Psychopathology

Annotations:

• 2 standard deviations away from the mean is considered abnormal

1. Defining abnormality in terms of statistics
2. Behaviour that is rarely seen is considered abnormal
3. EG. IQ

   Annotations:

   • Iq is normally distributed with the average being 100. Only 2% have a score below 70, and these people are considered abnormal
4. Unusual characteristics can also be positive

   Annotations:

   • If very few people display a behaviour, that makes the behaviour statistically abnormal but doesn't mean the person requires treatment
   • IQ scores over 130 are just as unusual as those under 70 but are not regarded as undesirable and requiring treatment
   • This is a serious limitation of the concept of statistical infrequency and means it should never be used alone to make a diagnosis
5. Real life application

   Annotations:

   • All assessments of patients with mental disorders includes some comparisons to statistical norms
   • Intellectual disability disorder demonstrates how statistical infrequency can be used
   • Statistical infrequency is thus a useful part of clinical assessment
6. Not everyone benefits from a label

   Annotations:

   • When someone is living a happy and fulfilled life, there is no benefit to them being labelled as abnormal
   • Someone with a very low IQ who was not distressed or out of work would not need a diagnosis of intellectual disability
   • Being labelled as abnormal may have a negative impact on the way others view them and the way they see themselves

1. Abnormality is based on social context

   Annotations:

   • Societies and social groups make collective judgements about 'correct' behaviours in particular circumstances
2. Culturally and Era dependant
3. E.g Antisocial Personality Disorder (APD)

   Annotations:

   • One important symptom of antisocial personality disorder (formerly psychopathy) is a failure to conform to 'lawful and culturally normative ethical behaviour'
   • In other words, a psychopath is abnormal because they deviate from social norms or standards. they generally lack empathy.
4. Not a sole explanation of abnormality
5. Social norms are culturally relative
6. Could lead to human rights abuses

1. Inability to cope with everyday living
2. Signs of failure to cope
3. E.g Intellectual disability disorder
4. Recognises patients perspective
5. Similar to deviation from social norms
6. Subjective judgement

1. Changing the emphasis
2. Jahoda's criteria
3. Overlap between definitions
4. Deviation from ideal mental health is comprehensive
5. May be culturally relative
6. Unrealistically high standard for mental health

1. Behavioural
   1. Panic

      Annotations:

      • This may involve a range of behaviours such as screaming, crying or running away from the phobic stimulus
   2. Avoidance

      Annotations:

      • Considerable effort to avoid coming into contact with the phobic stimulus. This can make it hard to go about everyday life, especially if the phobic stimulus is often seen, e.g dogs
2. Emotional
   1. Anxiety and fear

      Annotations:

      • Fear is the immediate experience when a phobic encounters or thinks about the phobic stimulus. This fear then leads to anxiety
   2. Unreasonable response

      Annotations:

      • The response is widely disproportionate to the threat posed,, e.g an arachnophobic will have a strong emotional response to a tiny spider 
3. Cognitive
   1. Selective attention to the phobic stimulus

      Annotations:

      • The phobic finds it hard to look away from the phobic stimulus, e.g a pogonophobic (fear of beards) cannot concentrate on a task if there is a bearded man in the room
   2. Irrational beliefs

      Annotations:

      • For example, a person with a social phobia will possibly believe 'if i blush, people will think I am weak'

1. The two process model
   1. Phobias are acquired through Classical and Operant condtioning

      Annotations:

      • Mowrer (1960) argued that phobias are learnt through classical conditioning and then maintained through operant conditioning
   2. Acquired through Classical Conditioning

      Annotations:

      • Classical conditioning involves association 1. UCS triggers a fear response (fear is a UCR) e.g being bitten creates anxiety 2. NS is associated with the UCS e.g being bitten bu a dog (the dog did not previously create anxiety 3. NS becomes a CS, producing fear, which is now the CR. The dog becomes a CS causing a CR of fear following the bite
   3. Little Albert: Conditioned Fear

      Annotations:

      • Watson and Raynor (1920) showed how a fear of rats could be conditioned in 'Little Albert' 1. Whenever Albert played with his white rat toy, a loud noise was made close to his ear. The noise (UCS) cause a fear response (UCR)  2. Rat (NS) did not create fear until the bang and the rat had been paired together several times  3. Albert showed a fear response (CR) every time he came into contact with the rat (now a CS)
   4. Maintenance by Operant Conditioning

      Annotations:

      • Operant Conditioning takes place when our behaviour is reinforced or punished. Negative reinforcement - an individual produces behaviour that avoids something unpleasantWhen a phobic avoids the phobic stimulus they escape the anxiety they would have experienced. This reduction in fear negatively reinforces the avoidance behaviour and the phobia is maintained. 
   5. Example of negative reinforcement

      Annotations:

      • If someone has a morbid fear of clowns, they will avoid all circuses and other situations where they may encounter clowns. The relief felt from avoiding clowns negatively reinforces the phobia and ensures it is maintained rather than confronted
   6. Good Explanatory power

      Annotations:

      • The two process model went beyond Watson and Rayner's simple classical conditioning explanation of phobias
      • It has important implications for therapy. If a patient is prevented from practising their avoidance behaviour then their phobic behaviour declines
      • The applications to therapy is a strength of the two process model
   7. Alternative Explanations for avoidance behaviour

      Annotations:

      • In more complex behaviours such as agoraphobia, there is evidence that at least some avoidance behaviour is motivated more by positive feelings of safety
      • This explains why some agoraphobics are able to leave their house with a trusted friend with very little anxiety, but not alone (Buck 2010)
      • This is a problem for the two process model, which suggests avoidance is motivated by anxiety reduction
   8. Incomplete Explanation

      Annotations:

      • Even if we accept that classical and operant conditioning are involved in the development and maintenance of phobias, there are some aspects of phobia behaviour that require further explaining
      • We easily acquire phobias of things that were a danger in our evolutionary past (e.g fear of snakes or the dark). This is biological preparedness - we are innately prepared to fear some things more than others (Seligman 1971)
      • The phenomenon of biological preparedness is a problem for the two process model because it shows there is more to acquiring phobias than simple conditioning 
   9. Not all bad experiences lead to phobias

      Annotations:

      • Sometimes phobias do appear following a bad experience and it is easy to see how they could be the result of conditioning
      • However, sometimes people have a bad experience (such as being bitten by a dog) and don't develop a phobia (DiNardo 1988)
      • This suggests that conditioning alone cannot explain phobias. They may only develop where a vulnerability exists.
   10. Doesn't consider the cognitive aspects of behaviour

       Annotations:

       • We know that behavioural explanations in general are oriented towards explaining behaviour rather than cognition 
       • This is why the two process model explains maintenance of phobias in terms of avoidance - but we also know phobias have a cognitive aspect
       • The two process theory does not adequately address the cognitive aspects of phobias

1. Systematic Desensitisation
   1. Based on classical conditioning, counter-conditioning and reciprocal inhinition

      Annotations:

      • The therapy aims to gradually reduce anxiety through counter-conditioning: - Phobia is learned so that phobic stimulus (CS) produces fear (CR)- CS is paired with relaxation and this becomes the new CRReciprocal inhibition - it's not possible to be afraid and relaxed at the same time, so one emotion prevents the other
   2. Formation of an anxiety hierachy

      Annotations:

      • Patient and therapist design an anxiety hierarchy - a list of fearful stimuli arranged in order from least to most frightening. An arachnophobic might identify seeing a picture of a small spider as low on their anxiety hierarchy and holding a tarantula as the final item
   3. Relaxation practised at each level of the hierachy

      Annotations:

      • Phobic individual is first taught relaxation techniques such as deep breathing and/or meditation.  Patient then works through the anxiety hierarchy. At each level, the phobic is exposed to the phobic stimulus in a relaxed state. This takes place over several sessions starting at the bottom of the hierarchy. Treatment is successful when the person can stay relaxed in situations high in the hierarchy
   4. It is effective

      Annotations:

      • Gilroy (2003) followed up 42 patients who had SD for spider phobia in three 45 minute sessions.
      • At both 3 and 33 months, the SD group were less fearful than a control group treated by relaxation without exposure
      • This is a strength because it shows that SD is helpful in reducing the anxiety in spider phobia and that the effects of the treatment are long lasting
   5. Suitable for a diverse range of patients

      Annotations:

      • The alternatives to SD such as flooding and cognitive therapies are not well suited to some patients
      • For example, having learning difficulties can make it very hard for some patients to understand what is happening during flooding or to engage with cognitive therapies which require reflection
      • For these patients, SD is probably the most important treatment
   6. Acceptable to patients

      Annotations:

      • A strength of SD is that patients prefer it. Those given the choice of SD or Flooding tend to prefer SD
      • This is because it does not cause the same degree of trauma as flooding. It may also be because SD includes some elements that are actually pleasant, such as time talking with a therapist
      • This is reflected in the low refusal rates of patients and the low attrition rates (number of patients dropping out partway through) for SD
2. Flooding
   1. Immediate exposure to the phobic stimulus

      Annotations:

      • Flooding involves bombarding the phobic patient with the phobic object without a gradual build up. 
      • For example, an arachnophobic may have a large spider crawl over their hand until they can relax fully
   2. Very quick learning

      Annotations:

      • Without the option of avoidance behaviour, the patient quickly learns that the phobic object is harmless through the exhaustion of the fear response. This is know as extinction
   3. Ethical Safeguards

      Annotations:

      • Flooding is not unethical but it is an unpleasant experience so it is important that the patients give informed consent. They must be full prepared and know what to expect.
   4. Less effective for some types of phobia

      Annotations:

      • Although flooding is highly effective for treating simple phobias, it appears to be less so for more complex phobias such as social phobias
      • This may be because social phobias have cognitive aspects, e.g a sufferer of social phobia doesn't simply experience anxiety but thinks unpleasant thoughts about the social situation
      • This type of phobia may benefit more from cognitive therapies as they tackle the irrational thinking behind the phobia
   5. Traumatic

      Annotations:

      • Perhaps the most serious issue with the use of flooding is that it is a highly traumatic experience
      • The problem is not that flooding is unethical as patients give informed consent, more that the patients are often unwilling to see the treatment through to the end
      • This is a limitation because ultimately it means the treatment is not effective, and time and money are wasted preparing the patients for the treatment only to have them refuse to start it.

1. Behavioural
   1. Compulsions

      Annotations:

      • Actions that are carried out repeatedly, e.g hand washing. The same behaviour is repeated in a ritualistic way to reduce anxiety
   2. Avoidance

      Annotations:

      • The OCD is managed by avoiding situations that trigger anxiety, e.g the sufferers who wash repeatedly may avoid coming into contact with germs
2. Emotional
   1. Anxiety and distress

      Annotations:

      • Obsessive thoughts are unpleasant and frightening, and the anxiety that goes with these can be overwhelming
   2. Guilt and Disgust

      Annotations:

      • Irrational guilt, for example over a minor moral issue, or disgust which is directed towards oneself or something external
3. Cognitive
   1. Obsessive thoughts

      Annotations:

      • About 90% of OCD sufferers have obsessive thoughts, e.g recurring intrusive thoughts about being contaminated
   2. Insight into excessive anxiety

      Annotations:

      • Awareness that thoughts and behaviours are irrational. In spite of this, sufferers experience catastrophic thoughts and are hyper vigilant or over aware of their obsessions

1. Genetic explanations
   1. Candidate Genes

      Annotations:

      • Researchers have identified specific genes which create a vulnerability for OCD, called candidate genes.  - Serotonin genes e.g 5HT1-D beta, are implicated in the transmission of serotonin across synapses - Dopamine genes are also implicated in OCD  Both Dopamine and Serotonin are neurotransmitters that have a role in regulating mood
   2. OCD is polygenic

      Annotations:

      • OCD is not cause by one single gene as several are involved. Taylor (2013) found evidence that up to 230 different genes may be involved in OCD
   3. Different types of OCD

      Annotations:

      • One group of genes may cause OCD in one person but a different group of genes may cause the disorder in another person - known as aetiologically heterogeneous  There is also evidence that different types of OCD may be the result of particular genetic variations such as hoarding disorder and religious obsession
   4. Good supporting Evidence

      Annotations:

      • There is evidence from a variety of sources which suggests that some people are vulnerable to OCD as a result of their genetic make up
      • For example, Nestadt (2010) reviewed twin studies and found that 68% of identical twins shared OCD as oppose to 31% of non identical twins
      • This strongly supports a genetic influence on OCD
   5. Too many candidate genes are identified

      Annotations:

      • Twin studies strongly suggest that OCD is largely genetic, but psychologists have been less successful at pinning down all the genes involved
      • One reason for this is that it appears that several genes are involved and that each genetic variation only increases the risk of OCD by a fraction
      • The consequence is that a genetic explanation is unlikely to ever be very useful because it provides little predictive value
   6. Environmental risk factors

      Annotations:

      • It is not just genes, but it seems environmental risk factors can also trigger or increase the risk of developing OCD
2. Neural
   1. Low levels of Serotonin lowers mood

      Annotations:

      • Neurotransmitters are responsible for relaying information from one neuron to another. For example, if a person has low levels of serotonin then normal transmissions of mood relevant information does not take place and mood is affected
   2. Decision making systems in frontal lobe impaired

      Annotations:

      • Some cases of OCD, and in particular hoarding disorder, seem to be associated with impaired decision making. This in turn may be associated with abnormal functioning of the lateral frontal lobes of the rain. The frontal lobes are responsible for logical thinking and making decisions
   3. Parahippocampal Gyrus dysfunctional

      Annotations:

      • There is also evidence to suggest that an area called the left Parahippocampal Gyrus associated with processing unpleasant emotions, functions abnormally in OCD
   4. Supporting evidence

      Annotations:

      • Antidepressants that work purely on the serotonin system are effective in reducing OCD symptoms and this suggests that the serotonin system may be involved in OCD
      • Also, OCD symptoms form part of biological conditions such as Parkinson's disease (Nestasdt 2010)
      • This suggests that the biological processes that cause the symptoms in these conditions may also be responsible for OCD
   5. Serotonin OCD link may not be limited to OCD

      Annotations:

      • Many people who suffer from OCD become depressed. Having two disorders together is called co-morbidity
      • This depression probably involves disruption to the serotonin system. This leaves us with a logical problem when it comes to the serotonin system as a possible basis for OCD
      • It could simply be that the serotonin system is disrupted in many patients with OCD because they are depressed as well.

1. Drug Therapy
   1. Changing levels of neurotransmitters

      Annotations:

      • Drug therapy for mental disorders aims to increase or decrease levels of neurotransmitters in the brain or to increase/decrease their activity. Low levels of serotonin are generally associated with OCD. Therefore drugs work in various ways to increase the levels of serotonin in the brain
   2. Selective serotonin reuptake inhibitors (SSRI's)

      Annotations:

      • SSRIs prevent the re-absorption and breakdown of serotonin in the brain. This increases its levels in the synapse and thus serotonin continues to stimulate the post-synaptic neuron. This compensates for whatever is wrong with the serotonin system in OCD
   3. Typical dosage

      Annotations:

      • A typical daily dose of Fluoxetine is 20mg although this may be increased if it is not benefitting the patient. It takes 3-4 months of daily use for SSRIs to impact upon symptoms.  
   4. Combining SSRI's with CBT

      Annotations:

      • Drugs are often used alongside CBT to treat OCD. The drugs reduce a patients emotional symptoms, such as feeling anxious or depressed. This means that patients can engage more effectively
   5. Alternates to SSRI's: Tricyclics

      Annotations:

      • Tricyclics are an older type of antidepressant and are sometimes used, for example Clomipramine. These have the same effect on the serotonin system as SSRIs but the side effects used to be more severe
   6. Alternatives to SSRI's: SNRI's

      Annotations:

      • In the last 5 years a different class of antidepressant drugs called serotonin noradrenaline reuptake inhibitor (SNRIs) have also been used to treat OCD. These are a second line of defence for patients that don't respond to CBT. SSRIs increase levels of serotonin as well as noradrenaline
   7. Effective at tackling OCD symptoms

      Annotations:

      • For example, Soomro (2009) reviewed 17 studies comparing SSRIs to placebos in the treatment of OCD. All 17 studies showed significantly better results for SSRIs than the placebo conditions
      • Effectiveness os greatest when SSRIs are combined with a psychological treatment, usually CBT
      • Typically symptoms reduce
   8. Drugs are cost effective and non disruptive

      Annotations:

      • A strength of drug treatments in general is that they are cheap compared to psychological treatments. Using drugs to treat OCD is therefore good value to the NHS
      • As compared to psychological therapies, SSRIs are also non disruptive to patients lives. If you wish you can simply take drugs until your symptoms decline and not engage with the hard work of psychological therapy
      • Many doctors and patients like drug treatments for these reasons
   9. Drugs can have side effects

      Annotations:

      • Although drugs such as SSRIs help most people, a small minority will get no benefit. Some patients also suffer side effects such as indigestion, blurred vision and loss of sex drive (although these side effects are usually temporary)
      • For those taking Clomipramine, side effects are more common and can be serious. More than 1 in 10 patients suffer erection problems and weight gain, 1 in 100 become aggressive and suffer disruption to blood pressure and heart rhythm.
      • Such factors reduce effectiveness because people stop taking the medication
   10. Evidence for drug treatments is unreliable

       Annotations:

       • Although SSRIs are fairly effective and any side effects will most likely be short term, like all drug treatments, SSRIs have some controversy attached
       • For example, some believe the evidence favouring drug treatments is biased because it is sponsored by drug companies who do not report all evidence (Goldacre 2013)
       • Such companies may try to supress evidence that does not suppress evidence that does not support the effectiveness of certain drugs to maximise their economic gain
   11. Some cases of OCD follow trauma

1. Behavioural
   1. Activity Levels

      Annotations:

      • Sufferers of depression have reduced levels of energy making them lethargic. In extreme cases, this can be so severe that the sufferer cannot get out of bed
   2. Disruption to sleep and eating behaviour

      Annotations:

      • Sufferers may experience reduced sleep or an increased need for sleep Appetite may increase or decrease, leading to weight gain or loss
2. Emotional
   1. Lowered Mood

      Annotations:

      • More pronounced than the daily experience of feeling lethargic or sad. Sufferers often describe themselves as feeling 'worthless' or 'empty'
   2. Anger

      Annotations:

      • On occasions, such emotions lead to aggression or self harming
3. Cognitive
   1. Poor Concentration

      Annotations:

      • Sufferers may find themselves unable to stick with a task as they usually would, or they may find simple decision making difficult
   2. Absolutist thinking

      Annotations:

      • 'Black and white' thinking. For example, when a mildly bad situation occurs, it is seen as a disaster in the eyes of the sufferer

1. Beck's Cognitive theory of depression
   1. Faulty information processing

      Annotations:

      • Beck suggested that some people are more prone to depression because of faulty information processing. 
      • When depressed people attend to the negative aspects of a situation and ignore positives, they also tend to blow smaller problems out of proportion and think in black and white terms
   2. Negative self schemas

      Annotations:

      • A schema is a package of ideas and information developed through experience. We use schemas to interpret the world, so if a person has a negative self schema, they interpret all information about themselves in  a negative way
   3. The negative triad

      Annotations:

      • There are 3 elements to the negative triad - Negative view of the world - Negative view of oneself - Negative view of the future
   4. Good supporting evidence

      Annotations:

      • Terry (2000) assessed 65 pregnant women for cognitive vulnerability and depression before and after birth
      • They found that those women judged to have been high in cognitive vulnerability were more likely to suffer post natal depression
      • These cognitions can be seen before depression develops, suggesting Beck may be right about cognition causing depression, at least in some cases
   5. Practical application as a therapy

      Annotations:

      • Becks cognitive explanation forms the basis of cognitive behaviour therapy (CBT)
      • The components of the negative triad can easily be identified and challenged in CBT, meaning a patient can test whether the elements of the negative triad are true
      • This is a strength of the explanation because it translates well into a successful therapy
   6. Does not explain all aspects of depression

      Annotations:

      • Depression is a complex disorder. Some depressed patients are deeply angry and Beck cannot explain this extreme emotion
      • Some depression patients suffer hallucinations and bizarre beliefs, or suffer Cotard syndrome, the belief that they are zombies (Jarrett 2013)
      • Beck's theory cannot always explain all cases of depression and just focuses on one aspect of the disorder
2. Ellis's ABC model
   1. A: Activating Event

      Annotations:

      • Ellis suggested that depression arises from irrational thoughts. According to Ellis, depression occurs when we experience negative events
   2. B: Beliefs

      Annotations:

      • Negative events trigger irrational beliefs, for example:  - Ellis called the event that we must always succeed 'musterbation' - 'I-can't-stand-it-itis' is the belief that it is a disaster when things don't go smoothly - 'Utopianism' is the belief that the world must always be fair and just
   3. C: Conseqences

      Annotations:

      • When an activating event triggers irrational beliefs there are emotional and behavioural consequences. For example, if you believe you must always succeed and you then fail at something, the consequence is depression
   4. Partial explanation of depression

      Annotations:

      • There is no doubt that some cases follow activating events
      • Psychologists call this reactive depression, and see it as different to the kind of depression that arises without and obvious cause
      • This means that Ellis' theory only applies to some types of depression
   5. Cognitions may not cause all aspects of depression

      Annotations:

      • Cognitive explanations are closely tied up with the concept of cognitive primacy, the idea that emotions are influenced by your cognition
      • This is sometimes the case, but not necessarily always. Other theories of depression see emotions, such as anxiety and distress, as stored like physical energy, to emerge sometime after their causal event
      • This casts doubt on the idea that cognitions are always the root and cause of depression and suggests that cognitive theories may not explain all aspects of the disorder

1. Cognitive Behaviour Therapy (CBT)
   1. Patient and therapist working together

      Annotations:

      • The patient and therapist work together to clarify the patients problems. They also identify where there might be negative or irrational thoughts that will benefit from challenge
   2. Challenging negative thoughts

      Annotations:

      • The aim is to identify negative thoughts about the patients negative triad. These thoughts must be challenged by the patient taking an active role in their treatment.
   3. The 'patient as scientist'

      Annotations:

      • Patients are encourage to test the reality of their irrational beliefs. They might be set homework, for example to record when a person was nice to them. This is referred to as 'patient as scientist'. In future sessions, if patients say that no-one is nice to them, the therapist can produce this evidence to prove the patients belief incorrect
   4. Ellis's 'Rational Emotive Behaviour Therapy' (REBT)

      Annotations:

      • REBT extends the ABC model to an ABCDE model. D - dispute (challenge) irrational beliefs E - effect
   5. Challenging irrational beliefs

      Annotations:

      • A patient might talk about how unlucky they have been and how unfair life is. An REBT therapist would identify this as utopianism and challenge it as an irrational belief.  Empirical argument -  disputing whether there is evidence to support the irrational belief Logical argument - disputing whether the negative thought actually follows from the facts 
   6. Behavioural action

      Annotations:

      • As individuals become depressed, they tend to increasingly avoid difficult situations and become isolated, which maintains or worsens symptoms. The goal of treatment, therefore, is to work with depressed individuals to gradually decrease their avoidance and isolation, and increase their engagement in activities that have been shown to improve mood, e.g exercising 
   7. It is effective

      Annotations:

      • There is a large body of evidence to support the effectiveness of CBT for depression, e.g March (2007) compared the effects of CBT with antidepressant drugs and a combination of the two in 327 depressed adolescents
      • After 36 weeks, 81% of the CBT group, 81% of the antidepressant group and 86% of the CBT and antidepressant group showed significant improvement. CBT emerged as just as effective as medication and helpful alongside medication 
      • This suggests there is a good case for making CBT the first choice of treatment in public health care systems like the NHS 
   8. May not work for severe cases of depression

      Annotations:

      • In some cases, depression can be so severe that patients cannot motivate themselves to take on the hard cognitive work required for CBT
      • Where this is the case it is possible to treat patients with antidepressant medication and commence CBT when they are more alert and motivated
      • This is a limitation of CBT because it means CBT cannot be used as the sole treatment for all cases of depression
   9. Success may be due to the therapist - patient relationship

      Annotations:

      • Rosenzweig (1936) suggested that the differences between various methods of psychotherapy might actually be quite small
      • All psychotherapies have one essential ingredient - the relationship between therapist and patient. It may be the quality of this relationship that determines success rather than any particular technique
      • Many comparative reviews (Luborsky 2002) find very small differences between therapies suggesting they share a common basis
   10. Some patients want to explore their past

       Annotations:

       • One of the basic principles of CBT is that the focus of the therapy is on the patients present and future, rather than their past
       • In some other forms psychotherapy patients make links between childhood experiences and current depression
       • The 'present-focus' of CBT may ignore an important aspect of the depressed patients experience
   11. May be overemphasis on cognition

       Annotations:

       • CBT may end up minimising the importance of the circumstances in which the patient is living (McCusker 2014)
       • A patient living in poverty or sufferring abuse needs to change their circumstances, and any approach that emphasises what is in the patients mind rather than their environment can prevent this
       • CBT techniques used inappropriately can demotivate people to change their situation