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Psychology, Mental Health and Distress

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1 From disorder to experience 3
2 History 19
3 Culture 55
4 Biology 75
5 Diagnosis and formulation 101
6 Causal infl uences 118
7 Service users and survivors 139
8 Interventions 158
PART 1CONCEPTS
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FROM DISORDER TO EXPERIENCECHAPTER 1
Bess’s story
Bess is a 19 year old African Caribbean woman. She was referred to clinical
psychology services after being admitted to a psychiatric hospital, because
her medication had not lessened the voices she heard nor altered the unusual
beliefs she held. Before her admission she had been living with her mother,
brothers and sisters in a large industrial town.
Bess is the oldest of four children. Since the age of 9 she had been largely
responsible for taking care of her siblings, whilst her mother worked long
hours to support the family. Nevertheless, Bess did well at school, although she
sometimes experienced racist bullying. Often, her father drank heavily and was
physically and verbally abusive – towards his wife, but occasionally towards
Bess. Then, when Bess was 12, her father came home drunk and pressured her
for sex. He threatened to hurt her brothers and sisters if she didn’t comply, and
Bess reluctantly agreed. She hated the sexual contact, but relished the a ec-
tion she received from him. After two years of this sexual abuse, Bess’s father
left to begin a new relationship. Bess was devastated. She deeply resented her
mother’s anguish at losing him, and their relationship deteriorated.
After her father left, Bess was confused. She resented the way he had treated
her, and wondered why he didn’t contact her. She continued to work hard at
school and did extremely well in her exams. When she was 16, Bess noticed
that although the bullying had mostly stopped she still felt like an outsider. She
began fi nding it di cult to concentrate, and became preoccupied with the belief
that one day she would meet someone who would take her away to a new life.
Around this time she had a new boyfriend who wanted to turn their relationship
into a sexual one, but Bess refused. When she eventually explained to him what
had happened with her father, he ended the relationship. Bess felt that everyone
she loved would abandon her. She was deeply shamed by what her father had
done to her, judging it to be her own fault.
Bess began to spend more time alone, praying. She believed she was receiv-
ing messages from God, and began listening to loud music to block out the
voices she increasingly heard. She drank large quantities of alcohol, and slowly
became convinced she had a personal relationship with sexual overtones
with one of the pop stars she listened to. This made her feel ashamed, but the
pop star told her that one day he would take her to heaven where she would nd
peace. She heard his voice often, especially when she felt lonely and miserable.
Increasingly, though, she also heard her father’s voice, commenting critically on
her actions and morals.
Eventually, Bess told her mother about these experiences. Her mother became
angry and contacted a doctor, who referred Bess to psychiatric services. This led
to a violent confrontation between Bess and her mother; Bess was then forcibly
admitted to hospital.
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What is distinctive about this book?
The approach taken by this book is somewhat di erent from
those of other books in this area. One very obvious di erence
is that, unlike many others, we do not use the term ‘abnormal
psychology’ to describe what our book is about (later, we o er
a detailed explanation for this). But in fact this book has several
distinctive features, so it will be useful to emphasize some of
them here.
First, in this book we take a consistently psychological
approach to mental health. Usually, psychology books on
mental health are already pre-structured in terms of psychi-
atric diagnostic manuals such as the Diagnostic and Statistical
Manual of the American Psychiatric Association – the DSM
(see Box 1.1). Chapter titles are usually based upon diagnostic
labels, and explanations are typically directed at ideas of mental
illness that have already been formulated within psychiatry or
medicine. Instead, in this book we o er a perspective that is
more suitable for students from non-medical backgrounds
who might want to train as (for example) clinical psycholo-
gists, social workers or CBT practitioners. We have already
suggested that we will do this by starting with experience
rather than notions of disorder, and there is more discussion
of what this means later in the chapter.
Second, most other books of this kind pay relatively little
attention to recent psychological research – much of it from
the UK – which has focused on particular kinds of experience,
such as ‘hearing voices’, rather than diagnostic categories,
such as schizophrenia. This research has shown that it is
possible to make signifi cant progress in understanding and
responding to people’s di culties without having to endorse
psychiatric diagnoses. Of course, this does not mean that we
don’t consider psychiatric diagnoses in this book – just that
we don’t treat them as necessarily explaining people’s mental
health di culties.
Third, many other textbooks claim that dimensional
models are less clinically useful than psychiatric diagnoses.
Dimensional models do not presume a sharp dividing line
between mental health and mental illness, and recognize that
all of us, sometimes, have distressing and unusual experiences
in our lives. They are usually contrasted with categorical
models, where mental illness is clearly distinguished from
mental health and is thought to fall into specifi c, separate
categories: psychiatric diagnosis exemplifi es this approach.
But in the UK, at least, the vast majority of clinical psycholo-
gists use dimensional models in their clinical practice, so this
book frequently takes a dimensional approach.
Fourth, most other mental health textbooks contain a series
of chapters, each focused on a particular psychiatric diagno-
sis. But although they present extensive information about
each diagnosis, they rarely try to explain the associations
and connections between them. Typically, textbooks claim
to promote a biopsychosocial model of mental health an
approach within which biological, psychological and social
infl uences are all considered or modelled together. But because
they don’t usually contain very much discussion of the links
between ‘bio’, ‘psycho’ and ‘social’, the model actually tends to
remain relatively obscure. Moreover, because these textbooks
are invariably structured around psychiatric diagnoses, they
also tend to be reductive – in other words, they tend to treat
biological infl uences as foundational, or as more important
than others. By contrast, in this book we try to consider the
Learning outcomes
After you have read this chapter, you will be able to:
Explain why terminology is especially important in 1
relation to mental health
Explain what is meant in this book by ‘distress’2
Describe some of the problems associated with everyday 3
defi nitions of normality
Explain the problem of thresholds in relation to 4
psychiatric diagnosis
Defi ne key terms, including: service user, distress, 5
madness, psychosis, neurosis, hallucination and delusion
Introduction
This book is about people like Bess. People distressed by life,
their relationships, and their position in the social world. It is
clear from Bess’s story that her distress is far from straightfor-
ward. Do her di culties arise from her unstable relationships,
from the way she thinks about the world, or the ways in which
she has learned to cope? Whilst there are no easy answers to
these questions, we hope that this book will provide some
ways of thinking psychologically about the kinds of issues
facing Bess and others who have had experiences like hers.
In this chapter, we fi rst of all explain what is distinctive
about this book and why we approached this topic in the way
that we did. We discuss the importance of terminology and
describe why language is important: both because it provides
the concepts we use when thinking, and because of its links
to stigma and discrimination. We explain how in this book we
will focus on distress (which for now you can simply read as
meaning ‘mental illness’ or ‘psychopathology’), and how we
will treat distress as a form of experience something that
happens within the life and the subjective awareness of a
person – rather than as a form of illness.
Then we give some of the reasons why we decided not to
call this a book about ‘abnormal psychology’. Approaches to
mental health and illness that do not endorse simple notions
of abnormality are often described as anti-psychiatry: this
is the collective term for a set of disparate work, published
mostly in the 1960s, which rejected the view that mental
health problems are illnesses or diseases. We explain why we
do not call our approach anti-psychiatry; consider the issues
raised by a focus on distress as something that is perhaps ‘in
the mind’; and briefl y describe some of the ways in which
mental health professionals have modelled and conceptual-
ized their fi eld.
These discussions are followed by a short overview of the
rest of the book, and a guide explaining how to get the most
out of reading it.
Guiding questions
As you read this chapter, you should bear in mind these
two questions:
Why might we question the notion of abnormal 1
psychology?
What are the implications of rejecting psychiatric 2
diagnoses in mental health?
4 CONCEPTS
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links between ‘bio’, ‘psycho’ and ‘social’ in a more nuanced
and conceptually sophisticated manner.
Finally, in these textbooks, the discussion of critics of psychia-
try, and of the controversies associated with its diagnoses and
assumptions, almost always seems to stop at the end of the 1960s.
If one were to judge by such books, one might almost believe
that all of the problems that these critics had raised were now
solved. But this is not the case, and in the ve decades since the
1960s there have been many more critiques of, and alternatives
to, psychiatry. These critiques and alternatives have come from
clinical psychologists and from those who use mental health
services, as well as from psychiatrists themselves. In recognition
of this, our book is also distinctive because it includes a chapter
written entirely by mental health service users.
In writing this book we have therefore made a number of
assumptions: for example, that psychiatric diagnosis does not
necessarily provide the best way to approach mental health
problems; that a more sophisticated psychological account of
mental health problems will be useful; that mental health service
users have valuable things to tell us about mental health di cul-
ties and interventions. All authors have an assumptive frame-
work a worldview within which certain things are implicit
and simply taken for granted. These assumptive frameworks
are rarely made explicit, but we thought it would be helpful for
you to have a sense of our starting points and assumptions so
that you can take them into account as you read the book.
Importantly, we have not written this book as a polemic
and we accept that you may agree or disagree with some of
our judgements. Throughout the book we will be presenting
evidence for and against di erent ways of conceptualizing
BOX 1.1
What is the DSM?
‘The DSM’ is The Diagnostic and
Statistical Manual of the American
Psychiatric Association. It contains
the diagnostic criteria that American
psychiatrists use in their practice. In
Europe and the UK, psychiatrists most
often favour the slightly di erent
psychiatric diagnostic criteria set out
in The International Classifi cation of
Diseases (ICD), produced by the World
Health Organization. However, although
they may use these criteria in their
practice, for research purposes UK and
European psychiatrists also tend to use
the DSM.
Both the ICD and the DSM have been
subject to frequent revisions. The ICD is
currently on version 10, whilst the current
DSM is known as DSM-IV-TR: version IV,
text revision. As we went to press, both
DSM-5 (the APA seem to have changed
their numbering system) and ICD 11 were
expected shortly.
At least in its current version, the
DSM claims to be purely descriptive and
a-theoretical, instead of depending
upon concepts derived from theories.
This means that it does not use earlier
concepts such as neurosis: a collective
term for forms of distress that involve
exaggerations of everyday responses
(e.g. excessive worrying) but do not
involve distorted perceptions or
unusual beliefs. Whereas the concept of
neurosis was originally derived
from psychoanalytic theory, the DSM
purports to be no more than a set of
descriptions of the disorders
frequently observed by clinicians. These
disorders are proposed by panels of
experts, and are subject to a consulta-
tion process and approval by a central
committee before they can be included in
the manual.
Despite this, critics argue that the
DSM is far from value-free and neutral.
They suggest that in practice the
DSM furthers the interests, not just of
psychiatry, but also of the pharmaceutical
and insurance industries (because, under
America’s insurance-based healthcare
system, a diagnosis is needed in order to
reclaim the cost of treatments such as
medication).
Another concern frequently raised
by critics is that the DSM has promoted
the medicalization of everyday life: in
other words, it encourages us to see
everyday di culties and stresses (for
example, shyness) as ‘symptoms’ of
‘illness’ that then require ‘treatment’.
Certainly, the number of separate
diagnoses within each version of the
DSM has tended to increase with each
revision, as the table shows. However,
advocates of diagnosis argue that
the system is simply becoming more
accurate and refi ned over time, and
that the changing numbers refl ect this
process of development.
TITLE YEAR DIAGNOSES
DSM 1952 106
DSM-II 1968 182
DSM-III 1980 265
DSM-III-R 1987 292
DSM-IV 1994 297
DSM-IV-TR 2000 297
Chapter 5 contains a lengthy discussion
of psychiatric diagnosis and the issues
that are frequently associated with it.
mental health and illness, so that you can come to your own
conclusions.
Of course, in attempting to write about mental health in a
di erent way we had to think carefully about the language we
used. There are many reasons for this, but perhaps the most
important is that language contains concepts that structure
our thinking. If we use concepts that are inconsistent or
unhelpful, our thinking can become muddled. This meant that
we needed to ensure that our approach was internally consist-
ent, so it is to the issue of terminology that we turn next.
Terminology
One of the fi rst challenges in learning about the psychology of
mental health is the wide variety of terms and concepts used.
Like the language used in relation to any other real-world
phenomenon, none of these terms is neutral or value-free.
All of them seem to imply something about the nature or the
causes of the phenomena they describe, and all of them are
more closely associated with certain disciplines and perspec-
tives than with others. The term mental illness, for example,
clearly suggests that our talk will be of matters related to health
and sickness, that it will have a medical character but that it
will also take a mentalistic or psychological focus. Another
widely used term, psychopathology, makes exactly the same
assumption because it adds the concept of disease pathol-
ogy – to the prefi x ‘psycho-, which is short forpsychological.
In both cases, then, the terminology already assumes that our
perspective upon these phenomena should be a fundamentally
FROM DISORDER TO EXPERIENCE 5
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severe forms of distress. These include experiences such
as hearing voices, which is an example of a hallucination:
a general term for the perception of a stimulus that is not
present. They also include advocating the unusual beliefs that
clinicians call delusions: beliefs that can be shown to be either
impossible or false, but which are sometimes proclaimed
strongly by service users. These experiences are primarily
associated with psychiatric diagnoses such as schizophrenia
and bipolar disorder, and are sometimes collectively referred to
as psychosis. There has been a recent debate in the UK about
terms like psychosis and schizophrenia, and a ‘Campaign
against the Schizophrenia Label’, which has received signifi -
cant media attention. As with the other terms we favour in this
book, we have used madness rather than psychosis because it
mostly avoids the many connotations of illness or disease that
accompany the alternatives.
You wi ll pr ob ab ly be fa mi li ar wi th di sc us si on s a bo ut te rmi -
nology from other areas of your studies. Because language
supplies the concepts that structure our thinking and debat-
ing – sometimes very subtly, in ways we don’t necessarily
realize – it is vital to ensure that we are using appropriate
terms. However, it’s also important to realize that, in relation to
distress, these discussions are often particularly contentious.
Because distress touches the lives of so many people, and
because the ways we understand it have very real implications
for the ways that we respond to it, there are often very strong
feelings about the terminology that is used.
For example, there is extensive disagreement about the
term we should use to refer to people who experience distress.
In recent years, the dominance of the medical perspective
associated with psychiatry has meant that the term patient is
very often used. Over the last 20 or 30 years, however, some
of those who experience distress have organized themselves
into activist groups and campaigned strongly for a change of
terminology. They have argued that the term ‘patient’ implies
a passive position where someone puts themselves in the
hands of experts to be fi xed. Some also object that the term
inappropriately focuses almost exclusively on the medical and
biological aspects of care (e.g. medication), rather than adopt-
ing a more holistic approach. As a result of these objections,
some professionals now refer to those who use their services
as clients. However, some groups have argued instead that
they should be referred to as consumers (popular in the
USA, Australia and New Zealand) or service users (popular
in the UK), and many professionals have also taken up this
language.
But these terms have also been challenged. Some suggest
that they obscure the fact that many people are not always will-
ing consumers of mental health services, unlike the consum-
ers of other goods and services: some, for example, will be
receiving compulsory treatment. Such critics have sometimes
suggested that the term recipient is more accurate. And yet
others have argued that, because they have had to cope not
only with their distress, but also with psychiatric interventions
which they have experienced as negative or unhelpful, the
term psychiatric system survivor is most appropriate.
In short, then, there is no ‘right’ term to use and people in
distress, like everyone else, have their own preferences and
understandings. In this book we will usually use the term ‘serv-
ice user’, since this is one of the terms most widely used in the
UK. But we will also sometimes use other terms, where other
people have used them or where the context demands it.
medical one, and that at its most basic level our concern is
with people who are diseased or sick.
We t hink that this ass umpt ion i s inc orrect. In o ur vi ew, wh en
people are given diagnoses such as schizophrenia or depres-
sion it is neither accurate nor helpful to think of them as being
medically ill or diseased. So in this book we will use the terms
‘psychopathology’ and ‘mental illness’ very infrequently, and
even then only when they are already being used by the people
whose work we are drawing upon. In their place, we will use
the term distress. When we use this term, we use it to refer to
just the same kinds of phenomena that textbooks of this kind
usually call mental illness or psychopathology. We use distress
to mean all of the di erent kinds of di cult or unusual experi-
ences associated with the hundreds of psychiatric diagnoses
currently employed. Distress is our term for the core subject
matter of this book: the experiences associated with diagnostic
categories such as schizophrenia and depression, and with the
work of professions such as clinical psychology, psychiatry,
social work and nursing.
However, to reduce repetitive language, we will occasionally
draw on other phrases like ‘mental health problem’. This termi-
nology is also open to challenge, because by locating these
experiences in relation to health it also implies a link to illness.
However, it is more ambiguous than ‘mental illness’, carries
less conceptual baggage, and is easily understood because it
is widely used.
Similarly, we will sometimes use the term madness to
collectively describe experiences associated with the more
How we see or represent the world depends on how we choose to
frame it, as well as upon what there is in the world for us to see
6 CONCEPTS
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these illnesses are what psychiatric diagnoses describe. The
second assumption is that this will result in less discrimina-
tion, because people will be more tolerant if they think that an
unusual behaviour is caused by a medical illness or disease;
otherwise, they might hold the person morally responsible.
Another problem noted by some critics of these campaigns is
that stigma is seen as caused by problematic attitudes located
inside individuals, rather than as a product of, or reaction
to, discrimination at a societal level in a similar manner to
sexism and racism (Sayce, 1998).
Stigma and discrimination
Language and terminology are important because of how they
a ect our thinking. However, they also matter in relation to
service users and their experiences of distress because of the
widespread discrimination to which such people are subject.
The UK government regularly surveys public attitudes about
‘mental illness’: a survey (O ce for National Statistics, 2010b)
of 1,745 people revealed that
78% of people agree that ‘people with mental illness have
for too long been the subject of ridicule’
75% agree that ‘people with mental health problems should
have the same rights to a job as anyone else’
87% agree that ‘we need to adopt a more tolerant attitude
towards people with mental illness’ (a fall from 92% in 1994)
At the same time, however, only 26% of people agreed that
‘most women who were once patients in a mental hospital can
be trusted as babysitters’. Only 34% agreed that ‘less emphasis
should be placed on protecting the public from people with
mental illness’, and only 33% agreed that ‘mental hospitals are
an outdated means of treating people with mental illness’.
This survey suggests that the public have ambivalent
feelings about service users and distress. One way of under-
standing this ambivalence is to see negative attitudes as an
example of stigma. This approach draws upon sociologist
Erving Go man’s (1963) work Stigma: Notes on the manage-
ment of spoiled identity, where he described the process of
stigmatization as involving being viewed as socially deviant
and linked with negative stereotypes. Since then, a number
of researchers have drawn on this paradigm to suggest that
experiencing distress or being given a psychiatric diagnosis
can lead to one being stigmatized. Drawing on this insight,
there has been a considerable amount of research into why
mental distress is linked to negative attitudes.
Research suggests that the development of negative attitudes
begins early in life. Rose, Thornicroft, Pinfold and Kassam (2007)
asked 472 14-year-old school students ‘What sorts of words or
phrases might you use to describe someone who experiences
mental health problems?’ They reported that around 250 words
were mentioned by the young people, including terms such
as nuts, psycho, loony, weird, freak, spastic and demented.
In their interview study of 1,737 adults, Crisp, Gelder, Rix,
Meltzer and Rowlands (2000) reported that their respondents
commonly perceived people who had been given a diagnosis
of schizophrenia as unpredictable and dangerous, even though
about half of them knew someone with a mental health prob-
lem. Unfortunately, research also shows that such prejudiced
views are even reported amongst doctors (Mukherjee, Fialho,
Wijetunge, Checkinski & Surgenor, 2002) and may be made
worse by some nurse training (Sadow, Ryder & Webster, 2002).
Despite a huge amount of money spent on ‘anti-stigma’
campaigns the e ects on public attitudes have been modest,
leading some to suggest that attitudes about mental health
may be di erent from other attitudes (Crisp et al., 2000).
However, in a recent review, Read, Haslam, Sayce and Davies
(2006) suggest that it may be the underlying assumptions of
the anti-stigma paradigm which are the reason for the lack of
change. These approaches are typically based on two assump-
tions, the rst of which is that the public need to be taught to
adopt a biomedical model of distress – to assume that distress
is caused by diseases or illnesses of the brain or mind, and that
If only it were this simple. The fact is, millions of people will suffer from some form of
mental health problem during their lives. We can’t promise a quick fix, but we can offer
support and sound, practical advice for a better life. Talk to us.
This poster was part of an advertising campaign by a UK mental health
charity. What does it make you think? Does it stigmatize people with
mental health problems, or does it challenge their stigmatization? What
does it suggest to you about the causes of distress?
A number of studies have reported that, whilst the public may
use medical terminology, they place a ‘greater emphasis on
psychosocial than biogenetic explanations of schizophrenia’
(Read et al., 2006, p. 311). Moreover, contrary to the assump-
tions of the anti-stigma paradigm, biomedical explanations
are associated with more negative attitudes and behaviour
than psychosocial models, in which mental health problems
are seen as psychological in nature and caused by adverse
life events and circumstances (Lam, Salkovskis & Warwick,
2005; Mehta & Farina, 1997; Read & Harré, 2001; Read et al.,
2006). Why might this be? One possibility is that, if unusual
experiences or behaviours are seen as biomedical in origin,
they become more mystifying and unpredictable. Conversely,
if they are seen as the result of someone’s life experiences,
they are perhaps more understandable. So public education
programmes focusing on psychosocial explanations may well
fare better than those that endorse biomedical approaches (see
Figure 1.1).
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reported that reliance on fi ctional television was associated
with higher ratings of unpredictability.
Rose (1998) compared UK TV news coverage in the summer
and winter of 1986 with TV news and other programmes
between May and July 1992. Although she found variety in TV
genres like soap operas and comedies, the category of danger
was very frequent. For example, a third of all camera shots in
her collection of TV news relevant to mental health dealt either
visually or verbally with danger, violence and crime. Moreover,
on the news, nearly two thirds of all stories involving those
with psychiatric diagnoses fell into the category of crime news,
although crime news accounts for only 10% of news coverage.
As well as increasing the general public’s fear, negative media
representations have an impact on people with mental health
problems themselves. Half the respondents of a UK mental
health charity’s survey of mental health service users said that
their mental health had been negatively a ected and a third
said others had reacted negatively towards them as a result of
such reports (Mind, 2000).
The media bias against mental health service users is
especially unhelpful because it largely ignores the available
evidence. A UK study found that murders by mental health
service users are infrequent and occur less than once a week
(Large, Smith, Swinson, Shaw & Nielssen, 2008). Whilst this
might sound alarming at fi rst, it should be seen in the context
of other statistics. First, only 10% of people convicted of murder
in the UK are thought to have any mental health di culties
at the time of their crime (Department of Health, 2001), and
95% of all murders are committed by people who have never
been given a psychiatric diagnosis (Institute of Psychiatry,
2006). Second, the number of people experiencing mental
health di culties at any one time is large – typically around
one in six of the population, or – in the UK – roughly 7 million
people. These gures show that the vast majority of murders
are committed by people without mental health problems, and
that the proportion of people with mental health problems
who commit murder is extremely small. Other violent attacks
by mental health service users (i.e. those not causing death) are
similarly much less frequent than media reporting suggests,
and when they do occur they are frequently also associated
with the use of alcohol or other drugs (Fazel, Langstrom, Hjern,
Grann & Lichtenstein, 2009).
In fact, contrary to public fears, people with mental health
problems are far more likely to be victims of violence than
perpetrators; for example, they are six times more likely than
the general population to die by homicide (Hiroeh, Appleby,
Mortensen & Dunn, 2001). A US study of people experiencing
Discrimination
Although many people experience mental health problems,
there is now substantial evidence that mental health service
users experience signifi cant discrimination across all areas of
their lives (Sayce, 2000). For example, only 24% of people with
long-term mental health problems were in work in England in
2003 – the lowest employment rate of any of the main groups
of people with disabilities (Social Exclusion Unit, 2004). Almost
half (47%) of Read and Baker’s (1996) respondents said that they
had been abused or harassed in public. Berzins, Petch and
Atkinson (2003) reported that people with mental health prob-
lems su ered much higher rates of verbal abuse and physical
harassment than the general public, with much of it commit-
ted by teenagers and neighbours.
Sadly, discrimination intrudes into even the most intimate
relationships and can lead to many people with mental health
problems feeling isolated (Mind, 2004) and being wary about
telling other people about their own or another’s distress
(Mental Health Foundation, 2000). There has also been an
increase in community opposition to nearby mental health
facilities. Research suggests that residents’ fears are fuelled by
media reporting, and are associated – on occasion – with both
vandalism and assaults (Repper, Sayce, Strong, Willmot and
Haines, 1997).
Another domain within which mental health service users
experience discrimination is the media. Headlines such
as ‘Schizophrenic Given Life for Murder’ (Daily Express, 24
March 2009), and terms such as ‘Psycho Cabbie’ (The Sun, 4
June 2010), serve to associate mental health service users with
violence and fear and help to spread negative attitudes. Indeed,
many commentators see disproportionate media report-
ing as an important maintaining factor in more widespread
discrimination. In one study of a range of print and broadcast
media, stories about homicides and crimes accounted for 27%
of all coverage of mental health (Care Services Improvement
Partnership/Shift, 2006). Messages about the risks of violence
posed by people with mental health problems were present in
15% of stories, most of which implied the risk was high.
News and entertainment media focus primarily on violence
against others when addressing issues relating to mental
illness, with these items receiving ‘headline’ treatment (Philo,
1994). These fi ndings are robust (e.g. CSIP/Shift, 2006; Philo,
1996; Pinfold & Thornicroft, 2006) and infl uence the public’s
fear of unpredictability and violence (Philo, 1996). Levey and
Howells noted (1995) that perceived dangerousness was not
as important as the perceived di erence and unpredictability
of people with a diagnosis of schizophrenia. Moreover, they
Biomedical approach Psychosocial approach
Sees the person’s mental health problems as the main problem Sees barriers in society as the main problem
Sees problems as a symptom of an underlying disease process and
illness
Sees problems as an understandable response to adverse life
events
Sees societal reactions as due to the stigma attached to having a
mental health problem
Sees societal reactions as due to discrimination against a
marginalised group (like racism, sexism etc)
Aim of public education is to remove perceived blame attached to
the individual by ‘blaming’ the illness rather than the person
Rejects the relevance of notions of ‘blame’ and aims to promote
diversity, reduce fear and increase empathy and understanding
Key public education slogan ‘Mental illness is an illness like any other’ Key public education slogans: ‘I’m crazy: so what?’ ‘It’s normal
to be di erent’
Figure 1.1 Contrasting biomedical and psychosocial approaches to public education about mental health
8 CONCEPTS
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From our perspective, however, experiences of distress are
part and parcel of the other experiences of everyday life. They
do not form a separate, unitary category of symptoms that can
be understood separately from everything else. Experiences
associated with distress – just like every other experience – are
bound up with social and material conditions, personal biog-
raphies, life events and relationships. And, just like every other
experience, they are infl uenced by our biological capacities, by
the many, variable potentials produced by our nature as living,
organic beings.
But if distress is not separate from other aspects of experi-
ence, and does not form a unitary category all to itself, how can
we know where it starts and ends? How can we reliably and
validly draw an objective line between distress – the province
of services such as clinical psychology and psychiatry and
more everyday experiences of being unhappy, worried and so
on?
Simply put, our answer is that we cannot draw such a line.
We do not belie ve that it is pos sibl e to produ ce a set of crite ria
or defi nitions that transcend history, place and culture and
that can be used objectively to discriminate between those
who are clinically distressed and those who are not. In the
DSM, the existence of a distinct line between normal and
abnormal is taken for granted even though it is recognized
that only appropriately trained expert psychiatrists might be
able to determine exactly where it lies. By contrast, we believe
that there is no value-free distinction between behaviours and
experiences that are considered normal and those that are
considered abnormal. Neither is there any universal standard
against which people’s emotions, thoughts and actions can
be judged, and by reference to which they can be categorized
as deviant. On the contrary, the identifi cation of distress as
distress will always be entwined with prevailing cultural norms
of emotionality, behaviour and morality.
However, this does not mean that cultural norms are the sole
criteria against which distress might be identifi ed. Sometimes
a person’s ways of acting or experiencing can make it di cult
for them to live their lives as they would like, or can have a bad
e ect upon their physical health. When this happens, their
behaviour is never somehow fl oating free of cultural norms:
what we want to do in our lives, for example, is continuously
infl uenced by the precepts, norms and values of our time and
culture.
Nevertheless, there are patterns of activity and experience
which would be unhelpful or damaging in most circumstances.
Gradually starving yourself – perhaps because you have come
to believe that only by doing so can you begin to meet all of
the many expectations placed upon you – will damage your
physical health, no matter where or when you live. Similarly,
being so profoundly miserable that you are unable even to get
out of bed is likely to prevent you from achieving your goals,
whatever those goals are. In the same way, experiencing angry
and abusive voices that no-one else can hear is likely to make
you frightened, confused and distracted, and this will probably
occur to some extent even in cultures where voice-hearing
is not as thoroughly stigmatized as it is in the West. So, whilst
these dysfunctional or damaging consequences are defi nitely
not separate from wider cultural norms and values, they do not
arise solely because of them: they are also a product of specifi c
patterns of experience and activity.
To some extent, distre ss can als o b e ide ntifi ed with respect
to the extent to which a person’s actions and experiences
psychosis found that they were 14 times more likely to be the
victims of violent crime than to be arrested for committing
violence themselves (Walsh et al., 2003). They are also far more
likely to be a danger to themselves than to other people; for
example, one infl uential study found that 90% of UK suicides
involve people with mental health problems (Barraclough,
Bunch, Nelson & Sainsbury, 1974).
How might we change stigmatizing attitudes and discrimi-
natory behaviour? As we have seen, promoting psychosocial
rather than biomedical explanations may help. In addition,
activists like Sayce (1998, 2000) have argued that lessons can be
learned from broader disability campaigns. Here, campaigners
argued that it was not a person’s disability which was the prob-
lem (as might be expected from an individualistic biomedical
approach), rather it was the way in which society unintention-
ally created barriers by organizing the environment in a way
which was convenient only for people without a disability. In
the same way, rather than focusing on individual experiences
of stigma, we might see public attitudes to service users –
fuelled by inaccurate media reporting – as socially-created
barriers to their acceptance by others.
What is distress?
Throughout this book, then, we use ‘distress’ as a generic
term to refer to all the phenomena and experiences that are
sometimes called ‘psychopathology’ or ‘mental illness’. But,
as we have suggested, this is not just about a preference for a
di erent way of describing these experiences: it also signals a
di erent way of conceptualizing them. We will now describe
in more detail how we conceptualize distress, and how – as
a concept – it di ers from concepts of mental illness or
psychopathology.
When we talk about distress, we are talking about a highly
variable and heterogeneous set of experiences. These experi-
ences can include
strong or overwhelming emotional states, of various
kinds, that disrupt everyday life and prevent people from
functioning
habitual and repetitive patterns of acting – for example,
in relation to personal hygiene, or to do with safety and
security – that create anxiety if they are not carried out
experiences of seeing and hearing things that other people
do not see or hear, or of holding beliefs that are considered
by others to be unusual and extreme.
In this book, we take these kinds of experiences as problems
in their own right. This contrasts with the approach frequently
taken in psychiatry, where service users’ talk of these kinds
of experiences can very quickly get re-interpreted as nothing
more than symptoms of an illness. In psychiatric settings,
doctors are frequently listening out for particular patterns
of di culty in order to match the person’s experience with
a pre-defi ned diagnostic category. However, this might
mean that they miss some of the complexity and fl uidity of
people’s actual experiences of distress: in attentively looking
for patterns of symptoms, they may fail to notice the ways in
which people’s distress is linked to the circumstances of their
situations. As a consequence, rich accounts of distress that
engage with its meaning and detail in a person’s life may be
di cult to achieve from within a psychiatric framework.
FROM DISORDER TO EXPERIENCE 9
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like these those norms are either mediated by other people’s
experiences, or codifi ed in legal or other requirements. These
examples show how the identifi cation of distress can be a
compassionate move, perhaps by attempting to keep safe
someone who might otherwise be a danger to themselves. But
they also show how distress is always bound up with the wider
structures of power that organize our lives, and by which
interventions might be imposed against our will.
To summa rize: distr ess is always concep tuali zed with resp ect
to cultural norms, but these norms are not the sole criteria
against which distress is understood. One consideration is
that distress always has a subjective component, regardless of
its location within culture. Another is that, intersecting with
cultural norms, we also have
Judgements about the extent to which a person’s actions
and experiences are harmful or dysfunctional
Judgements about the extent to which they are unusual
Judgements about the meaning of actions and
experiences
The infl uence of power relations
None of these judgements is simply objective, just as the
operation of hierarchical power relations cannot simply be
seen as ‘objectively’ correct. But whilst these judgements and
infl uences do not escape the in uence of cultural norms, they
are not identical to them, either. Instead, they point to numer-
ous ways in which the contexts, consequences and meanings
of experience are part of its conceptualization as distress. They
make it clear that distress is always socially and culturally
positioned, that it will vary according to the specifi cs of time
are unusual and inexplicable. Again, cultural norms play an
important role here, and in two ways. First, almost by defi ni-
tion, norms refer to the ways of acting and experiencing
displayed by the majority. However, there are di cult issues
involved in trying to agree the threshold at which an experi-
ence becomes seen as clinically signifi cant (see Box 1.2 for a
discussion). Second, norms are relevant because we are far
more ready to ascribe distress to people when their ways of
being in the world do not make sense to us. When what people
say or how they act is not only unusual but also seems to lack
any obvious explanation, we are more likely to conclude that
they are experiencing distress of some kind. In other words, it
is not just the frequency or rarity of someone’s acts and expe-
riences that counts – it is also the sense or the meaning that
we are able to give to them.
Another issue is that there are signifi cant numbers of people
who receive treatment from psychiatric or clinical psychologi-
cal services but who do not want these interventions. Some
might be experiencing the transient states of extreme euphoria
and intense energy that psychiatrists call mania; others might
be hearing voices that are friendly and supportive, rather than
angry or abusive; yet others might be very unhappy, worried
or confused, but have nevertheless come to believe that the
treatments are not working, or that they produce as many
di culties as they solve. Some such people might end up
receiving services, not because they themselves are distressed,
but because their behaviours and experiences are distressing
to others around them. Others may end up receiving services
because their behaviour leads them to fall foul of the law.
Again, cultural norms are highly relevant here: but in cases
BOX 1.2
The problem of thresholds
We have seen that one criterion for
identifying experiences as mental health
problems is how unusual they are. But
what is the threshold beyond which an
experience is considered so unusual
that it is signifi cant? This question is
important, because research shows
that some phenomena associated with
distress are far more common than is
usually supposed.
Of a random sample of 7, 076
Dutch people, Van Os, Hannsen, Bijl
and Ravelli (2000) reported that, whilst
3.3% had ‘true’ delusions (i.e. meeting all
diagnostic criteria) an additional 8.7% an
additional 8.7% had delusions that were
‘not clinically relevant’ – that is, they
were ‘not bothered by it and not
seeking help for it’ (van Os et al., 2000,
p. 13). Similar fi ndings have been
reported in relation to hearing voices (see
Chapter 11).
Stein, Walker and Forde (1994)
conducted a telephone survey in Canada
to ask about experiences of social
anxiety, fi nding that 61% of respondents
reported being much or somewhat
more anxious than others in at least one
of the seven social situations surveyed.
However, if the threshold at which
a person’s distress was considered
clinically signifi cant was moved, the
prevalence of ‘social anxiety syndrome’
varied from 1.9% to 18.7%. Many diagnos-
tic criteria are formulated without any
empirical investigation of base rates in
the general population. This may explain
why there is a frequent disparity between
numbers of people seen by mental
health services and numbers of people in
community surveys who meet diagnostic
criteria.
Mo t et al. (2010) have suggested
that many estimates of prevalence in
community surveys undercount because
they rely on retrospective accounts.
Their prospective study, which followed
participants between the ages of 18
and 32 and interviewed them four times
during this period, found prevalence
rates for DSM diagnoses that were twice
those of other national surveys. They
conclude by suggesting that ‘researchers
might begin to ask why so many people
experience a DSM-defi ned disorder at
least once during their life-times, and
what this prevalence means for etiologi-
cal theory, the construct validity of the
DSM approach to defi ning disorder,
service delivery policy, the economic
burden of disease, and public percep-
tions of the stigma of mental disorder’
(p. 907).
Because there are cultural norms
about what might be regarded as
grounds for distress, where the
threshold for distress is set will have
a considerable impact. One US study
has suggested that ‘about half of
Americans will meet the criteria for a
DSM-IV disorder sometime in their life’
(Kessler et al., 2005, p. 593). If half of the
population experiences something, is it
unusual? To some extent, this depends
on one’s worldview. For example,
Sigmund Freud, one of the founders
of psychoanalysis, did not see it as his
job to make people happy: instead he
simply argued that ‘you will see for
yourself that much has been gained if
we succeed in turning your hysterical
misery into common unhappiness’
(Freud & Breuer, 1895/2004, p. 306).
10 CONCEPTS
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culture (Hebdige, 1979). Social defi nitions recognize the cultur-
ally normative dimension of distress that we described above,
but when we try to formalize them it becomes apparent that
we also have to invoke other (typically unspecifi ed) criteria
to decide which social norms, when, and where, to use as the
basis of our decisions.
So concepts of normality and abnormality do not provide
an objective basis for the identifi cation of mental illness or
psychopathology, and this in part explains why we have not
relied upon these concepts in this book. But the term ‘abnormal
psychology’ is nevertheless widely used, and seems acceptable
to the majority of psychology lecturers and students. Despite
this, there are other reasons why we choose not to describe
this as a book about abnormal psychology.
Abnormal psychology is confusing
and unclear
One reason we haven’t used the term ‘abnormal psychology’
is that it is ambiguous: is it the psychology itself that is abnor-
mal, or does the term refer to the psychology of abnormality?
Common sense would suggest that it is the second of these
options that most people have in mind; if so, this only leads to
a second, thornier set of confusions.
As we have already discussed, there is no straightforward,
objective way to distinguish abnormal behaviours and experi-
ences from normal ones. Even more fundamentally, though,
it is impossible to easily identify a body of psychological
theory and practice that is both exclusive to abnormality and
unconnected with other topics. Psychological explanations in
abnormal psychology tend to draw upon just the same kinds of
paradigms and theories as other psychological explanations –
biological, cognitive, behavioural, social, developmental and so
on. It does not seem necessary to assume that the psychologi-
cal processes that occur in distress are fundamentally di er-
ent or abnormal in comparison to those that occur in other,
supposedly normal, experiences. There are many successful
psychological models of distress that draw upon established
psychological theories and concepts such as learning theory,
attribution theory, schema and so on.
Abnormal psychology is not consistently
psychological
A further way in which abnormal psychology is confusing is
that it is not consistently psychological. Frequently, abnormal
psychology entirely abandons psychology and turns instead
to psychiatry. This is clearly demonstrated in the overall struc-
ture of most textbooks, which typically follow, more or less
faithfully, the diagnostic categories associated with one of the
major psychiatric diagnostic systems such as the DSM or ICD.
But this necessarily means that the inconsistency also runs
deeper: even where psychological explanations are o ered,
they are directed at problems already defi ned in psychiatric
terms. So in abnormal psychology there is an unresolved
tension between psychiatry and psychology, and frequent
shifts from one to the other. Moreover, when this happens,
abnormal psychology typically o ers no rationale for this shift
from a psychological mode of explanation and description to a
medical, psychiatric one.
In this textbook, we try to avoid these confusions by present-
ing consistently psychological accounts of distress. This does
not mean, of course, that we entirely ignore psychiatry: this
and place, and will be patterned according to broader socio-
logical variables such as socio-economic status, gender and
ethnicity. Conceptualized in this way, distress is quite di erent
from mental illness or psychopathology, both of which imply
objective disease states that can be identifi ed in ways that are
distinct from cultural norms.
Why not abnormal psychology?
Our claim that there are no objective criteria by which distress
can be distinguished from other kinds of experience is a chal-
lenge to the idea that some kinds of experience – and perhaps
even some kinds of person – are simply abnormal. But this
is such a taken-for-granted idea that it even lends its name
to the most commonly used title for textbooks like this one,
which are typically described as books on abnormal psychol-
ogy. This term is very widely used, perhaps because classifying
some kinds of experience as abnormal makes it reasonable to
describe them as expressions of psychopathology or mental
illness. Since abnormal psychology is such a common term,
we should explain why we do not use it in this book.
Whilst the notion that trained professionals can use objec-
tive criteria to distinguish between normality and abnormality
is perhaps comforting, it is nevertheless mistaken. Speaking
very generally, formal defi nitions of abnormality can be
classed as medical, as statistical, or as social – but whichever
kind of defi nition we use, we encounter contradictions and
problems. Each kind of defi nition excludes some phenomena
we might intuitively want to defi ne as psychologically abnor-
mal, includes some we would not want to defi ne as abnormal,
or smuggles elements of subjective opinion into what are
ostensibly objective judgements.
For example, if we use a medical defi nition of normality,
we will tend to class as normal those activities which contrib-
ute to health and wellbeing, and class as abnormal those that
endanger life or wellbeing or which cause harm to bodily
organs or tissues. But this means that many highly prevalent
everyday activities – such as smoking, drinking alcohol, diet-
ing, extreme sports, body-piercing and tattooing – would be
classed as abnormal, because they all involve actual or poten-
tial damage to the body.
If we use a statistical defi nition of normality, we will class
as abnormal those activities, behaviours and characteristics
that are, numerically, relatively unusual in a given population.
Statistical defi nitions of normality derived from psychology
sometimes use psychometric instruments, normal distribu-
tions and similar procedures by which to distinguish those
who are abnormal from those who are not. But without also
drawing on cultural values and norms (for example, in decid-
ing which experiences to include in psychometric scales)
statistical defi nitions will always generate contradictions,
because some highly valued attributes – being a member of
the royal family, perhaps, or excelling at sport – are statistically
highly abnormal.
If instead we use a social defi nition of abnormality, this will
refl ect the specifi c kinds of activities and experiences approved
or disapproved of in that time and place, so will inevitably be
subject to marked variation. This variation operates within as
well as between cultures: groups and subcultures have their
own norms of behaviour and conduct that sometimes di er
signifi cantly from those of the dominant or mainstream
FROM DISORDER TO EXPERIENCE 11
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will tend to possess a limited and restrictive set of conceptual
frameworks when they themselves, or people in their lives,
encounter mental health problems. These limitations, and
the assumptions of abnormality which they reproduce, may
act as barriers to people’s ability to understand di culties and
respond to them appropriately.
Of course, all teaching and learning starts from a set of
assumptions about what we imagine to be the nature of the
topic and what students need to learn about it. We do not imag-
ine that by avoiding the term ‘abnormal psychology’ we have
somehow written a textbook that is free from any assumptions
far from it. We simply hope that the assumptions we started
from will prove more helpful and appropriate for psychologists
and many others who wish to engage with this topic.
Isn’t this just anti-psychiatry?
Some readers might consider that our arguments so far are
‘just anti-psychiatry’. By t hi s, p eo pl e m ea n th e wo rk o f ps yc hi -
atrists and others in the 1960s, like Ronald Laing in the UK and
Thomas Szasz in the USA, both of whom were critical of the
legitimacy of psychiatric claims. As we will see in Chapter 2,
the so-called anti-psychiatrists were not a homogenous
group, and there were important di erences between the key
gures. Moreover, both Laing and Szasz were unhappy with
the term ‘anti-psychiatry’, and they were clearly not against all
ideas and practices in this area, since they both continued to
practise psychotherapy.
Many modern abnormal psychology and psychiatry text-
books give the impression that the challenges raised by the
would be impossible, given that so much of the evidence we
have about distress is associated with it. Nor does it mean that
we ignore any of the multiple facets of distress, such as its
biological, cognitive or developmental aspects.
However, it does mean that we treat psychological explana-
tions of distress as su cient in their own right. Rather than
subordinating them to psychiatry by applying them only to
problems defi ned in the fi rst instance as medical and psychiat-
ric, we also use psychology to defi ne the nature and character
of people’s distress.
Abnormal psychology is unhelpful
A third reason we haven’t used the term ‘abnormal psychol-
ogy’ is that it is likely to be particularly unhelpful for many
of the people who will be expected to study it. As we note
throughout this book, distress is very common and it is likely
that most readers will know someone who has experienced it
(see Box 1.3).
In this context, teaching that is framed from the outset as
being about something abnormal will already import a range
of assumptions that, for many readers, are likely to be di cult
or unhelpful. It is hard to engage constructively with teach-
ing that labels you, or the people you love and care for, as
abnormal.
Even more serio usly, this unhelpful aspect of abnormal
psychology is not confi ned to its likely e ects upon the learn-
ing and teaching of psychology. Although the majority of
people who study psychology do not go on to have careers
in the profession, they will nevertheless draw upon what they
have learned at other points in their lives. This means that they
BOX 1.3
I know someone who has a
mental health problem
Many readers of this book will either
know someone who has had a mental
health problem, will have experienced a
problem themselves, or may do so in the
future. UK mental health campaigners
suggest that about one in four people
will, at some point in the course of
their lives, experience clinical levels of
distress. Elsewhere in this book, we ask
whether such fi gures challenge common
defi nitions of mental illness based upon
notions of organic disease and dysfunc-
tion. For now, all we need to recognize is
that such experiences are very common,
so if you have experienced distress – or
know someone who has – you are not
alone.
In a survey of students attending an
abnormal psychology class in the US,
Patricia Connor-Greene (2001) found that
almost every student reported knowing
someone with a mental health problem,
that quite often students knew several
such people, and that the people they
knew were most often family members.
She observed that taking part in such a
class is not ‘simply an abstract academic
exercise; it is a potential source of
knowledge and skills that could have a
signifi cant impact on students, families
and friends’ (Connor-Greene, 2001, p. 211).
We take this point seriously.
Throughout the book we have sought to
portray people in distress in a respectful
manner, and to avoid an ‘us and them’
attitude. We have tried to investigate
and present the evidence behind, for
example, claims about particular mental
health interventions, so that readers of
the book can act as informed citizens
when helping a family member to
weigh up the pros and cons of di erent
intervention options.
When reading about mental health,
one can easily start to recognize oneself
in the descriptions of certain kinds of
problem. As we will see in later chapters,
studies of the normal population suggest
that many mental health problems are
normally distributed, such that a lot of
us experience them at a low level (i.e.
in a manner which does not get in the
way of our lives or cause signifi cant
di culties for us or those close to us).
Thus, if you feel that you are a little
obsessive because you like things to be
neat and tidy, it does not mean you have
a disease called obsessive compulsive
disorder. This self-recognition problem
is very common. If you asked the other
students in the class if they have started
to question whether they have a mental
health problem, we think it is likely they
will say that they have too!
If, however, you do have a problem
that is long-lasting, and that is causing
di culties that get in the way of your
life and causing you further distress,
then you should consider seeking help.
Most universities and colleges have
mental health or counselling services,
and these can be an appropriate place
to start. For those who are not students,
local voluntary services in your area can
usually be identifi ed by searching the
internet. You could also try discussing
your di culties with your GP, who – if it
is appropriate – will be able to refer you
to more specialist services.
12 CONCEPTS
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place since the 1960s. The term ‘anti-psychiatry’ seems to
exclude all of this more recent work, is simplistic, and carries far
too much historical and conceptual baggage; for these reasons
we would not use this label to characterize our approach.
From disorder to experience
Most mental health textbooks, then, focus on psychiatric
disorders; Box 1.4 shows how disorder is typically defi ned
within psychiatry, and discusses some problems associated
with such defi nitions. By contrast, in this book we focus on
experience. By this we mean that we will describe and try to
explain experiences of distress without presuming that they
are always caused by an underlying disorder of some kind.
We will t reat the di culties themselves as something to be
explained, rather than attributing them to an underlying
disorder that in fact may not even exist.
In the last few years there has been a growing tendency
for psychology to engage directly with the particularities of
experience itself, rather than, for example, engaging with
general biological or cognitive capacities. There have been
three recent books on the psychology of experience, each one
taking a slightly di erent focus. Ben Bradley (2005) empha-
sizes that experience is always relational and shaped by the
simultaneous experiences of other people. He also discusses
ways of thinking about the signifi cance of time in relation to
experience. Dave Middleton and Steve Brown (2005) show how
our experience is made in part from our memories, exploring
how they help give meaning to everything we see, hear and
feel. Niamh Stephenson and Dimitris Papadopoulos (2007)
anti-psychiatry movement were addressed with a new edition
of the DSM in the 1980s. However, this new manual did not
solve the more fundamental conceptual problems noted by
these critics – for example, that value judgements are neces-
sarily involved in defi nitions of mental illness, and that there
is no clearly evidenced biological basis for mental illness, and
thus no physical tests for (say) schizophrenia in the way that
there are for infections or viruses. Moreover, there has been
a considerable body of empirical research over the last fty
years which has cast new light on some of the debates which
began in the 1960s. Throughout the book we will draw on this
research to demonstrate that there are continuing problems
with the validity and reliability of diagnostic constructs.
Likewise, we will draw on this research to show that a focus
on the experience of forms of distress can yield results that are
valuable to service users, researchers and clinicians.
It may help here to consider some of the debates in other
areas of psychology, for example between di erent approaches
to social psychology or between paradigms like learning
theory and psychoanalysis. Here, too, there are debates about
assumptive frameworks, key concepts, terminology and
methodology. In these areas, too, we have had to accept that
research is always, to some degree, a refl ection of its time,
a ected by cultural norms and so on. Our contention is that
this is also true in mental health, so throughout the book you
will see debates analogous to those found in other areas of
psychology.
In short, there are some similarities between aspects of our
approach and the ideas of the anti-psychiatrists, but there are
also signifi cant di erences. This book re ects the fi ndings of
the nearly fi fty years of research and discussion that has taken
BOX 1.4
DSM-IV defi nition of mental
disorder
In DSM-IV each of the mental disor-
ders is conceptualized as a clinically
signifi cant behavioural or psychologi-
cal syndrome or pattern that occurs
in an individual and that is associated
with present distress (a painful
symptom) or disability (impairment
in or more areas of functioning). This
syndrome or pattern must not be
merely an expectable and culturally
sanctioned response to a particular
event, for example the death of a
loved one. Whatever its original
cause, it must currently be consid-
ered a manifestation of a behavioural,
psychological or biological dysfunc-
tion in the individual. Neither deviant
behaviour nor confl icts that are
primarily between the individual and
society are mental disorders unless
the deviance or confl ict is a symptom
of dysfunction in the individual.
Reproduced in Stein et al.
(2010, p. 1760)
This defi nition raises many issues that
recur throughout this book: whether
or not distress should be seen as a
medical or biological problem, the
relationships between individuals and
their culture, the kinds of reactions
we should expect people to show to
unpleasant but common experiences
such as bereavement, and so on.
Notably, however, the defi nition also
displays a continual concern with
notions of dysfunction, and this raises
some complex issues.
For example, Wakefi eld (1992)
distinguishes between disorder and
dysfunction. He argues that a disorder
is a harmful dysfunction, and that what
is considered harmful will be judged
according to prevailing social norms.
By contrast, a dysfunction – for example,
of a cognitive mechanism designed to
conduct a specifi c function – might be
identifi ed objectively, so is not subject to
the same kinds of infl uences or biases.
This suggestion is insightful: it avoids
many of the di culties associated with
defi nitions of normality and abnormality
whilst also recognizing that the notion
of disorder is inescapably social in
character.
However, as Kirk and Kutchins
(1999) observe, we can only reliably
identify a dysfunction if we can say
with confi dence what the function of a
system or organ is meant to be.
But in relation to human minds and
brains, our knowledge of these
functions is still remarkably limited. For
example, we know that many neural
systems frequently serve more than
one function, that most basic abilities
are enabled by multiple neural systems
working in parallel, and that there
are frequently many di erent neural
pathways by which the same
(or a similar) behavioural or cognitive
goal can be reached. They argue
further that many forms of distress
are probably not dysfunctional in any
simple sense: for example, that it may
well be ‘natural’ and a sign that your
neural systems are working as they
should if you end up feeling deeply
miserable because you have lost your
job and have no immediate prospect of
getting another.
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Like all of the other examples in this book, these are fi ctional
they are not descriptions of real people. Nevertheless, they are
ctions closely informed both by clinical practice and by the
research literature describing mental health di culties. This
means that we can use them to draw out important issues that
are relevant to our understandings of distress – for example,
how people are socially positioned. Dave is a middle-class
professional, whereas Ellie and Mark are less wealthy and have
fewer resources. Studies show that the incidence of psychiatric
diagnoses varies with wider economic and social conditions
and is patterned according to sociological variables such as
class or socio-economic status, gender and ethnicity. Similarly,
there is much evidence that women are more likely to be
given some psychiatric diagnoses than men, and that overall
they are more likely to experience distress. Nevertheless, as
our examples illustrate, at the individual level these infl uences
appear complex and uneven.
Ultimately, each of our examples is an attempt to reduce the
messy complexity of a lived experience, in all its uncertainty
and ambiguity, to a single narrative told from a specifi c point
of view. Inevitably, doing this raises issues. For example, there
are always other stories that could have been told: even though
we have tried to illustrate something of the great diversity of
distressing experiences, it is impossible to encapsulate the
variety of experiences being lived out around us all the time. So
we could have told many other stories; but we could also have
told the stories we did tell in di erent ways. Marks stepfather,
for example, might have told a story that emphasized Mark’s
unreasonable behaviour, and described how he frequently
becomes aggressive without any apparent justifi cation.
focus mainly on the ways in which experience is shaped by
the wider power relations of society, relations which regulate
our experience and – at the same time – create contradictions
that can put us somewhat at odds with their requirements.
These di erent perspectives on experience begin to show
how it always spreads in two directions: ‘outside’ ourselves,
into the social and material circumstances that give experi-
ence its character and content, and ‘inside’ ourselves, by way
of the many thoughts, feelings and memories it consists of.
In this book we will try to explore experience from both of
these directions, in the hope that by doing so we can make
even superfi cially ba ing experiences more open to expla-
nation. The alternative – attributing what we cannot readily
understand to the e ects of an underlying disorder – tends
to produce unsatisfying, circular explanations: we know that
Jenny has schizophrenia because she hears voices, and the
reason she hears voices is because she has schizophrenia.
Whilst the kinds of experiences we will consider are quite
varied, they are all of the kinds that mental health profession-
als might encounter in the course of their work. At the start of
this chapter we presented Bess’s story and suggested that her
experiences are fairly typical of those that clinicians encoun-
ter. Here are some more examples:
Dave is a 45 year old man who is frustrated with his career.
Although he has a well paid, highly respected job and a
comfortable home, he is dissatisfi ed with other aspects of
his life and his negative feelings have recently started to
become overwhelming. At work, Dave feels that his talents
are not being recognized, and that his manager is a bully
who does not take his suggestions seriously. In recent
months, this situation has begun to preoccupy Dave’s
thoughts. He has frequent trouble sleeping, and has started
experiencing pains in his neck and back. His GP can nd
no physical cause for these pains, but since Dave recently
began experiencing panic attacks he has referred him to
a counsellor attached to the practice. Together with the
counsellor, Dave has begun exploring how his responses to
his manager are shaped by other experiences in his life.
Ellie is a 19 year old woman who got pregnant when
she was just 15, although she has not seen her son’s father
since then. She has tried to provide her son with a stable
home, but despairs that she is only surrounding him
with the same kinds of instability and confusion that she
experienced herself when she was growing up. For a long
time now Ellie has felt very miserable, but she has come
to believe that if only she had cosmetic surgery to make
her body look ‘younger’, more attractive to men, she would
feel much better. When her doctor would not refer her
for cosmetic surgery of this kind, Ellie attempted suicide.
Since then she has been taking anti-depressant medica-
tion and receiving cognitive-behavioural therapy.
Mark is a 25 year old unemployed man who lives with his
mother and stepfather in a poor suburb. He never knew his
own father, who left home when he was small. His mother
remarried and had a daughter with her new partner, and
Mark grew up feeling that he always took second place to
his sister. Following a long and angry argument with his
stepfather, Mark has been lonely and miserable and has
started locking himself into his room. Alone at night, he
has begun to hear angry male voices criticizing him. Mark
is terrifi ed by these experiences, but has not told anyone
about them because he fears that people will laugh.
Both psychiatry and psychology are imbued with interests – for example,
those of commerce and professional status. Although the problems
associated with these interests may be more acute in respect of
psychiatry, psychology does not provide a neutral ground from which to
approach distress
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don’t understand it in these dismissive terms because there
is a clear and visible explanation for its severity. Those who
experience chronic back pain, by contrast, may also fall prey
to such discrimination: having a visible cause for pain – or for
distress – helps.
Third, the experiences of distress that are categorized by
psychiatric diagnoses are, in any case, overwhelmingly psycho-
logical in character. There are no reliable biological markers for
di erent diagnoses, no blood tests or scans that can be used to
make diagnoses of depression or schizophrenia. Instead, there
are reports – usually verbal – of various kinds of experience:
unusual beliefs, profound unhappiness, extreme agitation,
hearing voices and so on. These experiences may well also have
aspects that are visible in the person’s bearing and manner:
people who are deeply unhappy, for example, often talk more
slowly than other people, and sometimes more quietly. They
may have di culty thinking of words or concentrating on the
ow of conversation, and may nd it hard to motivate them-
selves. But the existence of these bodily elements does not
necessarily mean that there is a physical disease called depres-
sion, although it does demonstrate, again, that psychological
states are simultaneously states of the body and brain.
Fourth, we should always keep in mind that even when
people’s own actions seem to be unhelpful and self-defeating,
this does not mean that they are simply responsible for their
own distress. Putting this another way, just because how we
respond to our distress can make a di erence to the outcome,
this doesn’t mean that individuals should be held personally
responsible for failing to respond in what, from an outsider’s
perspective, is the ‘correct’ manner. In actuality, most people’s
room to manoeuvre is far more limited than it might at fi rst
appear, and many simply do not have the resources to deal
with their situation in ways that are markedly di erent.
Moreover, just like everyone else, when people experiencing
distress make choices, they always do so with limited knowl-
edge of their consequences: we can know what we do, but
cannot so readily know all of the e ects of what we do.
Far from den ying the real ity of peo ple’s dis tress , th en,
psychological explanations begin with this reality and attempt
to understand how it has been constituted. In our view,
Anything that is ‘in the mind’ is also a state of the brain and body
This suggests that there will often be tensions between what
people say about distress according to how they have experi-
enced it, how they have been exposed to it, and how they have
been encouraged to understand it. Moreover, these tensions will
often have moral, ethical or political dimensions to them. This is
only to be expected: partly because distress often fi rst becomes
a matter for intervention when people agrantly breach every-
day moral codes and expectations, partly because distress is
associated with inequality, disadvantage, discrimination and
prejudice, and partly because the stigma associated with it can
be used to discredit or denounce the actions and pronounce-
ments of individuals. Stories about distress (like all stories, in
fact) are never neutral: they are always told from a point of view,
and that point of view always refl ects a set of interests.
We have no defi nitive solution to these problems. We
certainly cannot claim that the account we give in this book
is somehow neutral, or that it fails to refl ect our interests as
academic and clinical psychologists. Instead, we have adopted
two strategies to take account of these problems. First, we will
continually emphasize the importance of all kinds of evidence
when considering, weighing and assessing the claims made
for di erent explanations of distress. And second, we have
included in this book some of the views and perspectives of
people who actually experience distress, so that our profes-
sional perspectives can be balanced by perspectives from
those who have actually received mental health services.
All in the mind?
By rejecting psychiatric disease categories we might appear
to be denying the reality of people’s distress: if the categories
aren’t real, are we saying that the distress isn’t real, either?
This is not the case. We have not based this book upon
psychiatric diagnoses because of the extensive evidence
regarding their lack of validity, poor reliability, dubious empiri-
cal grounding and much-discussed conceptual di culties (we
discuss this evidence in much more detail throughout the
book, especially in Chapters 4 and 5).
In place of psychiatric diagnoses, we advocate consistently
psychological explanations, but from a psychological perspec-
tive, people’s distress is just as ‘real’ as it is from a psychiatric
one. The pejorative term ‘it’s all in her mind’ is sometimes
used to imply that psychological distress should be something
we can simply overcome by an e ort of will. It is a moral
judgement which ultimately implies that only those of weak
character fall prey to psychological disorders. In this book we
need to avoid such unjustifi ed moralizing, whilst holding on
to the idea that distress is fundamentally psychological. We
can do so in a number of ways.
First, we should recall that nothing is simply ‘all in the
mind’. Mind, body and brain are intimately joined together,
and anything that is ‘in the mind’ is simultaneously a state
of the body–brain system. The denigration of psychological
distress as being ‘all in the mind’, in other words, relies for its
force upon the cultural commonplace of mind–body dual-
ism. Mind–body dualism also sometimes called Cartesian
d u a l i s m refers to a tendency, common in Western
cultures and associated historically with the philosophy of
René Descartes, to treat mind and body as distinct, separate
substances with no necessary links between them.
Second, we should recall that pain, such as that from a
broken leg, is just as much ‘in the mind’ as distress, but we
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focus of study will be what occurs inside the brain and body of
someone experiencing distress; other infl uences will only be
important to the extent that they make a di erence to the body
and brain.
Models also supply a mode of representation – an analogy
or set of metaphors that is useful for communication and
conceptualization. In the cognitive model, for example, the
analogy is that the mind works like a computer, so we conceive
of distress as caused by faulty information processing. In this
way, models also organize events and phenomena into (possi-
ble) causal chains. If distress is cognitive and arises because of
faulty information processing, the causal chains will implicate
psychological mechanisms and strategies (attributions, percep-
tions etc.); if distress is biological, the causal chains will depend
on biological phenomena such as features of the brain.
However, these benefi ts can also become limitations.
Because models are analogies or metaphors for distress, rather
than actual distress, they can easily be over-extended. Once
we begin to think of distress in terms of (for example) a cogni-
tive model, we might be tempted to keep on thinking of it this
way even when we encounter aspects that might be better
explained in other ways. For example, although some aspects
of being extremely sad can be conceptualized cognitively (in
terms of a set of negative cognitive biases), other aspects are
probably better explained by reference to biological or social
processes. This might seem to imply that a biopsychosocial
model is what is needed, and whilst in a superfi cial sense this
is obviously true, in practice most biopsychosocial accounts
are inadequate (we discuss this issue in Chapter 4, especially
in Box 4.5).
Another possible disadvantage of using models is that, in
simplifying distress by focusing on what is most relevant from
a given perspective, they might actually leave out what is most
important, but we will never know this unless we start from
the actual phenomena (the experience of being distressed, in
all of its complexity and confusions) rather than from within
the bounds of a model to which we have already made an
intellectual or professional commitment.
A nal disadvantage is that models of distress can be
misleading with respect to causality because they might imply
sets of relations that, in actuality, do not exist. For example,
a biological model of distress that emphasizes the role of
hormones might give the impression that these hormones
only interact with each other, and lose sight of the fact that
levels of hormones also uctuate according to external in u-
ences such as social and relationship status.
There are also deeper conceptual issues with most
commonly used models of distress because for the most part
they accept boundaries that we might wish to question. For
example, biological and social infl uences tend to be either
kept apart or – when they are brought together – mediated by
psychology. Whilst there is some sense in this, it then makes it
very di cult to consider situations where biological and social
infl uences might interact directly, without necessarily being
psychologically mediated, such as in the development of an
embryo in the womb, or in the very early days of a human
infant’s life.
Throughout this book we will sometimes have to make
reference to models of distress, and you can use the table in
this section to orient yourself toward them. However, whilst
they can be useful, you should always bear in mind that they
can also be misleading.
only the existence of a cultural prejudice against psycho-
logical explanations for distress prevents this from being more
obvious.
Models of distress
In science, models are often used as an aid to thinking about
and researching problems. Formal scientifi c models are
derived from theories and bear a systematic relationship to
them. There are also more ‘informal’ models that are most
accurately located within a paradigm rather than a theory,
and these are the kind of models typically used in relation
to distress. We have already mentioned biopsychosocial,
biomedical and psychosocial models of distress, but in the
literature many more are described. Figure 1.2 shows some of
the most commonly-cited models of distress, together with
their most frequently used synonyms.
Whilst for convenience we have named these models as
though they were separate and distinct entities, you need to
be aware that in actual practice things are far more confusing.
For example, it is possible to conceive of the diathesis-stress
model as a variant of the biopsychosocial model, because it
attempts to unite biology, in the form of an organic vulnerabil-
ity or diathesis, with the psychological and social infl uences
that cause stress.
However, it is equally possible to conceive of the diathesis-
stress model as a variant of the medical or psychiatric model,
because it posits that clinical distress only arises in people who
are medically (biologically) vulnerable. Likewise, some family
systems models are also psychoanalytic; and many psycho-
logical models are cognitive as well as behavioural. Similarly,
many people would see the biological model as being the
same as the medical or psychiatric one, whereas some would
di erentiate these.
Using models to understand distress can yield a number of
advantages. Models simplify complex issues, making it easier
to think about them and to generate ways of researching them
empirically. They do this largely by selecting some aspects
of distress as most relevant to enquiry, and others as less
relevant: this assists with both theory and empirical research.
Using a biological model of distress, for example, the primary
Biomedical (biological)
Medical (psychiatric, illness)
Diathesis-stress (stress-diathesis, stress-vulnerability)
Behavioural
Cognitive
Humanistic (existential)
Psychodynamic (psychoanalytic)
Family systems
Psychosocial (sociocultural)
Biopsychosocial
Figure 1.2 Models of distress
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diagnosis is not valid and reliable enough to provide a fi rm
scientifi c basis for understanding distress. It then sketches an
alternative, consistently psychological approach to classifying
distress.
Causal Infl uences: In some instances, the causes of a
person’s distress might seem quite obvious; in others, they
may seem mysterious or obscure. This chapter provides a
detailed discussion of the notion of causality in relation to
distress, showing how it is often more di cult to ascertain and
understand than we imagine. We describe and evaluate the
research methods used to establish causality in distress, and
then review evidence showing that – regardless of the specifi c
form that distress takes –it is associated time and again with a
common set of causal infl uences.
Service Users and Survivors: Mental health service users
sometimes describe themselves as experts by experience. This
chapter draws upon some of that expertise and describes how
the service user movement in the UK has mounted a series of
challenges to the treatments o ered by services. A discussion
of the work of the ‘Hearing Voices Network’ shows how serv-
ice users are continuing to challenge conventional services
by organizing themselves to provide viable alternatives to
conventional therapies.
Interventions: Here we describe the kinds of interventions
for distress typically o ered by Western mental health services.
We de scri be psy chiatri c medica tion , p sychoth erap y, and
community psychology interventions, using these to show
how each o ers di erent potential sources of help to people
experiencing distress. A number of di erent mental health
professionals are involved in o ering interventions to people
in distress – in the appendix to the book we describe some of
the key professional groups and the kinds of settings within
which they work.
Part 2
Part two of the book contains ve chapters. In each one
we discuss in detail one of the major kinds of distress that
contemporary Western mental health services encounter.
We h ad to m ake som e di cult choices about how we should
present this material. On the one hand, we did not want to
organize the material around psychiatric diagnoses. On the
other hand, we knew that many mental health modules are
structured in this way. This meant that we needed to present
our material in a way that was useful to as many people as
possible.
We have done thi s b y s tructur ing these ch apte rs arou nd
broad forms of distress where there is some commonality in
the underlying phenomenology of an experience. In psychol-
ogy, phenomenology refers to exactly what an experience is
like – what kinds of characteristics, features and subjective
qualities it has. Refl ecting some of its links with philosophy
(phenomenology is also an important branch of philosophy),
this usually means that e orts are made to include the bodily
or embodied aspects of experience, as well as those usually
described as mental or cognitive.
What does this look like in practice? Well, for example, it
means that Chapter 9, ‘Sadness and Worry’, deliberately treats
together aspects of experience that are usually treated sepa-
rately in books organized according to the DSM classifi cation.
In other books, these experiences are likely to be addressed
in two separate chapters, one focused upon ‘Depression’ and
Overview of this book
This book is in two parts. The rst part provides a foundation
for the second by systematically setting out key concepts,
debates and evidence. The aim of the rst part is to supply a
detailed account of distress that describes its character, identi-
es causal infl uences, and discusses responses to it. In the
second part, we apply this account of distress to a subset of the
most common kinds of mental health problems encountered
by professionals in clinical psychology, psychiatry, social work
and related disciplines.
Part 1
This part contains eight chapters which, read together, provide
a consistently psychological account of distress. Although we
frequently discuss psychiatric diagnoses in this part, we do
not use them as explanations. Instead, we o er explanations
that draw upon psychological theories and concepts, supple-
mented where appropriate with evidence and ideas from
disciplines including neuroscience, anthropology, sociology,
epidemiology and other relevant disciplines. In this way we
provide an account of distress that avoids ‘jumping ship’ and
uncritically importing wholesale a set of concepts and theories
from psychiatry. Part 1 has eight chapters:
Introduction (this chapter)
History
Culture
Biology
Diagnosis and Formulation
Causal Infl uences
Service Users and Survivors
Interventions
History: To under stand why we have the ideas we do today it
is vital to look at how those ideas were developed, so in this
chapter we provide a survey of the di erent ways that distress
has been understood and treated over the centuries. Our
history shows how there have always been competing strands
of explanation and treatment for distress, some primarily
implicating the body and its organs and some primarily impli-
cating experiences, meanings, thoughts and feelings.
Culture: This chapter describes how distress di ers between
cultures. It discusses some of the great variability in the forms
of distress, the variability in the ways that it gets linked to other
aspects of experience, and the variability in the outcomes
associated with it. As we have already suggested, distress is
thoroughly bound up with culture, and this chapter illustrates
the extent and consequences of this.
Biology: Our approach to biology treats it as an inescapable
part of distress, but does not make the unfounded psychiatric
assumption that it is always the ultimate cause of people’s
di culties. In this chapter we explain why there are problems
with biopsychosocial accounts of distress, and in their place
o er an alternative view of the role of biology. We summarize
evidence that supports our approach, drawing upon studies
of attachment as well as upon recent work in psychology and
neuroscience.
Diagnosis and Formulation: Textbooks of ‘abnormal
psychology’ are usually organized around systems of psychi-
atric diagnosis, such as one of the versions of the DSM.
This chapter presents some of the evidence that psychiatric
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will get a lot more out of reading all of them if you fi rst read the
chapters in Part 1.
Questions
Each of the chapters has a set of questions associated with it.
You ca n u se th es e q ue st io ns to ch ec k y ou r o wn le ar ni ng an d
make sure that you understand the material in the book in the
way that we intend. There are guiding questions at the start of
each chapter that will alert you to recurrent themes to keep in
mind as you read. There are also summary or revision ques-
tions at the end, which you can use to check that your learning
is proceeding adequately.
Boxes
All through the book we use boxes to introduce additional
material alongside the main text. Some of the boxes simply
contain material that, although linked to the main text, is easier
to explain separately. Other boxes contain discussions of key
theories, concepts or issues which will recur throughout the
book.
Key terms and concepts
You h av e p ro ba bl y a lr ea dy no ti ce d th at w he ne ve r w e u se
any specialist terms or language for the rst time, the term is
printed in bold and a defi nition or explanation appears very
close by – mostly immediately afterwards, occasionally just
beforehand.
Stories and experiences
Almost all of the chapters in this book start with a story about
someone’s experience. As we have already explained, these
stories are all fi ctional but, at the same time, they are informed
by clinical practice and by close readings of the mental health
literature. You can read them as a very quick and accessible
way of orienting yourself to the concerns and issues that each
chapter raises.
the other focused upon ‘Anxiety Disorders’. Similarly, Chapter
11 on ‘Madness’ includes experiences that, in other textbooks,
would be addressed separately in relation to psychiatric diag-
noses such as schizophrenia and bipolar disorder.
Although the number of di erent kinds of distress we
discuss in this way is fairly small, they will account for the vast
majority of the referrals received by UK mental health services.
The chapters are
Sadness and Worry
Sexuality and Gender
Madness
Distressed Bodies and Eating
Disordered Personalities
Each of these ve chapters is structured in a similar way, and
each one builds upon the concepts and evidence laid out in
Part 1 of the book. Within each of these chapters there are
sections on history and culture, a summary of the psychiatric
diagnoses typically given to people experiencing this form of
distress, a review of the evidence regarding causality, and a
description of the kinds of treatments and interventions avail-
able for this kind of distress.
How to use this book
Sequence
Because most ‘abnormal psychology’ textbooks are structured
around the diagnostic categories of the DSM, they often do not
make a sequential, structured argument. This means that it is
usually quite easy to dip into them, regardless of the order of
the chapters, in order to read about specifi c diagnoses.
This book is a little di erent. In Part 1, especially, all of the
chapters are linked so that together they provide a systematic
argument that explains our approach to distress. The chapters
in Part 2 are more like the chapters in other textbooks, in that
it does not especially matter in which order you look at them.
However, whilst these chapters can be read in isolation, you
18 CONCEPTS
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... Σημαντική επιρροή στον σημερινό ορισμό της σχιζοφρένειας είχε στα μέσα του 20 ού αιώνα ο Γερμανός ψυχίατρος Kurt Schneider, ο οποίος διαμόρφωσε μία λίστα των «πρωταρχικών συμπτωμάτων» της σχιζοφρένειας, που περιλάμβανε αποκλειστικά τύπους ψευδαισθήσεων και παραληρητικών ιδεών. Αυτό επηρέασε αποφασιστικά τις κατοπινές προσεγγίσεις, όπως και τη σημερινή προσέγγιση της σχιζοφρένειας, με έμφαση στα επονομαζόμενα «θετικά συμπτώματα», κυρίως ψευδαισθήσεις και παραληρητικές ιδέες, θεωρώντας τα επονομαζόμενα «αρνητικά συμπτώματα», όπως η απάθεια, η έλλειψη ενέργειας, ενδιαφέροντος κλπ., δευτερεύουσας σημασίας για τον ορισμό και τη διάγνωση της διαταραχής (Cromby et al., 2013). ...
... Στις συνηθισμένες «θεραπείες» της τρέλας κατά τον 18 ο και 19 ο αιώνα περιλαμβάνονταν η αφαίμαξη, η χρήση καθαρκτικών, η πρόκληση εμετού, η μόλυνση με ψώρα, η αναγκαστική κατάποση στάχτης. Συνηθισμένες πρακτικές στα άσυλα μέχρι και τα μέσα του 20 ού αιώνα ήταν να δένουν τους έγκλειστους σε καρέκλες που στριφογυρίζουν με δύναμη, να τους κλείνουν σε κλουβιά, να τους κρεμούν από το ταβάνι και να τους ρίχνουν σε μπανιέρες με παγωμένο νερό (Cromby et al., 2013. Η κυρίαρχη άποψη στις αρχές του 20 ού αιώνα ότι η τρέλα, όπως και άλλες μορφές «εκφυλισμού», πχ. ...
... Δεκάδες χιλιάδες ανθρώπων με διάγνωση ψυχωτικών διαταραχών υποβλήθηκαν σε λοβοτομή για μερικές δεκαετίες, έως ότου έγινε ξεκάθαρο, όπως άλλωστε θα ήταν αναμενόμενο, ότι η λοβοτομή προκαλεί ανεπανόρθωτες βλάβες στη σκέψη και το συναίσθημα, και τελικά εγκαταλείφθηκε. Άλλη εφεύρεση της εποχής, που τελικά εγκαταλείφθηκε, ήταν η «θεραπεία κώματος μέσω ινσουλίνης», στην οποία χορηγούνταν μεγάλες δόσεις ινσουλίνης που προκαλούσαν κατάσταση κώματος με σπασμούς (Cromby et al., 2013. Johnstone, 2000. ...
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Η Μονογραφία αυτή συνεισφέρει στη βιβλιογραφία για την ανάπτυξη ενός κοινοτικά και κοινωνικά προσανατολισμένου συστήματος ψυχικής υγείας. Οι δεκαετίες της ψυχιατρικής μεταρρύθμισης στην Ελλάδα συνέβαλαν ουσιαστικά στην προαγωγή και την προστασία των ανθρωπίνων δικαιωμάτων των ατόμων με ψυχικές διαταραχές, και στην ποιότητα ζωής τους. Τα τελευταία χρόνια, το κοινοτικό μοντέλο φροντίδας ενισχύεται από νέες προσεγγίσεις, όπως το μοντέλο της ανάρρωσης που δίνει έμφαση στην ενδυνάμωση των ατόμων με ακραίες ψυχικές εμπειρίες αναγνωρίζοντας τις προσωπικές τους εμπειρίες ως πηγή γνώσης και νοηματοδότησης. Η Μονογραφία υπηρετεί τις σύγχρονες αυτές προσεγγίσεις, κομίζοντας τη διεθνή βιβλιογραφία αιχμής στο συγκεκριμένο πεδίο. Στο πρώτο μέρος, αναπτύσσεται μια επιστημονικά τεκμηριωμένη ανασκόπηση της σύγχρονης βιβλιογραφίας αναφορικά με την κατανόηση και αντιμετώπιση της ψύχωσης. Στο δεύτερο μέρος, παρουσιάζονται ευρήματα μιας πρωτότυπης, πρωτογενούς έρευνας που εφάρμοσε αφηγηματική βιογραφική προσέγγιση για την ανάδειξη των μαρτυριών των ανθρώπων με ψύχωση. Μέσα από τις μαρτυρίες των συμμετεχόντων, αναδεικνύονται οι εμπειρίες της ζωής πριν την εμφάνιση της ψύχωσης και οι κοινωνικοί παράγοντες που πιθανόν συντέλεσαν σ’ αυτήν. Χαρτογραφούνται, επίσης, οι τρόποι με τους οποίους βίωσαν, νοηματοδότησαν και διαχειρίστηκαν τις ψυχωτικές τους εμπειρίες. Με δεδομένη τη δυναμική ενσωμάτωση νέων επιστημονικών πεδίων, όπως της κοινοτικής κλινικής ψυχολογίας και της κοινωνιολογίας της υγείας και της ασθένειας, στα Προπτυχιακά και στα Μεταπτυχιακά Προγράμματα Σπουδών, η Μονογραφία αναμένεται να αποτελέσει έναν χρήσιμο βιβλιογραφικό πόρο σε φοιτητές/-τριες, ερευνητές/-τριες και επαγγελματίες που επιθυμούν να εργαστούν προς μια ανθρωπιστική κατεύθυνση κατανόησης και αντιμετώπισης του ψυχικού πόνου και να αναπτύξουν επαγγελματικές πρακτικές υποστήριξης της ανάρρωσης, κάτι το οποίο αποτελεί εκπεφρασμένο στόχο και ζητούμενο για τους σύγχρονους επαγγελματίες ψυχικής υγείας.
... UBI was not referred to so as to reduce the likelihood of oversampling from participants with a pre-existing interest in UBI. All participants were presented with a definition of psychological distress adapted from Cromby et al., (2013): Psychological distress is a term often used by psychologists and mental health practitioners to refer to all of the difficult, troubling or unusual experiences associated with psychiatric diagnoses or mental illness. The subsequent text differed according to which condition participants had been randomly allocated to. ...
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Background. Despite increasing recognition that clinical interventions are insufficient to improve mental health without corresponding emphasis on population mental health, few studies have compared public perspectives on population and clinical interventions.Aims. We begin to address this here by examining views of one intervention that holds considerable promise for improving population mental health: provision of basic income as implemented by universal or unconditional basic income (UBI) schemes.Methods. 622 participants rated the effectiveness of ensuring access to medication, psychotherapy, and income for reducing psychological distress. We manipulated whether participants were asked to rate effectiveness for an individual vs. the population and we asked participants to indicate their support for UBI either before or after making such ratings.Results. We find that income was rated as effective as psychotherapy for improving an individual’s distress and as most effective at reducing distress in the population. Participants who rated their support for UBI after giving these ratings had significantly higher support than those who answered this question before.Conclusions. These data reveal the mental health benefits of a traditionally economic instrument to be intuitive to participants in this sample, especially when viewed as population-level intervention.
... For example, the long-term physical effects of abuse and neglect include higher rates of cancer, strokes, arthritis, diabetes, lung disease, heart attacks, high blood pressure and bowel disease (Afifi et al., 2016;Monnat & Chandler, 2015;Widom et al., 2012). The long-term mental health impacts of child abuse and neglect include anxiety, depression, PTSD, eating difficulties, 'personality disorders', dissociation, sexual difficulties, substance abuse, psychosis and mood swings (Arnekrans et al., 2018;Cromby et al., 2018;Kendler et al., 2000;Kessler et al., 2010;Varese et al., 2012). In a general population study in the USA, those reporting at least one ACE experienced significantly lower levels of life satisfaction than those who did not, after controlling for demographic variables (Mosley-Johnson et al., 2019). ...
Article
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Adverse childhood experiences (ACEs) have been repeatedly associated with a wide range of physical and mental health issues. Research has indicated high levels of anxiety and depression among university students, and a few studies have documented the relationship between ACEs and anxiety in the university student population. This study surveyed first year students at a university located in the most ethnically diverse district in England, with the second highest poverty rate. Eight hundred and fifty-eight responded; a response rate of 12%. The survey included questions about adverse childhood events, recent life stressors, current deprivation, quality of life, positive physical health and positive mental health, and used the Generalized Anxiety Disorder Scale, a standardised measure. Thirty-seven percent of the responding students met the diagnosis for generalised anxiety disorder. In a multivariate multiple regression model, life stressors and childhood adversities were significantly associated with higher levels of anxiety and lower levels of physical and mental health. Only childhood adversities significantly predicted lower levels of quality of life. The findings highlight the importance of considering adverse childhood experiences in enhancing the wellbeing of the student population. Given the demographics of the student population at the University of East London, the high rates of ACEs and anxiety are likely to partially reflect poverty and racism. The implications of the findings for trauma-informed policies and practices in universities are discussed. Supplementary information: The online version contains supplementary material available at 10.1007/s10734-021-00774-9.
... Although evidence indicates that certain circumstances precipitate and influence hallucinations -such as adversity, trauma, sensory deprivation, sleep difficulties or bereavement -much remains unknown about the specificity of these relationships (Alameda et al., 2020;Longden & Read, 2016;Melvin, 2020;Parrett & Mason, 2010). Whereas research, healthcare practice and discourse on hallucinations have increasingly acknowledged the contribution of biological, psychological and sociocultural factors to causal accounts of hallucinations, progress remains to integrate the diversity of individuals' lived experiences (Cassidy et al., 2018;Cromby et al., 2013;Longden & Read, 2016). ...
Article
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Introduction Neurocognitive models of hallucinations posit theories of misattribution and deficits in the monitoring of mental or perceptual phenomena but cannot yet account for the subjective experience of hallucinations across individuals and diagnostic categories. Arts-based research methods (ABRM) have potential for advancing research, as art depicts experiences which cognitive neuropsychiatry seeks to explain. Methods To examine how incorporating ABRM may advance hallucination research and theories, we explore data on the lived experiences of hallucinations in psychiatric and neurological populations. We present a multiple case study of two empirical ABRM studies, which used participant-generated artwork and artist collaborations alongside interviews. Results ABRM combined with interviews illustrated that hallucinations were infused with sensory features, characterised by embodiment, and situated within lived circumstances. These findings advance neurocognitive models of hallucinations by nuancing their multimodal nature, illustrating their embodied feelings, and exploring their content and themes. The process of generating artworks aided in disclosing difficult to discuss hallucinations, promoted participant self-reflection, and clarified multimodal details that may have been misconstrued through interview alone. ABRM were relevant and acceptable for participants and researchers. Conclusion ABRM may contribute to the development of neurocognitive models of hallucinations by making hallucination experiences more visible, tangible, and accessible.
... Current developments in neuroscience and genetics also undermine most of its theoretical underpinnings (8). There seems to be no straightforward distinction between "mental health" and "mental illness" (17) and evidence suggests that psychiatric symptoms are on a continuum with the normal experiences (18). ...
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Objective: Although there is a wide range of theoretical perspectives and clinical practices, there is no assessment tool that reveals these variations among clinicians. In this study, we presented the development process of a new measure for clinicians that assess their psychological flexibility levels, attitudes towards psychotherapy and inclination to the mechanistic approach. Method: Participants included 167 psychiatrists and psychiatry residents from all over Turkey. They completed 29 items intended to form the basis for the Bakirkoy Clinician's Attitude Questionnaire (BCSQ). Item-total correlation and Cronbach's alpha correlation analyses were performed to determine internal consistency. The Acceptance and Action Questionnaire-II (AAQ-II) and the Mental Illness: Clinicians' Attitude Scale V.4 (MICA v4) were used to assess the convergent and concurrent validity of BCSQ. Results: Principal component analyses with varimax rotation were conducted to ensure construct validity and to explore sub-dimensions. Finally, a three-dimensional version (Clinical inflexibility, Treatment preference, Mechanistic approach) of the scale with 20 items was created. The BCSQ demonstrated good internal consistency (Cronbach's alpha coefficient was 0.82) and transient stability. Convergent validity analyses showed that BCSQ subscales have significant relationships with higher psychological inflexibility and stigmatization levels. Conclusion: BCSQ proves to be a valuable tool for assessing changes in the level of psychological flexibility of clinicians in clinical practice, their attitudes towards psychotherapy/psychopharmacology and their view of psychopathology.
... Current developments in neuroscience and genetics also undermine most of its theoretical underpinnings (8). There seems to be no straightforward distinction between "mental health" and "mental illness" (17) and evidence suggests that psychiatric symptoms are on a continuum with the normal experiences (18). ...
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The overall aim of this Participatory Action Research (PAR; Chevalier & Buckles, 2013; Lewin, 1946) project was to design, implement, and evaluate a specialized sport-focused mental health service delivery model for competitive and high-performance athletes, integrated within a broader Canadian Centre for Mental Health and Sport (CCMHS). A transformative mixed methods research design (Cresswell, 2014) guided by the PAR approach was employed across three phases during which (a) a sport-specific mental health service delivery model for competitive and high-performance athletes was collaboratively designed by stakeholders (Design Phase [Study 1]), (b) the model was pilot-tested within the CCMHS (Implementation Phase [Study 2]), and (c) the model was evaluated to understand whether practitioners and service-users perceived the care delivered / received within the model to be acceptable and appropriate (Evaluation Phase [Study 3]).
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There are concerns globally about the emotional wellbeing and mental health of young people and in this paper a critical orientation comprises both theoretical and empirical data sources. The case is made that 1) the medical model of mental health - that of problem identification, diagnosis and medical treatment at the level of the individual - is not appropriate for the vast majority of children and young people in schools and 2) relational approaches would be more sensitive in responding to the complexity of the ‘conditions’ in the schools, homes and communities in which young people live. Articulations of these conditions are explored from the literature while we also draw on empirical data from part of an Evaluation of a school-based teacher-training programme in which interviewees and respondents too mapped out their own conditions for emotional wellbeing and mental health. We conclude with proposals for relational approaches which 1) acknowledge the links between affect, cognition and school climate and culture; 2) foreground mental health and poverty as impacting on young people’s emotional wellbeing in their communities, families and schools; 3) attend to voice – provide spaces in which young people can develop their own ‘preferred narratives’ concerning emotional wellbeing and mental health.
Article
The concept of ‘paradoxical outcome’ refers to instances of differences in evaluation of the outcome of psychotherapy when taken from different sources and/or by different modes of evaluation. Paradoxical outcome has become a central issue in psychotherapy practice and research because of its prevalence as well as its implications for the aims and process of therapy. The concept of paradoxical outcome treats discrepancies in the evaluation of psychotherapy as problematic, indicating that the underlying expectation is that the outcome of psychotherapy should be consistent. In this commentary to the special issue, I propose that this assumption that the outcome of psychotherapy is a unified construct that is agreed among interested parties, that underlies the concept of paradoxical outcome, is a fundamental fallacy. Moreover, I argue that it is important to recognize that the outcome of psychotherapy is a complex notion that has different meanings for the various agents implicated in it. This recognition may in turn open the way to exploring the function and goal of psychotherapy for each of the different agents involved in it, and this will highlight its central role as a social and institutional practice that regulates contemporary subjectivities and practices.
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There exist different theories about the causes of psychological distress. The purpose of this study was to examine the predictions made by the social status identity hypothesis and psychodynamic theory (ego psychology model) about psychological distress. Accordingly, the role of an individual’s perception of economic needs, social status, and social power and the role of defense mechanisms (immature, neurotic, and mature) in the severity of psychological distress were investigated. The study population was citizens of Tehran, Iran and the research sample consisted of 152 people from two middle-class districts of Tehran. The required data was gathered by social status identity questionnaire, Kessler psychological distress scale, and defense mechanism questionnaire. All the elements of social status were negatively associated with psychological distress. Simultaneous regression showed that elements of perception of social status and defense mechanisms can predict 42% of the variance related to psychological distress. Defense mechanisms (immature, mature, and neurotic) and perceived social power significantly predicted psychological distress. Based on the findings of this study, it can be argued that people who use maladaptive defense mechanisms and people who have a lower perception of social power are more prone to psychological turmoil.
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