Diagnostic assessment in educational and clinical contexts

¶ … real problems faced by real people in the world, it might seem foolish to analyze a fictitious character. But sometimes it is easier to understand human nature when we look to art or fiction, in part because art provides us with some needed distance at times and in part because fictitious characters are often relatively pure distillations of character types. This is the case with the character of Grace from the television show "Grace Under Pressure." This paper provides an analysis of this character using first the Adlerian therapy model, then analyzing her through a behavior model and then finally suggesting a treatment plan for a person with the profile of Grace.

Grace's character - to begin with a thumbnail of her - is presented in the series as a no-nonsense, take-no-guff survivor of a bad marriage that was often abusive (at least in psychological terms). After eight years of putting up with this bad marriage, Grace decided that low pay and long hours was a better choice than staying married, and the show follows her as she lives with the consequences of this choice as she works to raise her three children on her own with few skills or advantages even as she works to overcome her own problems with alcohol.

Grace is in many ways an ideal candidate for Adlerian Therapy, which stresses the importance of personal growth and the need for each individual to take control of her or her life. This model allows for people to make significant changes in their lives, something that is often very difficult for women (especially women with children) in abusive situations:

Adlerian Therapy is a growth model. It stresses a positive view of human nature and that we are in control of our own fate and not a victim to it. We start at an early age in creating our own unique style of life and that style stays relatively constant through the remained of our life. That we are motivated by our setting of goals, how we deal with the tasks we face in life, and our social interest (http://www.psyweb.com/psywebsub/MentalDis/AdvPsych.html).

Adlerian therapy stresses the importance of challenging people to set goals that are as high as they can reach so that they are not defeated by repeated failures to achieve those goals but also sufficiently high that an individual can in fact make those changes in her or his life that are needed to make significant and substantive changes so that they emerge with a sense of self-worth and personal and social competence.

An Adlerian therapist encouraging goals "that are useful socially and to help them feel equal... from any component of life including, parenting skills, marital skills, ending substance-abuse, and most anything else." This approach would mesh very well with someone like grace, who struggles as a parent and as someone with an addictive personality and problems with alcohol (http://www.psyweb.com/psywebsub/MentalDis/AdvPsych.html).

One of the issues that an Adlerian therapist would certainly address vis-a-vis a character like Grace is that of learning to recognize and avoid situations of domestic violence. The issue of domestic violence - always of concern to the victims, some researchers, and many social and women's shelter workers - became an issue of national concern during the O.J. Simpson trial. Just as the Clarence Thomas hearings raised the issue of sexual harassment in places where before it had been ignored, the pictures of a battered and bruised Nicole Brown - pictures that she had made so that if Simpson ever killed his/her past violence to her would be known -- gave an unforgettable face to the problem of domestic violence. That case also highlighted some of the complex problems that scholars studying the issue of domestic violence and social workers trying to end the beatings face in their work.

But as soon as the Simpson trials - criminal and civil - were over, the issue of domestic violence began to fade again into the woodwork. It once again became something that people knew about but - unless they were directly involved - didn't talk about, didn't think about. But it is a subject that people should think about both because of the magnitude of the problem and because it has enduring implications: Abuse does not stop with a single generation. This paper examines the recent research done on the subject of domestic violence in general before focusing specifically on the ways in which immigrant women are especially at risk.

The character of Grace, like that of many women who find themselves seeking Adlerian therapy to give them the skills to help better their own lives, is not atypical. Thousands of American women are abused, either physically or psychologically or both, by their partners, and alcohol is a major contributing factor in a majority of these cases.

Grace's reflects the following statistics - although she chose to remove herself and her children from a dangerous situation before it turned lethal.

Women were attacked about six times more often by offenders with whom they had an intimate relationship than were male violence victims.

Nearly 30% of all female homicide victims were known to have been killed by their husbands, former husbands or boyfriends.

In contrast, just over 3% of male homicide victims were known to have been killed by their wives, former wives or girlfriends.

Husbands, former husbands, boyfriends and ex-boyfriends committed more than one million violent acts against women.

Family members or other people they knew committed more than 2.7 million violent crimes against women.

Husbands, former husbands, boyfriends and ex-boyfriends committed 26% of rapes and sexual assaults.

Women of all races were equally vulnerable to attacks by intimates.

Female victims of violence were more likely to be injured when attacked by someone they knew than female victims of violence who were attacked by strangers (http://www.usda.gov/da/shmd/aware.htm#BREAK).

In order to understand how Grace is lucky in escaping from her marriage as well as the ways in which the divorced Grace would benefit from a program of Adlerian therapy we must understand the nature of the abusive situation that she has escaped from. So what exactly are we referring to when we discuss domestic violence? A generally accepted definition is violence by one adult member of a household against another. This obviously excludes child abuse, not because this is an area of lesser concern but because the dynamics of child abuse (while similar in some ways) are different enough that it should be considered separately.

This definition is obviously and intentionally gender-neutral, for it does happen that women are always the victims but sometimes the aggressors in situations of domestic violence. (And sometimes one individual can play both roles in different situations.) While of course no act of violence should ever be trivialized, violence perpetuated by men against women is far more serious for two reasons. The first is that male-against-female violence accounts for the greatest majority of incidents of domestic violence; the second is that male-against-female violence accounts for the great majority of lethal domestic violence (Renzetti and Miley 13). This differential of lethalness in this type of domestic violence is true in part because men are usually stronger and larger than women but also because it seems to be the case that men in general (and especially abusive men) have less psychological resistance to escalating the levels of violence in a relationship (http://www.nlm.nih.gov/medlineplus/domesticviolence.html).

Grace has to deal with other issues as well as her past abusive marriage, although it results in many ways from her being in an abusive relationship for eight years. She definitely could improve her self-esteem. It is generally acknowledged that low self-esteem is one of the main characteristics of many mental disorders including depression. It must also be acknowledged that low self-esteem is widespread amongst Americans. This is due in no small part to the fact that many parents and other caretakers do not provide an environment that is sufficiently nurturing for their children.

However, this is not the only reason that there exists such a large percentage of the population with low self-esteem. Equally important to consider is the self's need for others (not only parents and early childhood caretakers) to perform self-object functions. Adlerian therapy encourages people to use the therapist as a new self-object to restructure the self, thus allowing an individual to find that in many cases she can reclaim and repair part of her (or his, of course) past. Elements of the past that cause continual problems for the subject can be "repaired" by the substitution of a new piece of information that the patient and the therapist create together.

Thus one of the most important actions that the Adlerian therapist can perform in working with a patient who is depressed and is suffering from low self-esteem is to take over some of the unfilled roles in the patient's life and by doing so provides a better overall environment for the patient. This seems to be the case for Grace. This empathic and supportive intervention provides a fundamentally supportive Adlerian therapy regime that results in the patient's capacity to become independent of the therapist, not in substituting him for his other dependency feelings (Ornestein, 1986).

In order to provide the best combination of therapies to a person like Grace, it is also essential to understand the nature of anxiety, which she sometimes suffers from. She might in fact be a candidate for a DSM-IV diagnosis of 300.02 or Generalized Anxiety Disorder. This diagnosis of GAD is part of the larger arena of anxiety disorders and manifests as a feeling of dread or fear that usually has no clear justification. Anxiety may thus be distinguished from true fear because the latter arises in response to a clear and actual danger - a tiger charging towards one should produce fear. Anxiety, by contrast, arises in response to apparently innocuous situations or is the product of subjective, internal emotional conflicts the causes of which may not be apparent to the person involved.

Some anxiety inevitably arises in the course of daily life and is normal. But the level of anxiety that Grace often demonstrates is not seemingly justified as a response to real-life stresses as so must be regarded as a sign of an emotional disorder. There are many causes (and psychiatric explanations) for anxiety. Sigmund Freud viewed anxiety as the symptomatic expression of the inner emotional conflict caused when a person suppresses from conscious awareness experiences or feelings that are too threatening to endure. (Of course, in the show, her anxiety may simply be being played for laughs.)

Behavior Therapy Model

Behavior therapy relies less on the kind of internal road-map that Adlerian therapy utilizes and emphasizes changes an individual's behavior. (We should note that this does not contradict Adlerian therapy, which also advocates individuals' taking control over their lives; however the ways in which one makes positive changes is different in the two different models even if the basic goal is the same.)

It might seem to be superficial to change behavior when there are underlying psychological problems, but if we examine this idea we find that it is more significant than it might appear. We can understand this if we apply this model of personal growth and therapy to Grace's life. She is (at the beginning of the series) having problems in part because of the way she sees herself and in part because of the choices that she makes.

However, she has also had problems because of her environment and her behavior. She had problems because she drank too much. While stopping excessive drinking does not cure the underlying problems that prompted a person to drink, it does prevent the problems that arise from drinking itself. Getting out of an abusive marriage does not solve the problems that led one to enter into an abusive relationship to begin with, but it does solve the problems that arise from that particular relationship.

Changing one's behavior, and one's environment, does not change long-lasting and underlying pathologies, but it can often be the first step in making important positive changes in one's life - as we see in the case of Grace.

Behavior therapy is always undergoing refinement and uses learning to overcome specific behavioral problems. In this type of therapy it is believed that behaviors are learned, that we are a product of our environment. Focus will be on present and overt behavior. In this type of therapy it is believed that reinforcement and imitation teaches normal behavior and that abnormal behavior is a direct result of defective learning. Therapy will be based on learning theory. The therapy will include a treatment plan, the goals of the treatment will be laid out up front, and the outcome expected from the therapy will be set right up front too. To eliminate unwanted behaviors you need to learn new behaviors. This may include assertion, behavioral rehearsal, coaching, cognitive restructuring, desensitization, modeling, reinforcement, relaxation methods, self-management, or new social skills (http://www.psyweb.com/psywebsub/MentalDis/AdvPsych.html).

Behavior therapy is especially useful in treating anger and depression - both of which affective states Grace feels at times - and the ways in which these two states overlap. Depression and anger are two of the strongest emotions that humans can feel: Both can seem to be overwhelming to an individual. And when the two co-occur, or when one prompts the other, the sensation can be overpowering.

We should perhaps note that we are not referring to "normal" anger or depression in this discussion of Grace's character, not to relatively short-lived emotions that are culturally and personally appropriate responses to events in an individual's life. Rather, we are referring to anger and depression that seem out of place in terms of their severity or length. Serious depression - especially if accompanied by anger - can cripple a person, can make suicide seem seductively attractive, can make an individual that made him lose all sense of connection with what it means to be human. Grace is not this depressed, but she does certainly suffer from more than minor depression at times.

It is this kind of depression and anger that we are talking about here, not the kind of "normal" depression caused by the death of a loved one, by a drunk driver totaling a much beloved car, being the victim of rape. In general, the kinds of depression that follow such events, while these bouts of depression are difficult for those enduring them, are not a cause for worry, as Solomon (1998) notes in chapter one. These episodes of depression and/or anger have specific causes and tend to be relatively short-lived. They are seen by mental health professionals as part of the normal healing process that occurs after various forms of trauma. In such "healthy" instances of anger or depression the two emotions tend not to be linked to one another. Rather, both anger and depression arise from an independent cause - such as illness or loss of a loved one.

However, in the case of clinical depression or unmanageable anger the two emotions do tend to be linked, tend to be dependent upon each other (Amen 2000). Clinical depression, depression that has no obvious cause and that descends with demonic weight, depression that cannot be reasoned with or seen past but that takes away the light of one's entire life, is quite often accompanied by uncontrollable anger - and uncontrollable anger (the kind that often manifests itself in violence against self or others) is often accompanied by clinical depression (Fernandez 2002). This level of depression or anger is rooted in the complex chemistry of the brain and must be considered as much as disease as polio or cancer. It is something that attacks the health of a person and endangers his or her life, and to save that person it must be fought against. It is also related to past trauma and abuse of the kind that Grace has experienced.

Depression is a serious problem but also one that can be addressed with a high degree of success with the behavioral model that we are discussing here:

Depression has many causes; biological changes can cause depression, rigid negative attitudes about oneself can cause depression, catastrophic events can cause depression. But one thing occurs after onset that is common to depression regardless of its etiology: negative thinking. Depressed people view the world in a negative manner; they view themselves in a debasing way; and they view their future as dismal. Cognitive therapy is a treatment designed to help people learn to identify and monitor negative ways of thinking, then to alter this tendency and think in a more realistic manner.

When depressed people learn to identify distorted automatic thinking and to replace them with more realistic ones, depression can be reduced. Moreover, when people become adept at altering negative thoughts and beliefs, their likelihood of experiencing episodes of depression in the future decreases (http://www.habitsmart.com/cogintro.html).

This may sound like an overly simplistic way to view the problem of depression, but in fact it is simply an acknowledgement of the fact that there are fundamental connections between behavior and mood. Most of us believe that this is in fact the case because most of us have ample experience with this phenomenon in our own lives.

This is the case even with complex mental states such as anger and depression. Although these are presented in a somewhat superficial way on Grace Under Fire, we do see in this show a serious attempt to show how individuals come to term with such important (and sometimes overwhelming) emotional conditions.

One of the reasons that the connection between depression and anger is not better understand is that while it is a very common condition it can be very hard to diagnose or recognize: There is no serum to test for when looking for depression (Yapko 1998). Difficulty of diagnosis is of course an issue in many affective disorders: In some real if rather vague way, mental health is simply the absence of mental disorders. And in the reverse we define mental illness as the absence of mental health. The circularity of this definition is certainly confusing, but it reflects the real confusion over the range of what may be considered to be mentally "normal" (Jones, 1994, p. 20).

Both anger and depression can be treated through a behavioral approach because it addresses the connections between cognition and behavior as in the following description of depression.

Depressive symptoms feed one another, and this is what prolongs the state. Consider the example of an applicant who is turned down after a job interview and comes to the following conclusions: "I'm a loser, I'm unemployable" These self-statements will certainly make her feel sad and guilty (emotional), which in turn will lead to a lethargic, listless physical state (physical), to which she might elect to spend all day in bed (behavioral), leading to insomnia that night (physical). During the wakeful hours of darkness and silence, she has other thoughts like "I can't do anything with my life" (cognitive) and to conjure ugly memories of past failures (cognitive). She'll undoubtedly have decreased energy the next day (physical) and find it hard to concentrate (cognitive). She may elect to cancel her lunch date with her friend (behavioral) then think thoughts like "my whole life is falling apart," (cognitive). This, in turn, will add anxiety to her experience (emotional) which will add restlessness to her fatigue, (physical), which may lead to the decision to cancel another scheduled job interview the following day (behavioral) and so on (http://www.habitsmart.com/dep.html).

The following section focuses more on this issue. It is important to stress that behavioral models of therapy work not because they posit that it is (surface) behavior alone that matters but rather because they assume that changing such (surface) behavior is a way of changing the underlying affective states that originally prompted such behavior.

Treatment Suggestions

Before looking in-depth at a cognitive therapy model of treatment, we will give an overview of the range of possible treatments for a person like Grace. Among the behavioral therapy techniques that might be appropriate to try with Grace are rational emotive therapy, which has as its goal the alteration of inaccurate or irrational thoughts that lead to negative emotions or maladaptive behavior. Other behavioral approaches attempt to modify physical responses. Biofeedback, for example, uses sensitive electronic devices and the principles of reinforcement to provide continuous visual or auditory "feedback" which helps patients learn to control subtle physical processes. And relaxation training, like deep muscle relaxation exercises, is a stress-reducing technique that can be used in a variety of situations and that Grace might helped her to break a downward emotional cycle. She might well benefit (as do many people) from a combination of these techniques.

Grace might also benefit from a family system model of therapy. Family systems therapy is part of the larger movement of general systems theory and must be understood within that context. Systems theories as a whole conceive of the individual as an interdependent part of larger social systems and as such do not focus on how problems start (and so are fundamentally different from traditional psychoanalytic theories). Instead, they are keyed to understanding how the dynamics of different relationships influence the problem at hand.

The system therapist's primary goal is thus to alter the dynamics of the relationships that the client finds problematic rather than to focus only on the individuated behavior or internal dynamics of individuals. Family systems therapy emphasizes the use of group discussion and other group activities in treatment of psychological disorders, which certainly seems as if it would help Grace if it could be arranged. Group therapeutic techniques are as varied as those of individual therapy. Like individual therapy they stress either alleviation of members' distress by direct measures or may in stead seek to create an ongoing atmosphere in the group atmosphere that is conducive to increased self-understanding on the part of each member.

The idea of treatment of the family as a group would obviously be central to the treatment offered in this case if it were possible. Family therapy is based on the view that whatever destructive interrelations exist amongst family members (and certainly there are a number of destructive dynamics that obtain here) may be made more at least less destructive it not outright positive by examining the behavior patterns of each individual toward each other person and analyzing how each family member tends to adopt various roles. For example, families frequently designate one member to play the martyr role and that individual's behavior is correspondingly shaped over time, sometimes to the point of emotional disturbance.

A readjustment of the roles that each person is playing can thus significantly reduce overall symptomology. Some readjustment of roles is possible even in the absence of the cooperation of other members of the family.

One of the important aspects of any type of therapeutic intervention to remember is that both parties to any such encounter bring their own cultural ideals and expectations to it, and it therefore is important for anyone trying to help someone else in a sincere way to have some understanding of her (or his) own cultural values.

Lynch and Hanson (1998) stress the importance of recognizing such cultural definitions as well as cultural differences between therapist and patient, emphasizing that to ignore them or underestimate their strength or importance is to make one's goals at therapeutic intervention nearly impossible (at best) to reach.

Service providers work with a variety of families though the provision of a range of education, health, and social services. In this process, they may travel, similar to the train passenger, through many cultures in a single day. The differences among these families often are much more pronounced then those found by the traveler crossing the European continent (p. 5).