Which theorist proposes that identity is a primary?

6.16.8.2 Psychosocial Theories and Treatments of Bipolar Disorder

Psychosocial theories and treatments of bipolar disorder follow from an understanding that, although the disorder has predominantly genetic causes, its course is responsive to environmental stressors (Johnson & Miller, 1997). As adjuncts to medication therapy, psychosocial treatments aim to enhance medication compliance, and to increase resilience to stress. Miklowitz and Goldstein (1990) have developed family-focused treatment (FFT) for bipolar disorder. The goal of FFT is to reduce family conflict, which is believed to precipitate relapse. In the initial phase of FFT, patients and their families are educated about the symptoms of the disorder, the importance of medication compliance, and the strategies to employ if the patient begins to relapse. In the later stages of FFT, the psychoeducational focus is on improving family interaction—all family members learn communication and problem-solving skills (Miklowitz, Frank, & George, 1996).

A similar psychoeducational approach is found in the treatment known as interpersonal and social rhythm therapy (IPSRT; Frank et al, 1997). IPSRT methods were developed in recognition that irregular sleep and circadian patterns can be detrimental to the bipolar patient. Patients are shown that interpersonal stressors and social role transitions may upset daily routines, which in turn may disrupt circadian regularity and lead to relapse. During the course of therapy, patients are taught how to negotiate interpersonal dilemmas and role transitions, and they are coached in how to regularize and maintain stable daily routines, even when they encounter stressors in their environments.

Both FFT and IPSRT therapies are currently under investigation in randomized clinical studies. Preliminary results show that both treatments produce high patient retention rates through the first year of treatment (Miklowitz et al., 1996). In addition, IPSRT patients have demonstrated increasing stability of daily routines over the course of treatment (Frank et al., 1997).

Newman and Beck (1992) have described a cognitive model in which mania is characterized by a positive cognitive triad: the self is seen as highly valued and powerful, experience is viewed as overly positive, and the future is replete with opportunity. The distortions associated with this triad are the focus of cognitive theory and treatment.

Cochran (1984) found that the addition of a six-week cognitive therapy component reduced medication noncompliance, as well as the frequency of hospitalizations, during a six-month follow-up. More recently, Basco and Rush (1996) and Newman and Beck (1992) have given extensive descriptions of adjunctive cognitive-behavioral programs for bipolar disorder. The primary goals of these programs are to educate the patient, to increase adherence to medication regimens, and to promote the use of cognitive-behavioral techniques when confronted with affective symptoms. Education about bipolar illness includes instruction in the self-monitoring of prodromal symptoms. Awareness of subtle changes in symptoms or behaviors can then serve as a warning system for relapse. This warning system can cue the patient to have their medications monitored or increased. Efforts to facilitate adherence to medication regimens include addressing patient concerns and beliefs about medication. Behavioral techniques, such as pairing medication intake with another daily activity, are used to ensure that medication is taken regularly.

Cognitive therapy also focuses on the cognitive distortions of manic patients. For example, feelings of grandiosity are perpetuated by magnification of the positive and minimization of, or obliviousness to, negative feedback. Paranoid thinking in mania is reinforced by selective attention to evidence that confirms paranoid beliefs, along with dismissal of disconfirming evidence. These tendencies, as well as the patient's desire to maintain a manic or hypomanic state, are addressed with standard cognitive therapy methods.

In cognitive therapy, behavioral interventions are used to limit self-stimulating behaviors. Activities that have a high potential for dangerous consequences or which might serve to exacerbate the episode are identified early on, and the therapist helps to plan strategies for avoiding or limiting these activities. These include, as in IPSRT, maintaining a regular sleep schedule, as well as limiting spending, alcohol and drug use, and other risky behavior. Problem-solving skills are employed to address stressful life events that might precipitate relapse, and to address difficulties arising in the aftermath of an affective episode, such as the financial difficulties that result from excessive gambling or the loss of employment. Thus far, there have been no controlled clinical studies of cognitive therapy of bipolar disorder.

Abstract

A psychosocial and developmental theory on spirituality and religion is outlined. The theory is based on the assumption that there is a core tendency for all people to appreciate, experience, accept, and express a spiritual dimension of life. There is a strong appreciation of how peoples’ culture and familial background are important in the development of religious practices. Even though people may adhere to similar religious practices, or nonreligious beliefs, there are varying pathways that people follow, which account for individual differences.

At the peripheral level, there are four major types, based on the infantile years, which develop varying motives, traits, and defenses. They develop varying emotional and cognitive internal working models that interact with the environment during critical developmental stages to create differing peripheral characteristics of their religious or nonreligious expressions.

Key developmental stages are the infant years, adolescence, middle adulthood, and late adulthood.

A number of psychosocial theories has been developed to predict, explain, and change health behaviors. These theories can be divided into two main groups which are commonly referred to as social cognition models and stage models, respectively. The term ‘social cognition models’ refers to a group of similar theories each of which specifies a small number of cognitive and affective factors (‘beliefs and attitudes’) as the proximal determinants of behavior. The five models that have been used most widely by health behavior researchers in recent years are: the health belief model, protection motivation theory, self-efficacy theory, the theory of reasoned action, and the theory of planned behavior. These models are outlined in turn, their similarities and differences are noted, and common criticisms are discussed. Stage models use similar concepts but organize them in a different way. According to this approach, behavior change involves movement through a sequence of discrete, qualitatively distinct, stages. The dominant stage model of health behavior, the transtheoretical model, is described, and some problems with the model and the research based on it are mentioned.

3.1 Erikson’s psychosocial theory

Erik Erikson’s psychosocial theory (1950) is one example of a theory of typical development that has the potential to aid in generating hypotheses and interpreting research findings relating to the transition to adulthood for individuals with ASD and their families. In this theory of personality, Erikson proposed eight stages of human development starting in infancy and extending into old age. Each stage focuses on becoming competent in an area of life and is characterized by a developmental “crisis” or conflict. Before the individual moves on to the next stage of development, the previous conflict must be resolved on a spectrum ranging from positive to negative. A positive resolution indicates that the person has acquired the skill or competency of that stage, whereas a negative resolution results when the individual fails to develop the competency. The way that a crisis is resolved at each developmental stage is not only important to that stage, but also to all subsequent stages, as each competency builds on the competencies from earlier stages. That is, a negative resolution to one stage will make it much more difficult to resolve the crisis of a subsequent stage in a positive way.

For the current discussion, two of Erikson’s psychosocial stages are most relevant. The first is “identity versus identity confusion,” which takes place during adolescence. As adolescents are exploring their independence and developing their sense of self, they begin to think about such questions as “Who am I, and what is my place in the world?” When this personal exploration is appropriately encouraged and reinforced, adolescents are able to choose their sets of values and their vocational goals and develop a lasting personal identity. Having developed a set of personal values and an independent identity allows adolescents to know where they fit into society and to confidently move into adulthood and the next stage of development. According to Erikson (1968), failure to develop an identity leads to confusion and insecurity about future adult roles and results in difficulty with successful resolution of future adult stages.

The second of the relevant psychosocial stages is “intimacy versus isolation,” which Erikson (1964) proposed as the major stage of early adulthood. Erikson believed that early adulthood was the time when people began exploring intimate relationships with those outside of their families of origin, and that the development of close, committed relationships with such others was vital to optimal psychosocial development. Those who are able to successfully resolve this phase develop committed and secure relationships, whereas those who are unsuccessful will experience isolation and loneliness. Keeping in mind that the resolution of each stage depends on the previous stage, Erikson believed that young adults who failed to develop a personal identity during the adolescent stage would have a difficult time finding intimacy with others in young adulthood.

Researchers have yet to empirically apply Erikson’s stages to those with intellectual and developmental disabilities; however, the concepts inherent in the adolescent and early adulthood stages have been shown to be salient for individuals with ASD. Finding an identity in terms of solidifying adult roles and gaining independence can be difficult for adolescents and young adults with ASD, who seldom live independently and often have difficulty finding and maintaining meaningful employment (Ballaban-Gil, Rapin, Tuchman, & Shinnar, 1996; Billstedt, Gillberg, & Gillberg, 2005; Eaves & Ho, 2008; Howlin, Goode, Hutton, & Rutter, 2004). Furthermore, multiple studies have suggested that these adolescents and young adults tend to have limited friendships and relationships with people outside of their families, with the relationships they do have often lacking in intimacy (Howlin, Mawhood, & Rutter, 2000; Koning & Magill-Evans, 2001; Orsmond, Krauss, & Seltzer, 2004); this leads to greater feelings of loneliness among adolescents and young adults with ASD than among typically developing individuals (Bauminger & Kasari, 2000). Although the pace at which individuals with ASD move through Erikson’s stages may be slower when more severe intellectual disabilities are present, there is no theory or research to suggest that these concepts do not remain important.

Using Erikson’s theory as a framework for the transition to adulthood implies that identity and intimacy seeking will be two major components of this transition. If the adolescent with ASD is able to form an identity that is independent from his or her family, particularly in terms of future adult roles and occupations, then he or she will be more likely to develop intimate relationships with others during the early adulthood stage (intimacy vs. isolation). According to Erikson, failing to encourage an independent identity may make it more difficult for adolescents and young adults with ASD to develop intimacy with others outside of the family and subsequently may contribute to their future social isolation and to family distress.

However, families of individuals with ASD—who are used to protecting their son or daughter throughout childhood—may have a more difficult time than families of typically developing adolescents encouraging independence, especially if the son or daughter has significant functional limitations (Cooney, 2002). Parents of all children use protective strategies to influence the stressful events to which their children are exposed. As children mature, parents move from protective strategies that directly guide or limit their children’s activities, such as participating in activities or direct prevention, to more indirect protective strategies such as being available or soliciting information (Power, 2004). It can be difficult for parents of typically developing children and adolescents to discern how much to protect their son or daughter; parents of adolescents with ASD have the additional complication of weighing their son or daughter’s functional abilities and safety when discerning how much to protect him or her. Parental overprotection can lead to problems adapting to difficult situations for typically developing children (for a review see Power, 2004), and it is logical to think that overprotecting adolescents with ASD—thereby limiting their autonomy—could also lead to problems in adaptation.