DISCUSS AND CRITICALLY ANALYSE YOUR UNDERSTANDING OF PSYCHOPATHOLOGY WITH REFERENCE TO TWO ‘COMMON MENTAL HEALTH DISORDERS’

INTRODUCTION

In trying to discuss and critically analyse an understanding of psychopathology, I will propose to use the relevant theory from the perspective of two common mental health disorders; Borderline Personality Disorder (BPD) and Major Depressive Episode (MDE).. I decided to focus on these two common mental health disorders as both hold particular interest for me.

MDE- What struck me most in researching this topic was the relative ease with which someone could find themselves diagnosed with MDE under current DSM-IV guidelines. Possibly without them having awareness of their impending path and journey into mental health difficulties.

I was impacted by BPD in regards to its more challenging behaviours to the therapist, who may be dealing with a client existing between borderline and psychotic worlds.

I will explore the application of two theoretical approaches, namely humanistic and cognitive behavioural in relation to these mental health disorders. I will also demonstrate the importance of cultural difference in relation to understanding mental health issues and I will highlight the role risk assessment plays in the provision of supports for clients and the therapists. I will also demonstrate the importance of supervision and record keeping and I will conclude the essay with a brief summary of my key learning, including my understanding of limitations and challenges facing me within the psychotherapeutic relationship.

PSYCHOPATHOLOGY

A helpful understanding of what pathology is and one that I agree with was suggested by Stirling, who contributed that psychopathology is,

‘The scientific study of abnormal behaviour. As such it differs from both clinical psychology and psychiatry which respectively focus on behavioural and medical management of mental disorders’
Stirling J, 2013 ,p.1.

This commentary gives me a clear understanding that psychopathology is the study of the normal versus the abnormal, but in order to have a firm understanding of common mental health disorders, I chose the DSM-IV as my reference point, as according to Dziegielewski, in her book DSM-IV-TR in Action, she proposes that;

‘Few professionals would debate that the most commonly used and accepted source of diagnostic criteria are the diagnostic and statistical manual of mental disorders, fourth edition’
Dziegielewski, 2010, p.4.

The DSM-IV offers a very helpful structure for the therapist and health care professional dealing with mental illness as the DSM-IV defines the categorization of mental disorders. The DSM-IV offers a controlled method for healthcare professionals to communicate with each other using this structure as a common reference point. In my view, there are challenges to the effectiveness of the DSM-IV as it uses behavioural measurement to identify mental illness which in my opinion is an approach that fails to acknowledge the individuals relationship history or their societal and cultural values, or their behavioural norms and behavioural abnormalities. It also has a predominately western viewpoint, though the cultural makeup of its contributors, a point also commented by, White Kress, who stated;

‘A growing body of literature suggests that diagnoses based on DSM criteria are particularly inaccurate for clients from “underrepresented and marginalized groups” and fails to take into account larger adjustment issues such as acculturation and immigration’
White Kress, 2005 ,p.98.

MENTAL HEALTH ISSUES

I will now explore Borderline Personality Disorder and Major Depressive Episode.

Borderline Personality Disorder (BPD) is coded on Axis 11of the DSM-IV. Axis 11 is used to classify personality disorders and BPD is cited as;

‘A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts.
A person must show an enduring pattern of behaviour that includes at least five of the following symptom, frantic efforts to avoid real or imagined abandonment, unstable and intense interpersonal relationships, Identity disturbance, impulsivity in at least two areas that are potentially self-damaging, recurrent suicidal behaviour, affective instability due to a marked reactivity of mood, chronic feelings of emptiness ,intense or inappropriate anger, stress-related paranoid ideation or severe dissociative'
American Psychiatric Association, 2000 ,p.706.

This comment offers the view that may demonstrate the wide displacement that people with BDP may experience. In my opinion, BPD sufferers may exist in a world built on insecurity, fears, abandonment, where their thoughts can be erratic, irrational and overly emotional. I believe that one of the main challenges in the therapeutic relationship for clients who present with BDP is their lack of ability to distinguish between reality from their own conception and perception of the world compared to others. People with this disorder may see others and normal life situations in “black-and-white” terms. They may also switch quickly from idealizing other people to devaluing them; feeling that the other person does not care enough, or does not give enough. This could be a concern within the therapeutic relationship as there may be perceived shifts around the stability of this or indeed any relationship.

I will now explore Major Depressive Episode (MDE) which is coded on Axis 1of the DSM-IV. Axis 1 refers to the diagnosis, or the presenting disorder. MDE in the DSM-IV is described as; abandonment fears, unstable intense relationship , identity disturbance, impulsivity, suicidal or self-injury behaviours, emotional instability , emptiness, anger and psychotic perceptual distortions. American Psychiatric Association, 2000 ,p.369.

MDE is an illness that illness that is currently experienced by many people and diagnosed by many practitioners, as Parker offers;

‘Depression is referred to a "the common cold of psyche’
Parker, 2005 ,p.6.

In my view MDE can offer challenges to both the suffer, and the therapist. As demonstrated within the DSM-IV its symptoms can dehabilitate and cause great distress to the sufferer, impairing their ability to function within relationships and work environments. However, I believe that there are also challenges in the diagnosis of MDE within the DSM-IV classification system as it operates within a very defined and structured approach to diagnosis's criteria. This could mean someone could show only three symptoms, which are very active and present, but this could have a more destabilising or upsetting effect than someone showing four milder symptoms. Secondly, people differ in their capacity, honesty and ability to communicate to the practitioner and may hide symptoms from them making diagnosis difficult.

INTERVENTIONS

Both BPD and MDE offer a challenge to both the therapist and to the client. For the client, daily living can be difficult. The therapist may also find it difficult to come up with the diagnosis accordingly and the nature of the conditions may hinder the ability of the person to interact fully and honestly within the therapeutic relationship. In my opinion the humanistic and cognitive behavioural offers the best path in relation to working with clients who present with BDP and MDE.

Humanistic approach.

The humanistic approach was developed from the theories of illustrated an emphasis on human potential. illustrated an emphasis on human potentialSSSSSSSSs Abraham Maslow, Carl Rogers and Rollo May. It approach holds the view that the focus of the therapeutic relationship centres on the ability of the person to fulfil their own full potential. Rogers called this "self actualization". The ability of the client to fulfil their potential is achieved through open communication and a non-judgmental approach to the client.

The humanistic approach would view that if a client is experiencing mental health issues then this is a deviation from normal well being and the client holds the solution to their recovery. This is vital for the building of the therapeutic relationship and this may gives the client grounding and a base, possibly something that was lacking or missing in their lives. The therapist's role is to lead the client toward this self-knowledge. Rogers endorses this point by in stating that;

‘Individuals have within themselves vast resources for self-understanding and for altering their self-concepts, basic attitudes, and self-directed behaviour; these resources can be tapped if a definable climate of facilitative psychological attitudes can be provided’
Rogers Carl R, 1995, p.115.

The humanistic approach does have some cultural challenges as it relies on the therapist interpreting the client from the therapist's own cultural perception, and secondly , what might be regarded as the therapist’s ideal self actualization which may be different from the client’s culturally defined self actualisation. It does however offer a pureness and a non-judgemental approach that offers the client a safe environment to achieve stability and a foundation to realise their own potential.

In my view, the humanistic approach offers a suitable therapeutic intervention for both MDE and BDP clients. as assuming that in both illnesses the person has lost their drive, motivation and ability to fulfil their own potential.
If the therapist can help the client regain this, it could to lead to the depression lifting in cases of the MDE. In regards to the BDP client; the therapeutic relationship can offer foundation and a base that may have not existed previously in their lives allowing them to develop themselves

Cognitive behavioural approach.

This approach has its foundations in the work of the conditioning and reinforcement theorists of Pavlov, Wolpe and Skinner. The term cognitive-behavioural therapy (CBT) is not a specific therapy but more a collective classification of therapies with shared similarities. In the cognitive behavioural approach, the client and therapists work to understand if the thinking of the client is irrational or negative. They both work to replace the irrational or negative thinking with new ways of thinking and behaving. This is augmented with a commitment from the client to actively peruse the more positive approach in everyday settings. It sets short-term goals for the client to achieve and through the goal setting structures it can fit well into the lives of people who need stability and a secure base.

In relation to the treatment of MDE and the cognitive behavioural approach; it was
Aaron T beck whose cognitive theory offered a view into how depression could enter the life of an individual through their thinking. According to Davey ;

‘This theory introduced the idea that depression could be caused by bias in the way of thinking and processing information’
Davy G, 2008 ,p.182.

The cognitive behavioural approach can be very effective for working with MDE sufferers as CBT aim to help the MDE client change patterns of behaviour that come from negative thinking and irrational thoughts. This process of thinking can lead to a negative schemata for the client whose continuous use of repeated negative thoughts could cause the onset of depression. The aim of the cognitive behavioural approach is to assist the client in changing their viewpoints and perception. This, if successful, could lead to the client arresting the downward spiral into more depressive episodes.

In relation to BDP; two specific behavioural approaches have been used in its treatment; Dialectical Behaviour Therapy (DBT) and Schema-focused therapy (SFT). In BDP, as described within the DSM-IV, the BDP client may be experiencing interpersonal relationship and self-image issues challenges. The cognitive behavioural approach may help the client rationalise and interpret their current challenges in a different manner, which could assist them in achieving a more stable world.

In dealing with clients of suffering from mental illness there are a number of considerations that the therapist need to observe in order to facilitate a safe, secure therapeutic relationship and alliance.

CONSIDERATIONS

When any person presents for therapy, it is important that a full assessment is completed.
The assessment should ensure that the therapist is informed of the background of the client. The assessment should include: a contract agreement and a confidentiality release clause. The therapist should be made aware of the client being in therapy before, whether they been referred, if they are on medication. This information is important to the therapist as it may determine the way and style of treatment used and also to help the therapist determine if they can help and support the client. It also assists in deciding whether the client needs a referral. As shown previously, the therapist will need to be aware of ways in which different cultures express, experience, and cope with feelings of distress. Within the first few meetings the therapist should establish reasons for the client presenting and determine if there are areas of concern with regard to safety, suicidality, or any medical or transference issues. If there are concerns, this should be raised immediately with the client's medical practitioners or through supervision. We also need to be vigilant and very observant to the behaviours thoughts and actions of our clients with BDP as Porr offers, that in regards to BPD it;

‘Has a 10% suicide rate and at least 75% of people with BDP make at least one non-lethal suicide attempt and at least 60% to 80% with BDP self-injure’
Porr V, 2010 ,p.121.

If any client presents with challenging behaviour, there needs to be an understanding to why the client is behaving this way and to question whether the current therapeutic intervention is sufficient or if there is a need to refer the client on.
The decision to refer or not to refer the client must be dealt with swiftly either by direct decision making by the therapist or raised through supervision.

In regards to record keeping; it is vital to ensure that proper records and summary notes are maintained from the client's sessions. Notes should be done immediately after each session to ensure a full accurate record is kept of each session.

As therapists we need to be aware of our own feelings toward the client when the client may display behaviour which is deemed inappropriate. These feelings need to be raised with the client (if appropriate) or within supervision. Again the importance of awareness of transference issues and the need and requirement to bring any issues to supervision is vital. There may also be a risk to the therapist of burnout as the challenge of hearing the experiences of clients who are struggling may impact on the therapist, so wellbeing and self care for the therapist are vital.

CONCLUSION

As shown, there are challenges to the therapist when entering into the client's world of mental health issues. There is the challenge of whether the therapist is presented with a client diagnosed with a mental illness or the challenge to the therapist to determine if there is a possibility of an undiagnosed mental illness presenting. There is the challenge to the therapists of how best to look after the needs of the client and also our own self-care. However a network and system to help and support our clients is available. Pharmacology, Psychiatry are accessible and the health care system can use a multi-disciplinary team approach to give the client a well balanced approach where psychotherapy can be a part of. My experience of researching this project has changed my previously held view where I did not feel confident in dealing with someone who presents or displays characteristics of mental health disorders. Now in my view clients who show a manageable or low level of either disorder can benefit from psychotherapy.

BIBLIOGRAPHY

American Psychiatric Association. 2000, DSM-IV-TR, American Psychiatric Pub

Dziegielewski. F Sophia, 2010, DSM-IV-TR in Action, John Wiley & Sons,

Davy. G, 2008, Psychopathology research, Assessment and treatment in Clinical Psychology. John Wiley and sons

Stirling, J, 2013, Psychopathology Modular Psychology, Routledge

Maddux, E James, 2012, Psychopathology: Foundations for a Contemporary Understanding Routledge,

Parker, G et al, David Straton Dealing with Depression: a Commonsense Guide to Mood Disorders, Allen & Unwin

Porr.V, 2010, Overcoming Borderline Personality Disorder: A Family Guide for Healing and Change Oxford University Press

Rogers. C, 1995, A Way of Being, Houghton Mifflin Harcourt

White Kress. E, 2005, The DSM-IV-TR and culture: Considerations for counsellors. Journal of Counselling & Development

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