georg Simmel, and Max Weber, among others—or, ultimately, other branches of human behavior.

Freud is interesting to some sociologists because he provides a detailed analysis of a rich set of disordered variations in thinking that are significant consequences of social relationships (Smelser 1998). Furthermore, psychoanalytic th\ eory covers some of the subtle features of human behavior that have been overlooked elsewhere in psychology and addresses the presence of unconscious influences\ upon the individual that is lacking in other theoretical analyses. Second, psychoanalytic theory is important because it offers a model that is inseparable from physiological concepts and is therefore an ideal psy\ chology for the physician. It provides the physician with an objective structure of the personality and a prescribed mode of treatment, as well as a classification system by which physicians can communicate about, attempt to treat, and \ compre- hend mental disorders. In the absence of other models that can be shown to be 1 For a comprehensive discussion of Freud’s work, see Freud (1953–1966), Karasu (1995), and Wong (1989).

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98 Chapter 4 • Concepts of Causes and Cures more effective when applied to the care and treatment of patients , the quasi- medical psychoanalytic model and the medical model dominate the practice\ of psychiatry. However, as psychiatry moves further into the twenty-first century, psychoanalysis, as previously noted, is losing considerable ground as a major therapeutic approach because of the success of psychopharmacology and th\ e potential of behavioral genetics. Freud’s theories are also beginning to hold less interest for scholars in various other fields, including sociology. In future years, Freudian theory may become an historical footnote, but for the near- present its influence persists in a weakened state. BEHAVIOR MODIFICATION Another alternative to the medical and psychoanalytic models of mental disor- der is behavior modification or the social learning model, based chiefly upon theories of learning and techniques of behavioral conditioning derived from the classical conditioning experiments of Ivan Pavlov (1849–1936) and Edward Thorndike (1874–1949). The underlying premise of this model is that behavior is learned, but it can also be unlearned and replaced with behavior that is more socially appropriate. The therapeutic technique of the social learning model, known as behavior modification, emphasizes that treatment should be centered upon behavior that is externally observable and measurable. Preferred tech- niques include symptom desensitization (learning to approach feared sit\ uations or objects without anxiety), positive reinforcement (reward), aversive condi- tioning (punishment), extinction (eliminating a stimulus), conditioned avoid- ance (electric shocks or drugs paired with situational stimuli), and c\ ontingency contracting (agreeing with others to engage in certain behavior in return for a similar response).

However, behavior modification is subject to four important limitations.

First, there are serious questions as to whether human beings can actual\ ly be “conditioned” to the extent that they respond more or less automatically to the play of stimuli upon their cerebral functions. Second, even if such conditioning is possible, there are questions concerning the duration of the effects and their strength in real-world, nonclinical settings. Third, behavior modification may not be the best form of therapy for many types of mental disorders in which the com- plexity of the disorder may require much more than just learning new behaviors.

And fourth, behavior modification requires that patients be willing and able to learn, have a certain amount of willpower, and recognize and cope with reality at least somewhat consistently—which many mental patients may not be able to do. Still, it can be argued that behavior modification does have certain strengths. It is based upon experimental psychology, which lends itself to research, and some studies suggest it can be effective, especially for short-term results and simple symptom configurations such as bed-wetting (Peterson 2010). This therapy may also be more appropriate for the treatment of lower- income and less well-educated persons, both because it is less expensive than psychoanalysis and because it does not demand a high degree of self-analysis Cockerham, William C.. Sociology of Mental Disorder, Taylor & Francis Group, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/umanitoba/detail.action?docID=4710761.

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99 Chapter 4 • Concepts of Causes and Cures and introspection. Just how effective behavior modification actually is has yet to be fully determined and whether it has long-term effects is questionable.

There are claims suggesting the effects are short term, which is a problem for the theory behind it, since learning is supposed to be lasting, and that\ only superficial behavior is affected that can easily change (Peterson 2010). THE SOCIAL STRESS MODEL A particularly active line of research, incorporating aspects of both medical and sociological concepts, is found in current investigations of the relationship between mental disorder and social stress. Usually, stress is thought to occur when individuals are faced with a situation for which their usual modes of behavior are inadequate, and the consequences of not adapting to the situati\ on are perceived as serious. Thus, we have a circumstance in which there is a gap between environmental demands and a person’s capability to respond— possibly leading to a mental breakdown. The medical factors in this condition pertain to the possible predisposition of some individuals toward mental dis- order when psychologically stressed because of genetic inheritance or so\ me triggering of biochemical abnormalities. The social factors relevant to this condition rest on the fact that the majority of studies on stress indicate that most stress is socially induced as a result of social interaction betwee\ n people and/or social structural conditions that have an adverse impact on a person’s sense of well-being, such as divorce, unpleasant social situations, demanding work, heavy debt, or loss of job due to an economic recession (Drentea and Reynolds 2015; McLeod 2012; Pearlin and Bierman 2013; Schieman, Whitestone, and van Gundy 2006; Turner 2013; Wheaton and Montazer 2010; Wheaton et al. 2013).

Stress can be defined as a heightened mind–body reaction to stimuli inducing fear or anxiety in the individual. It can result in a psychophysiological reaction that causes changes in bodily tissues and promotes the onset of\ physi- cal disorders such as heart disease, hypertension, peptic ulcer, muscular pain, and migraine headaches. The stress model in mental health research, in turn, is oriented more toward mental dysfunction than physical dysfunction, as would be expected—although both types of disorders may be present in a stressed\ individual. Leonard Pearlin’s (1989) paper in the Journal of Health and Behavior , the most cited article ever on stress in sociology, maintained that the stress process consists of three components: (1) stressors , which he defines as any condition having the potential to arouse the adaptive capacity of the individual; (2) moderators , which consist of coping abilities, sense of mastery, and sources of social support; and (3) outcomes , the extent of distress experienced by the person. Pearlin’s (1989; Aneshensel and Avison 2015) work resulted in the stress process model in sociology, which holds that not all people react to stress the same way because of differences in how they cope. People at the bottom of society are most disadvantaged because they are exposed to greater amounts Cockerham, William C.. Sociology of Mental Disorder, Taylor & Francis Group, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/umanitoba/detail.action?docID=4710761.

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100 Chapter 4 • Concepts of Causes and Cures of stress and are more vulnerable to it since they have the most limited social and psychological coping resources.

The most studied outcome is emotional distress, which can range from very mild to serious, even traumatic, but other outcomes can involve substance abuse and dependence as individuals self-medicate themselves with drugs or alcohol to reduce tension. Yet to claim that stress is a likely cause of mental disorders is not a particularly useful statement unless it can be shown what social events are most apt to be stressful and who is most likely to be affected by them. Some people cope with stress by drinking alcohol, and others ma\ y respond by becoming violent, but they are intoxicated or angry rather than mentally disordered. There is considerable evidence, for example, that many people can adjust to stressful situations and not suffer extensively, but other people simply fall apart and become susceptible to mental or physiological change (Thoits 2013; Wheaton and Montazer 2010). Whether a stressful situation actually induces such change depends upon \ an individual’s perception of the stress stimulus and the personal meaning that the stimulus holds for him or her (McLeod 2012; Thoits 2013). A person’s reaction, for instance, may or may not correspond to the actual reality \ of the dangers that the stimulus represents; that is, a person may react approp\ riately, overreact, or even underreact. An individual’s subjective interpretation of a social situation is the trigger that produces physiological and mental r\ esponses.

Therefore, a considerable amount of attention in stress research focuses\ on the relative importance of life events and differences in the vulnerabilities of the people exposed to these events. First, let us consider what we know about reac- tions to extreme situations, such as natural disasters and wars, and second, let us review the research on the more common stressful life events of ordinary day-to-day living.

Extreme Situations Extreme situations such as natural disasters would appear to be a likely starting point for research on stress and mental disorder because of the great an\ xiety people usually attach to being caught in such circumstances. But a commo\ n misconception about disasters is the notion of people fleeing in panic f\ rom the site of a potential disaster area. In reality, it is often difficult to get people to evacuate their homes, even when damage or destruction is imminent. This was seen during Hurricane Katrina, which hit New Orleans in 2005, Hurricane Ike, which struck Galveston, Texas in 2008, and Hurricane Sandy, which came ashore in New York and New Jersey in 2012. Moreover, some people are attracted to potential disasters. For example, in Hawaii, tidal wave alerts bring a few people to beach areas to watch the big wave come in, rather than cause them to move to high ground. It is usually necessary for the police to clear the be\ aches of spectators. In the Midwest, some people may take risks to see a tornado.

Trying to view a disaster and being a victim of one, however, are two entirely different matters. Past studies show that extreme situations such as earthquakes, Cockerham, William C.. Sociology of Mental Disorder, Taylor & Francis Group, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/umanitoba/detail.action?docID=4710761.

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101 Chapter 4 • Concepts of Causes and Cures hurricanes, and tornados obviously induce stress (Dohrenwend 2000; Lowe et al. 2015). Mass media reports commonly show or describe people in large- scale disasters experiencing intense feelings of grief, loss, anguish, and despair.

Thus, there is sound reason for understanding the social and psychologi-\ cal consequences of disasters, especially from the standpoint of developing and implementing programs to assist disaster victims. Yet most studies suggest that the majority of people who experience disasters show resilience and do not go insane or develop incapacitating psychological reactions in catastrophes (Lowe et al. 2015). For example, research in the aftermath of Hurricane Ike in Galves- ton in 2008 found high levels of mental health wellness over time in relation to posttraumatic stress and depression (Lowe et al. 2015). This situation was enhanced by both formal and informal helping networks organized to give support to the victims. This is not to say that disaster victims generally escape all psychological trauma—quite the contrary. There is almost unanimous agreement that disasters do promote acute psychological stress, emotiona\ l dif- ficulties, and anxiety related to coping with grief, property damage, financial loss, and adverse living conditions. Groups of people with special needs in the aftermath of disasters are usually identified as the children and elderly. Older people, in particular, find it difficult to adjust to life after a disaster. Low- income groups also present special problems because they are often left with- out any material resources and become especially dependent on aid. A pattern that emerges in studies of natural disasters and psychopathol- ogy is that the disaster experience, although severe, is usually short in duration, and the effects on mental health likewise tend to be short term and usually self-limiting. The question thus arises about the possible effects of stress in extreme situations lasting long periods of time. Such situations are repr\ esented by the experiences of people exposed to the brutalities of Nazi concentration camps and the horrors of war. There is evidence that many concentration camp survivors suffered persistent emotional problems and were particularly prone to physical illness and early death (Eitinger 1964, 1973). However, as Aaron Antonovsky (1979) notes, other concentration camp survivors adjusted to the effects of having been subjected to a most terrible experience, and went on to live lives that were essentially normal. In other research on concentration camp survivors living in Montreal, Morton Weinfeld, John Sigal, and William Eaton (1981) found only modest or no significant differences between the respondents in mental stress. Weinfeld and his coworkers (1981:14) explained that their findings do not deny the reality of severe mental and physiological consequences or diminish the horror suffered by the survivors but, rather, “focus attention on the magnificent ability of human beings to rebuild shattered lives, careers, and families, even as they wrestle with the bitterest of memories.” When considering what differentiates people who are generally vulnera- ble to stress-related health problems, not just concentration camp survi\ vors, from those who are not so vulnerable, Antonovsky argues that a strong sense of coherence is the key factor. Coherence, in his view, is a personal orientation Cockerham, William C.. Sociology of Mental Disorder, Taylor & Francis Group, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/umanitoba/detail.action?docID=4710761.

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102 Chapter 4 • Concepts of Causes and Cures that allows a person to view the world with feelings of confidence, faith in the predictability of events, and a notion that things will most likely work out reasonably well. One achieves this sense of coherence as a result of life experi- ences in which one meets challenges, participates in shaping outcomes (\ usually satisfactorily), and copes with varying degrees of stimuli. Hence, the person has the resources to cope with unexpected situations. On the other hand, persons whose lives are so routine and completely predictable that their sense of coherence as defined previously is weakened will find it difficult to handle unpleasant surprises and events; these people are more likely to be susceptible to stress-induced health dysfunctions as they are overwhelmed by events.

In other words, what Antonovsky is saying is that people who have the capabil- ity to come to terms with their situation rather than to be overcome by it are those who are most likely to emerge from an extreme situation in a healthy condition. 2 A similar conclusion can be reached about soldiers in combat. The envi- ronmental stresses faced in combat are among the hardest faced by anyone in modern society. They include the overt threat of death; loss of limbs; sights and sounds of the dead and dying; battle noise; fatigue; loss of sleep; deprivation of family relationships; exposure to rain, mud, insects, heat, or cold; and so forth—all occasioned by deliberate exposure to the most extreme forms of vio- lence intentionally directed at the soldier by the opposing side. Many years ago, military sociologist Charles Moskos (1970) compared combat with the Hobbesian analogy of primitive life: Both can be nasty, brutish, and short.

According to the British military historian John Keegan (1976:297), “What battles have in common is human: the behaviour of men struggling to reconcile their instinct for self-preservation, their sense of honour and the achievement of some aim over which other men are ready to kill them.” Yet somehow men generally seem to come to terms with the circum- stances because most combat soldiers do not become psychiatric casualtie\ s.

Two factors may be largely responsible. First is the existence of group or combat team demands for discipline and efficiency under fire (Hancock and Szalma 2008). For example, one of the most efficient techniques that allows soldiers to generally adjust to battle is to interpret combat not as a c\ ontinued threat of personal injury or death but as a sequence of demands to be responded to by precise military performances (Kellett 1982). Second is the psychological mobilization of an internal discipline in which the individual soldier employs a sense of personal invulnerability, the use of action to reduce tension, and a lack of personal introspection to perceive the environment in such a way that personal threat is reduced (Bourne 1970). When soldiers do break down emotionally in combat, data from World War II cite the loss of comrades as a particularly important factor. For instance, in a study of over 2,500 American soldiers who had broken down during combat 2 In regard to concentration camp survivors, however, Antonovsky believes their survival in the camps was due mostly to chance.

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103 Chapter 4 • Concepts of Causes and Cures in the Normandy invasion, the expression of emotional stress and combat exhaustion in even previously normal soldiers seemed to occur when about 65 percent of their companions had been killed or wounded (Swank 1949).

Primary group relations embodied in the squad or platoon were apparently\ very important sources of social support during World War II. The importance of the primary group in combat was that it established and emphasized group standards of behavior and provided social support to the individual in difficult situations.

The subjective reward of following group norms also enhanced the individual soldier’s resources in dealing with combat. What motivated him to fight, accord- ing to an extensive study by Samuel Stouffer and his colleagues (1949), was the need to show other members of his group that he supported them so that he in turn would deserve their support in confrontations with the enemy.

In Vietnam, however, the United States had the lowest incidence up until that time of combat psychiatric casualties (Jones and Johnson 1975). The dif- ference in Vietnam appeared to be the rotation policy, the availability of short rest-and-relaxation trips, the absence of large artillery barrages, the periodic safety of base camps, the general effectiveness of precombat training, rapid helicopter evacuation of the wounded, and psychiatric treatment (including the greater availability of psychotropic drugs). Most psychiatric casualties were treated in an atmosphere that emphasized a rapid return to duty. Psychiatric casualties were also limited in relatively short-duration American conflicts in the Gulf War and peacekeeping in Somalia and the Balkans. However, the inva- sion of Afghanistan and Iraq in 2001 and subsequent long-term occupation, sometimes resulting in multiple tours of duty for American troops, produced a significant number of mental health problems among veterans of those con- flicts. Some 37 percent of Iraq and Afghanistan veterans treated in Veterans Administration hospitals received mental health diagnoses of either posttrau- matic stress or depression between 2002 and 2008 (Seal et al. 2009). Extreme situations differ from negative ordinary events in people’s lives because they are often both uncontrollable and life threatening. According to Bruce Dohrenwend (2000), the greater the uncontrollable negative changes and the more central those changes are in affecting the goals of the individual (i.e., staying alive), the greater the likelihood that posttraumatic stress disorder, major depression, alcoholism, substance-use disorder, or other psychological problems will develop. The type of adversity and predispositions of the indi- vidual (i.e., family history of psychopathology) are also important. Some people do indeed suffer psychological distress after life-threatening experiences.

Yet whatever emotional difficulties are generated, especially in relation to short-term natural disasters, tend to be temporary and disappear after a\ while.

The same can be said about armed combat, although the effects—when present—can be longer lasting. Some people are not emotionally affected at all, even when the circumstances are highly stressful. However, extreme situations are relatively rare occurrences in the lives of ordinary people in modern societies at peace. It is therefore necessary \ to focus on those life events that are common in the lives of most people in order to Cockerham, William C.. Sociology of Mental Disorder, Taylor & Francis Group, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/umanitoba/detail.action?docID=4710761.

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104 Chapter 4 • Concepts of Causes and Cures demonstrate that stress is a major factor in the onset of mental disorders in the general population. If stressful situations play a major role in causing\ mental disorder, the relevant events must be more ordinary and more frequent experi- ences in the lives of most people. These would be events such as marriage, birth of a child, death of a loved one, and loss of a job. Although such events are not extraordinary in a large population, they are extraordinary in the lives of the individuals who experience them. Life Events Life events research constitutes a significant area of inquiry in the attempt to understand what causes mental disorder. This approach does not focus on one particular life event (e.g., exposure to combat) and then claim that it is more stressful than another life event (e.g., unemployment). Rather, it is generally based on the assumption that it is the accumulation of several events in a person’s life that eventually builds up to a stressful impact (Thoits 2010). Therefore, Bruce Dohrenwend (1975:384) observes that the central research questions pertaining to a stress model of mental disorder now become: “What kinds of events, in what combinations, over what periods of time, and under what circumstances are causally implicated in various types of psychiatric disorder?” At the present time, these questions are not fully resolved. An important area of contention in life events research is, for example, the issue of whether any type of change in one’s life, either pleasant or unpleasant, produces significant stress, or whether stress is largely a result of only unpleas- ant events. One view supports the idea that any type of environmental change requiring the individual to adapt can produce a specific stress response. Another view comes down on the side of unpleasant events as being more important.

Robert Lauer (1974), for example, tested a “future shock” hypothesis on col- lege students in a Midwestern university several years ago to determine whether the rate or speed of change and the type of change, either positive or negative, were the most important variables in stress produced by change. Although stress was directly related to the perceived rate of change, his findings indi- cated that the effect of rapid change can be moderated by whether the change was perceived to be desirable. Rapid change and undesirability were the most stressful conditions. Other research finds undesirability is the most stressful characteristic of life events (Thoits 2013). Obviously long-term depression results from negative circumstances, not positive ones (Brown and Harris 1978; Brown 2002). Death of a spouse is a particularly stressful life event, even though the vulnerability of men and women may differ (Pai and Carr 2010; Umberson, Thomeer, and Williams 2013; Young and Foy 2013). Losing one’s job is an undesirable life event that can also have potentially harmful effects on a person’s physical and mental well-being (Lennon and Limonic 2010; Tausig 2013). Reemployment, however, produces positive emotional effects, leading to the conclusion that the Cockerham, William C.. Sociology of Mental Disorder, Taylor & Francis Group, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/umanitoba/detail.action?docID=4710761.

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105 Chapter 4 • Concepts of Causes and Cures worst psychological effects of job loss can be minimized or disappear with reemployment (Tausig 2013).

Another area of research related to the pleasantness of an event focuses on whether the event is resolved. R. Jay Turner and William Avison (1992) define resolved events as those from which individuals are able to derive positive meaning for themselves or their futures and from which they obtain new skills and attitudes or positive self-images. They found that successful resolution of a life event significantly reduced the amount of stress associated with it, especially for people with a low sense of mastery and members of lower socioeconomic groups. Resolution was not as important for high-status individuals who typi- cally bring a well-developed sense of personal mastery to their life events. The importance of resolution in reducing the stress of life events for some people is seen in Peggy Thoits’ (1994) study of a sample of adults in Indianap- olis. Thoits focused on problems stemming from a person’s job and love life.

She found that people are often motivated to act in ways that deliberately reduce their stress. Negative psychological outcomes were attributable primarily to stressors that they were unable to resolve. Other research found that daily has- sles (minor irritations, such as an argument with one’s children or a malfunc- tioning oven) were more stressful if the individual was already experiencing chronic (persistent) stressors in the home (Serido, Almeida, and Wethington 2004). Daily hassles remained minor irritations in the absence of such \ stressors.

Personal control over situations and the ability to resolve problems successfully therefore appear important in reducing the stress associated with life e\ vents (Ross and Mirowsky 2013). Research on the effect of life events also entails the severe problem of accurately measuring the presumed relationships between stress and parti\ cular life experiences. One approach has been use of the classic Social Readjustment\ Rating Scale developed by T. H. Holmes and R. H. Rahe (1967). This scale is based on the assumption that change, no matter how good or how bad, demands a certain degree of adjustment on the part of an individual; the greater the adjustment, the greater the stress. Holmes and Rahe carried their analys\ is one step further and suggested that changes in life events occur in a cumulative pattern that can eventually build up to a stressful impact. Thus, the type of change does not matter so much; it is the extent to which change disrupts nor- mal patterns of life that is important. The Holmes and Rahe Social Readjustment Rating Scale lists certain life events that are associated with varying amounts of disruption in the life of an average person, both positive and negative. It was constructed by having hundreds of people of different social backgrounds rank the relative amount of adjustment accompanying a particular life experience. Death of a spouse is ranked highest, with a stress value of 100; divorce is next, with a value of 73; marriage is ranked seventh, with a value of 50; and retirement tenth, with a value of 45. Among other life events are outstanding personal achieve- ment with a value of 28, trouble with one’s boss at work at 23, and taking a vacation at 13. Holmes and Rahe call each stress value a “life change” unit.

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106 Chapter 4 • Concepts of Causes and Cures They suggest that, as the total value of life change units increases, the prob- ability of having a serious illness also increases, particularly if a person accu- mulates too many life change units in too short a time period. If the individual accumulates 200 or more life change units within the period of a year, Holmes and Rahe believe such a person will be at risk for a serious health disorder.

Once used extensively, the Holmes and Rahe Social Readjustment Rating Scale is not as popular as it once was because of certain flaws (Thoits 2013).

Some studies have found that the scale does not adequately account for differ- ences between ethnic and cultural subgroups in the relative importance of the various life events (Turner and Avison 2003). In other words, the Holmes and Rahe scale measures the quantity of change rather than the qualitative meaning of the event (Thoits 2013). Also some life events, such as divorce, can be regarded as a consequence of stress instead of a cause. In addition to divorce, events such as “changes in sleeping habits,” “changes in arguments with spouse,” “sexual difficulties,” and “being fired from work” may result from stress rather than causing it. This situation thus confounds the relationships being measured. Another problem is that the scale does not account for intervening vari- ables, such as social support (feelings of being loved and cared for), that for many individuals might modify the effects of life events and exercise a very important intervening influence upon psychiatric symptoms. Some studies indicate that the extent of one’s integration into a social system significantly mediates the impact of adverse life events and that family members provide support in times of crisis that helps prevent mental instability or, conversely, helps cause it (Avison and Comeau 2013; Turner and Brown 2010; Turner and Turner 2013; Umberson et al. 2013). There is little doubt that supportive inter- personal influences reduce stressful feelings (Thoits 2011a, 2013; Turner and Turner 2013). In fact, it may be the lack of affective support that is the most important stressor for some people (Brown 2002). While life events research remains important, there has been a shift in recent years from studies of acute stressors that are short-term experiences like single life events to chronic stressors that are long-lasting and continuous (Wheaton and Montazer 2010; Wheaton et al. 2013). Chronic stressors usually develop more slowly, last longer, and are not as self-limiting as an acute stressor. For example, as Blair Wheaton and Shirin Montazer (2010:180) point out, the adverse psychological effects of “ getting divorced” (an acute stressor) differ from the longer-term effects of “ being divorced” (a chronic stressor).

Although both acute and chronic stressors can cause depression, anxiety, and other mental health problems, long-term traumatic stress situations, inc\ luding those that originate with a life event, have been found to be more harmful to a person’s mental state (Wheaton and Montazer 2010). The relationship between stress and life events as a precipitating factor in causing or contributing to the onset of mental disorder is a highly complex phenomenon and not easily amenable to a simple cause-and-effect explanation.

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107 Chapter 4 • Concepts of Causes and Cures The process of explanation and prediction is confounded by the varying types of life events, subjective meanings attached to those events, forms of social support, personal and group vulnerabilities, acute versus chronic stressors, and so forth, which need to be accounted for before a definitive model of social stress can be formulated. There is a general recognition in both sociology and psychiatry that subjective stress is highly significant. The research reported in this section attests to that. Moreover, major support for a stress model of mental disorder comes from genetics, which has accumulated evidence of a genetic role in mental disorder but looks to social factors as instrumental in explaining the mechanisms that trigger genetic predispositions and help shape the e\ xisting variability (Pescosolido et al. 2009; Schwartz and Corcoran 2010; Toyokawa et al. 2012). Hence, the issue seems to be not so much whether social f\ actors such as life events and longer-term situations are important, but in what spe- cific ways they are important. THE ANTIPSYCHIATRIC MODEL Another concept of mental disorder is the antipsychiatric view, which rejects the notion that mental disorder qualifies as illness. The forerunner of this view was R. D. Laing (1967, 1969), a psychiatrist, who made the provocative sugges- tion that schizophrenia is a sane response to an insane world. Schizophrenia was seen as primarily a reaction to a disturbing environment and that appeared practical from the schizophrenic’s view. Therefore, it is Laing’s position that schizophrenia is not a disease, but a form of dissociation from intolerable social situations that affect what a person may say, do, or feel. In Laing’s view, mental disorder is caused by social, political, and economic circumstances that\ influ- ence an individual to dissociate himself or herself from the environment.

Szasz: The Myth of Mental Illness Another psychiatrist who reinforced antipsychiatric views was Thomas Szasz, who claimed that mental illness is simply not an “illness” in any form. In his books The Myth of Mental Illness (1974) and Insanity (1987), Szasz argued the following: (1) only symptoms with demonstrable physical lesions qualify as \ evidence of disease; (2) physical symptoms are objective and independent of sociocultural norms, but mental symptoms are subjective and dependent upon sociocultural norms; (3) mental symptoms result from problems of living; (4) therefore, mental disorders are not diseases but are conflicts resulting from differing social values that the medical profession disguises as illnesses through the use of medical terminology. “Mental illness,” claims Szasz (1974:267), “is not something a person has but is something he does or is.” For example, Szasz says that a man’s belief that he is Napoleon or is being persecuted by Communists cannot be explained by a defect or disease of the nervous system. Such statements are considered to be mental symptoms only if the observer (the audience) believes that the patient is not Napoleon or Cockerham, William C.. Sociology of Mental Disorder, Taylor & Francis Group, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/umanitoba/detail.action?docID=4710761.

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108 Chapter 4 • Concepts of Causes and Cures is not being persecuted by Communists. Thus, the statement that X is a symp- tom of a mental disorder includes a social judgment. The observer must match the person’s ideas and beliefs to those held by the observer and the rest of society. In other words, a person’s behavior is judged by how well his or her actions “fit” a concept of normality held by a social audience. It is upon this\ basis, then, that Szasz insists that mental illness cannot be defined in a medical context. Mental illness should be defined within a social and ethical context, with psychiatrists recognizing that in actual practice they are dealing with problems of living rather than with illnesses. There have been several critiques of Szasz’s position, primarily by advo- cates of the medical model (Reiss 1972; Spitzer and Wilson 1975). Generally, these critiques hold that mental symptoms do not have to result from physical lesions or obviously identifiable physiological pathologies to be defined as a disease. Subjective pain, for instance, is regarded as a disease state. Therefore, as previously noted, the medical model holds that mental symptoms, physio- logical or psychological, can be classified as disease if the personality is impaired and behavior is adversely affected. This view, of course, is based upon the broad perspective of disease that sees disease as being disease , a con- dition of discomfort, pain, or suffering that can be relieved by medical means.

Thus, in psychiatry, Szasz’s concept of mental disorder as a problem of living rather than an illness or a disease state is seen as a radical position \ that is inter- esting but not terribly relevant to actual psychiatric practice. Szasz offers no particular form of therapy or ideas about how to treat insanity. Additionally, there is no evidence that conceptualizing mental disorder solely as interper- sonal conflict is more useful in solving or managing abnormal behavior than an approach based upon the medical model (Spitzer and Wilson 1975). However, among behavioral scientists who object to an exclusive medical orientation toward mental disorder, Szasz’s work has been influential. Regard- less of what causes mental disorder, its detection depends upon how well the person in question acts in his or her usual social role. Therefore, Szasz is correct when he argues that deciding if a person is mentally ill is a social judgment derived from comparing how well a person’s behavior matches a standard of normality considered by others to be appropriate for the circumstances. \ But this view does not tell us what causes mental disorder or what to do about it. Summary This chapter has presented an overview of the various concepts of mental disorder based upon the competing perspectives of the medical, psychoanalytic, behavior modification, social stress, and antipsychiatric models. None of these models provides a completely satisfactory overall explanation of mental disor- der, but the medical model is nevertheless dominant. This is so because the medical profession has high expectations for drug therapy and studies of brain chemistry, along with the potential of genetics. This trend seems likely, although Cockerham, William C.. Sociology of Mental Disorder, Taylor & Francis Group, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/umanitoba/detail.action?docID=4710761.

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109 Chapter 4 • Concepts of Causes and Cures such an approach ignores most psychological and sociological correlates \ of mental disorder and does not adequately deal with nonchemical causes or \ the external environments that provoke behavioral abnormalities. In the absence of definitive cures, the use of medical techniques such as psychoactive drugs and ECT aims at the stabilization and reversal of symptoms to allow the patient to function as normally as possible. Medical procedures in this regard, however, are best viewed as a “holding” action in that they attempt to achieve and main- tain a mental state that holds the patient in a relatively normal range of behavior in day-to-day social interaction. Sometimes, some form of counseling, ps\ ycho- analytically based psychotherapy, or behavior modification will be employed to reinforce stability and encourage the patient to gain psychological stre\ ngth to reduce dependence on drugs. Nevertheless, there are those in psychiatry who insist that biochemistry is the key and that other measures will no longer be relevant once the brain’s biochemical secrets have been determined. There are others who believe that the medical model is only one possible approach and that other methods may be more suitable for certain patients.

The psychoanalytic model seems to be losing influence, but still persists.

A particular source of support for the psychoanalytic model is that some\ group therapies are based upon psychoanalytic techniques. The social learning model, with its emphasis upon behavior modification, seems to be primarily influential among clinical psychologists. It deals with the present rather than with\ the past, since its techniques focus on unlearning abnormal behavior and on learning other behavior that is more personally and socially suitable. Thus, the advan- tage that the medical, psychoanalytic, and social learning models offer is both a concept of mental disorder and a particular method of treating mental \ dysfunctions through which a patient’s symptoms can be alleviated. As for the social stress model, it is a highly active arena of research.

A major focus is on the effects of stressful life events that occur routinely and eventually accumulate to trigger a stress-induced mental disorder. Many ques- tions remain to be answered, however, in regard to the stress model, and any contribution to therapy remains to be fully articulated. The antipsychiatry model is an interesting but somewhat radical view that offers little insight for therapy administered on an individual basis. Its significance lies in helping us to understand how social and cultural standards of behavior help determine judgments about who is and who is not insane. In sum, we have no scientifically verified theory of mental disorder that objectively explains what causes it, nor do we fully understand how various types of therapy actually work, even though they do seem to reduce the symptoms. Critical Thinking Questions 1. What are the strengths and weaknesses of the medical model? 2. Why are psychotropic drugs the preferred treatment method for mental disorder? Cockerham, William C.. Sociology of Mental Disorder, Taylor & Francis Group, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/umanitoba/detail.action?docID=4710761.

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110 Chapter 4 • Concepts of Causes and Cures 3. Describe the potential of behavioral genetics for treating mental disorders. 4. Should electroconvulsive therapy be outlawed? 5. What is the future of psychoanalysis? 6. Describe the social stress model and explain how it links with genetics. 7. How influential is the antipsychiatric perspective? Suggested Readings Aneshensel, Carol S., and Uchechi A. Mitchell (2014) “Stress process, the.” Pp. 2334–46 in W. Cockerham, R. Dingwall, and S. Quah (eds.), Wiley Blackwell encyclopedia of health, illness, behavior, and society . Oxford: Wiley Blackwell. A detailed discus- sion of the stress process, with examples of mental illness.

Busfield, Joan (2011) Mental illness . Cambridge: Polity. A British sociologist reviews and critiques the various concepts of mental illness.

Mossakowski, Krysia N. (2014) “Stress and mental illness.” Pp. 2317–21 in W. Cockerham, R. Dingwall, and S. Quah (eds.), Wiley Blackwell encyclopedia of health, illness, behavior, and society . Oxford: Wiley Blackwell. An explanation of the relationship between stress and mental illness.

Perry, Brea L. (2014) “Mental illness, Geneticization.” Pp. 1578–82 in W. Cockerham, R. Dingwall, and S. Quah (eds.), Wiley Blackwell encyclopedia of health, illness, behavior, and society . Oxford: Wiley Blackwell. A review of the genetics of mental illness.

Smith, Dena T. (2014) “The diminished resistance to medicalization in psychiatry\ : Psy- choanalysis meets the medical model of mental illness.” Society and Mental Health 4:75–91. An informative study of medicalization in psychiatry from the standpoint of psychoanalysts.

Wurtzburg, Susan J. and Nicholas Thomson (2014) “Mental illness, anti-psychiatry per- spectives.” Pp. 5550–3 in W. Cockerham, R. Dingwall, and S. Quah (eds.), Wiley Blackwell encyclopedia of health, illness, behavior, and society . Oxford: Wiley Blackwell. A discussion of the antipsychiatry approach to mental illness. Cockerham, William C.. Sociology of Mental Disorder, Taylor & Francis Group, 2016. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/umanitoba/detail.action?docID=4710761.

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