A Behavioral Approach to Mental Disorders

Fear is the normal human response to imminent danger. It is an adaptive response, in that it is helpful to survival, and it occurs in almost all animal species. When our cave-dwelling ancestors were attacked by mountain lions, they probably experienced acute fear. This fear gave them an extra burst of energy to flee the danger, or, if flight were impossible, to turn and fight. Today in most parts of the world, there is little danger of attack from wild animals. As areas develop economically and culturally, these kinds of acute dangers are systematically eliminated or at least drastically reduced. Close encounters with tornadoes, hurricanes, rattlesnakes, car accidents, etc., can still arouse full-blown fear responses, but most people in developed countries can go months – even years – without experiencing these kinds of situations. ...

CONDUCT DISORDER The essential feature of Conduct Disorder, according to the APA, is a “repetitive and persistent pattern” of rule breaking or activity which violates other people’s basic rights. The manual identifies four broad categories of behavior under this heading: aggression; destruction of property; theft or deceitfulness; and serious violation of rules. DSM goes on to state that individuals with this disorder display little concern for the feelings or welfare of others, are frequently callous and indifferent to other people’s pain and loss, and show little in the way of feelings of guilt or remorse. Poor frustration tolerance, irritability, temper tantrums, and recklessness are cited as frequently associated features. ...

Attention Deficit/Hyperactivity Disorder is defined as “a persistent pattern of inattention and/or hyperimpulsivity that is more frequent and severe than is typically observed in individuals at a comparable level of development.” There is a requirement that the problem existed before age seven and that some of the problems are present in at least two settings. There also must be clear evidence that the inappropriate activity interferes with the individual’s social, academic, or occupational functioning. With regards to the actual diagnostic procedure, the APA lists eighteen behavioral indicators, nine under the heading “inattention,” six under “hyperactivity,” and three under “impulsivity.” For the diagnosis to be considered positive, the child must exhibit at least six problems from either the inattention list or the hyperimpulsivity lists. ...

The notion of a professional group such as the APA sitting in their councils and committees inventing illnesses for themselves to treat seems so preposterous that a measure of disbelief on the part of the reader is understandable. In its historical context, however, the development is not so surprising. The original 1952 DSM was very simple and unpretentious, and whilst part of the APA’s motivation in drafting the document was undoubtedly to draw some credibility and respectability to their profession, there is at the same time nothing to suggest any great drive at that time towards aggrandizement or service expansion. However, having agreed in 1952 that neurosis was a form of mental disorder, it was inevitable that subsequent revisions of the manual would attempt to define this feature further and look for subdivisions of the general category. This, of course, is exactly what has happened, and the current version of DSM lists literally dozens of disorders of this sort, although the general term neurosis is no longer used. (For an interesting discussion of this matter, see Karen Franklin’s post at In The News.) ...

Although psychiatrists are the primary and most influential players in the mental health business, they are not the only professionals involved. Most agencies also employ psychologists, social workers, and counselors, and it is important to recognize how the developments of recent decades have impacted their roles also. Psychologists are licensed professionals who have obtained a psychology degree at a doctorate level. They have no medical training. They work in a wide range of settings, including industry and education. Psychologists became involved in mental health work largely because they were instrumental in the development of psychological tests, and the numbers of psychologists employed by hospitals and out-patient agencies increased fairly steadily through the second half of the twentieth century. Despite this apparent acceptance, however, there has always been a measure of tension between the psychiatrists and the psychologists. Some of this derives from conflicting ideologies, but a good deal of it is driven by simple rivalry and competitiveness, and by considerations of “who’s in charge.” Psychiatrists have consistently attempted to relegate the psychologists to an assistant or underling role, whilst the psychologists have striven for independent status. These tensions continue to this day, and in fact have gained a measure of prominence as psychologists lobby vigorously for prescription rights against the vehement opposition of the psychiatrists. ...

Psychiatrists are medical doctors who after graduation from medical school specialize in the treatment of mental disorders. In 1950 there were about 7000 psychiatrists in the United States. Most of these worked either in the state mental hospitals or in private practice, and in both settings treatment was conceptualized primarily on the lines of talking to the patients, gaining an understanding of their problems, and encouraging them in positive directions. In the hospitals, considerations of containment and control sometimes eclipsed those of treatment, but in their private practices psychiatrists practiced the newly emerging art of psychotherapy with vigor and enthusiasm. Different schools of thought emerged, and there existed a healthy measure of dialog and debate as to the merits and demerits of various techniques. Articles were published in learned journals, and in every respect psychiatry was poised for development as a “talking” profession. ...

In December 1999, David Satcher, MD, then Surgeon General of the United States, reported that almost one fifth of the American population will experience a mental disorder in any given year, and that fully half of the population will have such a disorder at some time in their lives. [Mental Health: A Report of the Surgeon General.] Most Americans have understandably become somewhat skeptical with regards to government press releases and statistics, and it is unlikely that the report received total acceptance by the general population. On the other hand, the report received no major challenge. Indeed, it was endorsed wholeheartedly by several leading healthcare organizations and lobbying groups. The American Academy of Family Physicians, for instance, described mental illness as “one of the most pressing concerns we are facing” and made it their annual clinical focus for the year 2000. The National Institute of Mental Health estimates that 22% of American adults have a diagnosable mental disorder in any given year, and that four of the ten leading causes of disability in the US are mental disorders. ...