Medical and Psychological

Models of Mental Health and

Illness

-Reeva DeSa
Final Year BOT
Introduction
• Theories attempt to explain how mental health problems may
develop and how a therapist may help someone deal with them.
• Historically OTs have used theories developed by psychologists or
psychiatrists.
• Although some are used less now than before, techniques based on
them are still in use.
• A theory is one explanation, but there is not yet any one “correct”
theory that explains all that we want to know about the human mind.
1. Theory of Object Relations
• This is a psychoanalytical theory based on the work of Freud and his
followers, who believed that mental health and illness are determined
by our relations with objects in our environment.
• These objects may be non-human or human.
• Our abilities to love and respond to other people and to take interest
in the things in our environment are seen as expressions of object
relations, which is believed to develop through relationships in very
early childhood.
• According to this theory, the infant develops relationships with
objects in the environment to satisfy needs, such as hunger and thirst.
• Humans have inborn tendencies, or drives, to try actively to satisfy needs.
• Drives originate in the id.
• At birth, id dominates. It is only through experiences of and relationships with
human and nonhuman objects that other parts of the personality develop.
• Eg. a baby cries when hungry, later they are taught by their parents and
society how to express their needs in a more socially acceptable manner, and
eventually these rules become part of the childs personality. Freud called this
the superego.
• The id and superego are at constant conflict, the ego controls anxiety by
compromising between the warring id and superego.
• The ego has many functions, among which are memory, perception, reality
testing and defence mechanisms.
• Sometimes the ego may use suppression to control the anxiety, but
occasionally the ego is overwhelmed and unable to resolve the conflict.
• According to object relations theory, the extreme anxiety that can result can
cause a breakdown of ego functions- in other words mental illness.
• Mental illness occurs when the ego is unable to successfully compromise
between the demands of id, superego and reality.
• Freud discovered that the analysis of symbols in patients’ dreams provided
clues to their unconscious feelings and that by talking to them he could make
them conscious of those feelings.
• In object relations theory, many symbols are used as keys to the meaning of
unconscious conflicts. Eg food symbolizes relationship with the mother, who
is the first object to satisfy the hunger need. Thus in our minds food is often
associated with love and trust.
• OTs who apply object relations theory use symbols in arts, crafts, and
everyday activities. Eg, Ceramics- wet clay can symbolize the anal
period,during which the child learns self control, hence the activity can be
used to explore issues of self-control versus control by others.
• Criticisms of object relations theory – needs extensive training, requires long
period of time for results, developed by men and is based on a
gender-specific view, ignores the essential therapeutic value of individually
chosen productive activity and instead exploits the symbolic elements of
activities that are not linked to functional participation in real life, does not
address the neurological impairments associated with schizophrenia and
other mental disorders.
2. Developmental Theory
• Several versions including Erikson, Piaget, and Gesell.
• A person matures through a series of developmental stages that occur
in a fixed sequence.
• At each stage the person encounters certain developmental tasks that
provide a foundation for later development.
• However many factors can hamper the growth process, which results
in a developmental lag.
• To help a person who has problems because of a developmental lag,
the therapist designs situations that will facilitate growth in the
deficient area.
 • Developmental theories are consistent with many of the basic ideas of OT.
The concept of gradation, of learning through successively more challenging
and complex stages, and the focus on solving problems and acquiring skills make
it an appealing choice.
There are 3 major difficulties with this approach.
1. Some persons with long standing mental illness (since childhood) lag in the
earliest stages of psychosocial development(trust vs mistrust); they have
always had difficulty trusting others and to change fundamental and lifelong
mistrust is a serious challenge.
2. Gradual process so takes a long time
3. Requires rigorous study and training due to complex interrelatd nature of
development.
• One developmental model used in psychiatric OT is development of adaptive
skills.
3. Behavioural Theories
• The central concept is that behaviour is learned.
• Behaviours that have pleasurable results tend to be repeated.
• Actions that have negative or unpleasant consequences tend not to be
repeated.
• If adaptive behaviours are rewarded and maladaptive behaviours are
ignored or punished, the result should be a mature and responsible human
being.
• OTs use an action-consequence approach as the therapist tries to change
the behaviour by changing the consequences of the behaviour.
• The first step in a behavioural program is identification of the terminal
behaviour. (desired behaviour)
• Next the therapist selects a reinforcement.
• The therapist then decides how often and for how long the reinforcement will
be given.(schedule)
• The therapists uses variety of techniques including shaping, chaining and
sensitive desensitization.
• Unlike object relations and developmental theories, behavioural therapy gives
quick results.
• OT treatment approaches based on behavioural theories include Mosey’s
activities therapy and the use of social skills training.
• Criticisms- treats people like machines, use of unhealthy reinforcers (eg
coffee,cigarettes), and use of punishment.
 4. Cognitive Behavioural Therapy
• The cognitive-behavioural frame reference is an emerging frame of reference
in which mans cognitive function is believed to mediate or influence his
affect and behaviour.
• It provides an assessment guide for determining cognitive function, affective
states, and generalized behaviours which are apparent as the patient
participates in his environment.
• The treatment include verbal and behavioural techniques to change the
patients thoughts, to bring about behavioural change and to improve
function.
• When applying the framework, the occupational therapist uses graded
activities to provide progressive challenges and success experiences in order
to develop cognitive abilities

• To expand the knowledge and strategies that the patient can use to act upon,
interact in, and gain control of his environment, to increase his self
knowledge, to problem solve and to cope with his life challenges.
 5. Client-centred therapy aka Humanistic
Therapy
• Developed by Carl Rogers. Central concept is that human beings possess
the potential for directing their own goals and development.
• No matter how disorganized the behaviour may appear, the client is
capable of self-understanding and ultimately changing the behaviour.
• Another concept is that people direct their own lives, hence the therapist
does not tell the client what to do, the client must determine what action
to take.
• A third concept is that mental health problems occur when a person is not
aware of feelings and available choices.
• A fourth concept is that a person can become more aware of feelings and
choices by experiencing them in a relationship with a therapist who
genuinely accepts themselves as well as the client. They must be able to
provide unconditional positive regard.
• One technique of this approach is the open invitation to talk. The invitation
to talk is conveyed through open questions.
• A second technique is minimal response, which shows the therapist is
listening to the client.
• A third technique is reflection of feeling.
• Using paraphrasing (4th technique) the therapist restates in different words
what the client has said.
• Fifth technique is withholding judgement.
 6.Neuroscience Theories
• Based on the assumption that normal human functioning requires a brain
that is anatomically normal, with normal neurophysiology and brain
chemicals in the proper proportions.
• Some mental disorders show variations from these normal conditions.
• Treatment thus involves changing the abnormal somatic conditions through
somatic intervention such as pharmacotherapy, psychosurgery and ECT.
• The traditional role of occupational therapy in this approach has been to
monitor the effects on functional performance of the treatments prescribed
by the physicians.
• By observing activity performance, the OT can help the psychiatrist verify the
diagnosis and later decide whether the treatment is working, whether it
should be increased or decreased.
• New advances – neuroimmunomodulation and psychoneuroimmunology.
• OT approaches – eg. King’s sensory integration approach to the treatment of
schizophrenia, Allen’s approach and Brown’s approach.
Psychiatric (PsyR) and Psychosocial
Rehabilitation
• Competing names for essentially the same approach.
• PsyR is an approach which combines principles and concepts from the fields
of physical rehabilitation, client-centred therapy, behavioural psychology
and psychosocial rehabilitation.
• Since it draws on many sources for techniques, it is atheoretical (without
theory) although it uses techniques associated with several theories.
• It does not try to explain why or how mental illnesses occur.
• “Psychosocial rehabilitation” is a term preferred by many health
professionals who are not psychiatrists (psychologists, nurses, occupational
therapists). Since many of the methods and principles have a social
emphasis, this term seems more descriptive.
• The approach is similar to Occupational Therapy in that it is oriented to the
present and future, focuses on development of skills and resources, and uses
activities and environmental adaptations as a base for intervention.
• Since it has no theory, we will look at goals, values and guiding principles.
• Goals-recovery, community integration and quality of life.
• Values are strongly oriented towards client self-direction
(self-determination, dignity and hope).
• The guiding principles include the following:-
• Client-centred, individual approach
• Services that emphasize normal functioning in the community
• Focus on the strengths of the client
• Assessment based on the client’s situations
• Coordination of services accessible to clients
• Focus on work
 • Focus on skill development
• Environmental modification and supports
• Family involvement
• Research and outcome orientation
• 3 stage process
1. Rehabilitation diagnosis
2. Rehabilitation planning
3. Rehabilitation intervention
2. Rehabilitation diagnosis consists of explaining to the client their role in the
process, setting the overall rehabilitation goal (ORG), evaluation of
functional skills, and assessment of resources.
3. In the planning stage, the practitioner and client determine and prioritise
deficit areas, then discuss and select appropriate interventions.
4. Rehabilitation intervention is enactment of the plan.
• The 2 main areas of intervention in PsyR are (a) developing the client’s
functional skills and (b) modifying the environment to maximise use of skills.
• Although it is atheoretical, it does make certain assumptions.
1. Functioning adequately in the environment of one’s choice is possible for everyone.
2. To function successfully, one must possess the needed skills and resources.
3. Skills that are lacking can be developed through training, and skills that are present
but weak can be strengthened through practice.
4. Environmental supports and resources enable and facilitate successful functioning.
5. Belief in and hope for the future facilitate rehabilitation outcomes.
• Thus Occupational Therapy is a natural fit with PsyR, which is a
multidisciplinary approach.
Explanatory Models from Various Cultures
• Some of the reasons given for emotional distress and abnormal
behaviour in different countries and cultures are as follows:-
❖ Possession by evil forces, ghosts, animals, spirits
❖ Sorcery and witchcraft
❖ Loss of semen (real or imagined)
❖ Belief that one’s genitals are shrinking or withdrawing into the body
❖ Wind in the body or the head
❖ Thinking too much
❖ Sickness sent by others
❖ Constitutional vulnerability to stress
❖ Departure of the soul from the body
❖ Fear that one is offensive to others, particularly in body odors