In this module, you learned the following:

• the problems and insufficiency of unidimensional explanations of mental disorders
• the importance of the biopsychosocial model for understanding that mental disorders arise through systemic interactions
• the value of the diathesis-stress and gene-environment-correlation models as ways of understanding the etiology of mental disorders
• to identify and explain the theoretical models based on parts of the biopsychosocial model that have been used to explain how symptoms develop and methods that can be used to treat mental disorders
• the range of modalities that exist to treat mental disorders in various environments and the larger environments where these treatments are used
• to explain why the sociocultural perspective is important in therapy, the importance of cultural competence in practice, and some of the types of cultural barriers that prevent some people from receiving mental health services

This module covered a lot of ground. You learned that overly simplistic unidimensional explanations of mental disorders, like saying that they are caused by a “chemical imbalance” or by how your mother treated you when you were little, are not only inadequate to explain how these disorders occur, but they are also mostly inaccurate on their own. Mental disorders are the outcome of systemic effects that occur inside our body and brain and that interact with the external environment including social and cultural forces. There is evidence that epigenetic processes are also involved meaning that the environment actually influences which genes in our DNA are turned on or off.

A systemic model that gives a better understanding of the complexity involved is the biopsychosocial model that integrates biological (including genetics, neural transmission, and other aspects), psychological (thoughts, attitudes, beliefs, emotions, behaviors, learning), and sociocultural elements (prejudice, discrimination, stress, abuse, poverty, healthcare, etc.) to help us better understand how disorders arise. Remember that these elements are interdependent, meaning that they influence each other—there is no one-way street here. You also learned about the diathesis-stress model, an older explanation that describes how a person may have a genetic vulnerability or predisposition towards developing a disorder, and that if that person experiences sufficient stress (from any of the biopsychosocial elements) to exceed a threshold, they will develop the disorder. The more modern version of this is the gene-environment-correlation model (rGE) that describes how a person’s genome (set of genes in their DNA) may not only make someone vulnerable to developing a disorder, but may actually contribute to generating the environmental stress that exceeds a threshold and triggers the disorder.

You then reviewed the various theoretical models that developed to explain the separate parts of the biopsychosocial model and that emerged either independently or in reaction to one another as scientists and clinicians tried to figure out how mental disorders arise. You started with the biological model that explained how mental disorders are polygenic, arising through the interactions of multiple genes. You found out about heritability and concordance rates that are used by scientists to estimate how much genetic variables contribute to a disorder versus the environment. You also learned about the structure of neurons, our primary brain cells, and how they communicate through producing neurotransmitters and releasing those into the synapse between neurons when they receive a signal of sufficient strength and how action potentials are all or none. You learned about receptor binding and reuptake when the presynaptic neurons “recycle” or repackage neurotransmitters for use again in a future signal. You also learned about the major neurotransmitters that are related to mental disorders: dopamine, norepinephrine, serotonin, GABA, and glutamate. You also learned about brain structures and the relationships between the brain and the endocrine system.

You learned about biomedical treatment approaches. These include the use of psychotropic medications for different mental disorders, an approach that is widely used today and that can be helpful for some, but not all, individuals. Most medications can create side effects that can be problematic and patients often relapse if medications are stopped. You also learned that combined therapy (medications and psychotherapy) can be helpful, especially when symptoms are more severe. For example, an individual with schizophrenia who is bombarded with visual or auditory hallucinations may find it difficult to focus in psychotherapy; with medication, the individual’s hallucinations can be eliminated or reduced to a level that allows the individual to benefit from psychotherapy. Other biomedical treatment included various forms of brain stimulation treatments such as electroconvulsive therapy (ECT) and repetitive transcranial magnetic stimulation; some of these therapies are still experimental and are being tested.

We then reviewed a wide range of psychotherapeutic models or theoretical explanations for how symptoms develop. These were paired with the treatment approaches or orientations that were developed based on these theories. These explanations included the following:

• psychodynamic approaches: based originally on the work of Freud, his models of personality, defense mechanisms, and unconscious conflicts, many different approaches or orientations to treatment have been developed. Many of Freud’s ideas have not been supported by modern research, although a few have found support and have been integrated into later approaches. Freud developed psychoanalysis, the modern descendants of which are a range of psychodynamic therapies. The primary focus is to reveal the unconscious content of a client’s psyche in an effort to alleviate psychic tension. Modern psychodynamic therapy tends to be briefer and less intensive than traditional psychoanalysis. Play therapy also originated in psychodynamic thought but has now been expanded into other forms of treatment as well.
• humanistic approaches: reacting to Freud’s ideas, Carl Rogers and Abraham Maslow were the primary developers of humanistic therapy which was grounded in a more holistic model of human beings that emphasized the potential for good in all people; accepted and encouraged human choice and will; and emphasized human desires for meaning, value, and creativity. Related treatment orientations and methods included existential therapy and person-centered therapy. Some of the foundational ideas of Rogers’ person-centered therapy, including unconditional positive regard and active listening, have been adopted in almost all subsequent forms of therapy and represent one of the common factors that appear to be related to the effectiveness of therapy regardless of orientation.
• behavioral approaches: rejecting ideas of that biology determined outcomes as well as Freud’s observational theories of human functioning, behaviorists emphasized a more objective scientific approach based on research of observable behaviors. Grounded in the primary work of Pavlov, Watson, Thorndike, and Skinner, behaviorists uncovered important aspects of human learning such as classical conditioning, operant conditioning, and observational learning. Remember that negative reinforcement increases a behavior (usually avoidant) and is the opposite of punishment! In working on observational learning, Bandura began to integrate ideas of how human cognition interact with behavioral principles to influence behavior. These models led to a wide range of effective methods for treating a variety of mental disorders such as exposure and extinction therapies, counterconditioniing, and more.
• cognitive and cognitive behavioral approaches (CBT): The cognitive model was grounded in the work of Adler, Ellis, and Beck, who explored the role that a person’s thought patterns played in generating intense emotions and problem behaviors. The core idea at the center of the cognitive revolution in treatment was that maladaptive thought patterns based on irrational or non-realistic thinking that was absolute or judgmental influenced and intensified emotions and then shaped behaviors that also influenced or reinforced behaviors. Ellis proposed the A-B-C model that explained this sequence. Beck also proposed a triangle of core belief systems with negative perspectives on oneself, the world, and the future. Cognitive therapy seeks to identify these maladaptive cognitions (thoughts), appraisals, beliefs, and reactions, with the aim of reducing negative emotions, freeing the client to explore more healthy and adaptive behaviors and thought processes. CBT combines cognitive therapy and behavioral therapy to address maladaptive cognitions as well as dysfunctional behaviors using techniques from both models; this approach has demonstrated significant effectiveness for a wide variety of mental disorders and is in wide use today.
• common factors and eclectic and integrative therapies: although there is ongoing discussion and arguments about the effectiveness of different forms of therapy, decades of research have identified some common core features that seem to assist with healing and positive outcomes regardless of the theory or methods used. These include a positive and trusting relationship with a therapist, relevant and focused treatment approaches, enhancing hope and the client’s belief that change is possible, and use of novel methods that the client has not used before. Many practitioners today are using an eclectic approach, meaning they combine aspects of multiple types of therapeutic methods targeting specific symptoms. Technical eclecticism does this without adopting any coherent or integrated ways of explaining a theory behind the patient’s symptoms. On the other hand, integrative therapies have been specifically designed to blend different therapy models, as well as their methods, with the result of a coherent approach to treatment that uses methods from many different approaches.

Figure 1. Group therapy is a great way for individuals to connect with others who may share similar experiences.

We also explored different treatment modalities or treatment environments where psychotherapy models and techniques are used. All these involve, at minimum, an intake session where the clinician assesses the client’s background and concerns and comes up with a treatment plan; this often involves a referral to another therapist who will carry out the actual treatment. These modalities include the following:

• individual therapy: one-on-one sessions between a client and a therapist
• group therapy: in this type of social therapy, one or more therapists treat a small group of clients together as a group (Figure 1)
• psychoeducation groups: a specialized form of group therapy that involves presentation of educational information to assist in coping and adapting to stressful situations
• couples therapy: two people in an intimate relationship working with a single therapist, focusing on enhancing and improving their relationship or deciding to terminate the relationship
• family therapy: a specialized form of group therapy focusing on a family unit where all members of the family are involved; the goal is to enhance relationships, improve communication, and clarify boundaries and structures within the family.
• larger treatment contexts or environments: we reviewed multiple contexts in which psychotherapies of various modalities are used, including inpatient hospitalization, partial hospitalization, residential treatment centers, outpatient therapy, and forensic units.]

Last, we explored the significant impact of sociocultural influences on a person’s functioning. This included understanding that each person’s identity consists of individual, group, and universal characteristics and how effective treatment must be grounded in the therapist understanding their own identity and biases as well as seeking to understand the client’s identity and how cultural variables might shape their decisions, emotions, and behaviors. This includes recognizing individualist and collectivist elements of culture and requires specialized training for therapists to be culturally competent. Expectations of professional cultural competence now are part of the ethical codes of clinical disciplines. It is also important to understand and seek to reduce structural social barriers to treatment including racism, discrimination, access to care, health insurance, and the impact of social stigma on people’s desire to seek treatment.

Having completed this module, you now have a much better understanding of the complexity of how mental disorders develop as well as the variety of theories and their connected treatment methods that exist today. You have an understanding of where those treatments are given and the importance of cultural competence. You are ready to start learning about specific disorders.