Psychiatric-mental health professionals (providers/practitioners) need to have a comprehensive knowledge foundation about mental illness and the theoretical underpinnings associated with it. Definitions of theory, as well as theories of mental health and illness, abound. Variation in these definitions can be influenced by or contingent on a number of factors, including the disciplinary and specialty perspective. Presently, theory development in psychiatric-mental health and mental illness is undergoing extensive change, and the implications for all psychiatric-mental health practitioners are many. In addition to theoretical understandings, evidence-based research and clinical practice standards have evolved as a critical and expected basis for developing appropriate interventions for and with patients diagnosed with psychiatric-mental health disorders. These theoretical, epidemiological, translational research and clinical practice standards, together with the clinical knowledge garnered through the interpersonal relationship that the provider has developed with the patient, provide a foundation for an efficacious, patient-centered therapeutic intervention.

This chapter provides an overview of various prominent theories of mental illness. The work of influential theorists, researchers, and practitioners from several disciplines, including but not limited to nursing, medicine, and psychology, is described. Theoretical concepts and explanations of the potential etiology of mental illness from within the framework of psychodynamic, behavioral, cognitive, social, humanistic, and biological theory also are presented. Pertinent definitions, historical background, epidemiological incidence and prevalence rates, and comparative disease burden (e.g., disability, economic cost) of mental illness also are included.

MENTAL ILLNESS

The question is: What is mental illness? When asking mental health care providers or when researching mental health care disciplines, the result would reveal a wide variation in the definition of this term. Many mental health professionals would most likely define mental illness based on the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013), which is the widely accepted resource for defining mental disorders. Additionally, nursing professionals may use the North American Nursing Diagnosis Association-International (NANDA, 2014) Definitions and Classification or the International Classification for Nursing Practice (ICNP) taxonomy for nursing-specific definitions that include mental illness.

The first U.S. surgeon general’s report on mental health and illness—Mental Health: A Report of the Surgeon General (U.S. Department of Health and Human Services [DHHS], 1999)—defined MENTAL ILLNESS as mental disorders that are diagnosable conditions characterized by abnormalities in cognition, emotion, or mood, or the highest integrative aspects of behavior, such as social interactions or planning of future activities. This definition is consistent with concepts included in nursing diagnosis classification systems.

Evolution of Thinking About Mental Illness

The mind and mental illness have been subjects of concern, philosophical and theoretical debate, and research for more than two millennia. The quest for knowledge and understanding of the human mind is evident in the writings of early philosophers and scientists such as Aristotle, Descartes, Locke, Hume, and Kant. They explored concepts of the human mind, emotions, thoughts, and behaviors, and how the mind relates to the material or physical body and human condition along the continuum of health. The early philosophical questions included whether a mind actually existed, and if it did, where was it located and was it a force for good or evil? Others asked, if there was a mind, was it (a) separate from or a part of the physical body that could be objectified, would expand with space, and be experienced, and (b) did it contain all the biological senses of sight, hearing, smell, touch, and taste?

An important and enduring question is that of nature versus nurture. Is an individual born with a mind and body that are destined to become the product of its nature, or are there some other internal or external influences that affect how well or poorly the mind and body will perform after the individual is born? These questions continue to be relevant today and remain part of the philosophical and theoretical dialogue and debate among researchers and practitioners. Research and practice based on mind–body theories of monism (mind and body are of one thing, inseparable), dualism (mind and body are separate entities), interactionism, and positive empiricism that began centuries ago can still be found to lesser or greater degrees in contemporary theories. Questions, debates, theories, and research hypotheses that guided early experimental and empirical research studies are the foundation of what became known as the science of psychology and the art and science of psychiatric-mental health nursing and psychiatric medicine.

Contemporary literature on mental illness is replete with research guided by different theoretical frameworks. However, the theoretical descriptions of the etiology and treatment approaches within these theories differ.

The Current State of Mental Illness

Comparative data from the 1996 and 2006 Medical Expenditure Panel Survey—Household Component (MEPS-HC), cosponsored by the Agency for Health Care Research and Quality (AHRQ) and the National Center for Health Statistics (NCHS), indicate that mental disorder was ranked among the top five most costly medical conditions in the United States in both 1996 and 2006 (Soni, 2009). That same study revealed that the number of people with a mental disorder had risen from 19.3 million to 36.2 million. In addition, comparison of the time period between 1996 and 2006 demonstrated that mental disorders accounted for the largest increase in expenditure of all medical conditions, rising from $35.2 billion in 1996 (adjusted for inflation) to $57.5 billion in 2006 (Soni, 2009). Mental illness is considered to be epidemic based on recent studies and statistics. For example, prevalence rates and descriptive statistical data reported by the National Institute of Mental Health (NIMH) in 2009 indicate that 26.2% of Americans ages 18 years and older suffer from a diagnosable mental disorder in a given year. This would be equivalent to 57.7 million people when applied to the 2004 U.S. Census data. In addition, major depression, the most commonly diagnosed mental disorder, is the leading cause of disability in the United States for ages 15 to 44 years (NIMH, 2009). Moreover, the Centers for Disease Control and Prevention National Vital Statistics Report (Heron et al., 2009) ranked suicide as the 11th leading cause of death in the United States. Thus, despite existing theory, research, and treatment options, mental illness remains an epidemic in the United States and is a major health concern that requires public health initiatives to reduce the magnitude of human suffering and the costs associated with it.

Based on the results of these studies, more questions have come to light:

The answers to these questions are not simple. Contemporary literature has a plethora of information; for example, research results stating that there is indeed more scientific information about mental illness etiology, diagnoses, and possible treatments. It is known that economic influences play a role in selecting criteria to be used for diagnosis of mental illnesses. Insurance reimbursement to mental health providers often requires that a patient be diagnosed with a mental disorder that is included in the DSM-5 and/or the International Classification of Diagnoses (ICD)-10 (the World Health Organization’s [WHO] version of illness classification). However, despite this plethora of information, there is no full disciplinary, interdisciplinary, or subspecialty consensus on the value, validity, or reliability of the understandings of mental illness.

THEORIES AND MENTAL ILLNESS

There are many definitions of THEORY in the literature. Some definitions are highly abstract while others are narrow and reductionistic. According to the American Psychological Association (2009), a theory is defined as an organized set of concepts that explains a phenomenon or set of phenomena. Nurse researchers Im and Meleis (1999) defined theory as an organized, coherent, and systematic articulation of a set of statements related to significant questions in a discipline that are communicated in a meaningful whole to describe or explain a phenomenon or set of phenomena. For theory and research to become useful and contribute to the best evidence-based practices and quality outcomes in health care, theory-driven research must:

Mental health and psychology are associated with numerous theories. Theories can be organized into a framework involving their level of abstraction. GRAND THEORIES, such as the six that are addressed in this chapter, are the most abstract and broad in scope. MIDDLE-RANGE THEORIES, such as self-efficacy theory that is highlighted in Bandura’s social cognitive theory later in this chapter, are less abstract (more concrete) than grand theories. The third category of theories is labeled MICRO-LEVEL THEORIES, which are the least abstract and narrow in scope (Smith & Liehr, 2003).

Many different schools of thought are also prevalent in mental health and psychology but all share the same commonality—the study of the mind, body, and/or behavior. Six grand theories in mental health and psychology, often used in guiding mental health research, are explored here. They are: (a) psychodynamic theory, (b) behavioral theory, (c) cognitive theory, (d) social theory, (e) humanistic theory, and (f) biological theory. Box 10-1 defines these six theories.

Psychodynamic Theories

Psychodynamic theories focus on the unconscious and assert that underlying unconscious or repressed conflicts are responsible for conflicts, disruptions, and disturbances in behavior and personality. Actions are believed to be motivated by emotions and thoughts. Therefore, to understand and change behavior, a person needs to develop awareness and insight into his or her thoughts and emotions. Psychodynamic theories are based on Sigmund Freud’s psychoanalytic theory.

Sigmund Freud

Freud developed the first psychodynamic theory, called psychoanalytic theory. He is considered the father of psychoanalysis. He identified two major components of the mind: the conscious portion, which includes awareness of events, thoughts, and feelings that can be remembered, and the unconscious portion, which includes thoughts and feelings that are not accessible to an individual’s conscious or subconscious awareness. Freud also described the personality as consisting of three continuously interacting parts: the id, ego, and superego. The id represents the impulsive part of the self based on unconscious drives and primitive instincts. It is based on pleasure and involved with satisfying needs to attain immediate gratification. The superego represents the moral self associated with ethics, standards, and self-criticism. It develops as the individual internalizes values and morals learned from the interaction with parents and other primary caretakers. The ego can be viewed as the mediator between the id and superego, the rational decision maker based in reality and used to reduce tension and anxiety (Carver & Scheier, 2004).

According to Freud, an individual’s personality develops over five stages from birth through approximately 20 years of age. Termed the psychosexual phases of personality development, the phases are oral, anal, phallic, latency, and genital. Each phase is associated with a specific developmental task. Failure to achieve the task during any of the first three early childhood psychosexual stages may lead to fixation in that stage, unconscious sexual or aggressive conflicts, and mental illness.

Freud developed the theory of EGO DEFENSE MECHANISMS, which are conscious and unconscious tools used to protect and defend the ego. The mechanisms are used to reduce anxiety when confronted with conflict between libido energy drives of the id and superego. Psychoanalytic defense mechanisms outlined by Freud include: denial, displacement, intellectualization, projection, rationalization, reaction formation, regression, repression, sublimation, and suppression (Table 10-1). Defense mechanisms are used by everyone at times. They can be helpful and healthy, especially when used temporarily over a short time to deal with a conflict. However, excessive use or overuse of defense mechanisms has the potential to lead to distortion or blurring of reality, leading to inappropriate aggressive or socially unacceptable behaviors or psychosis.

Freud believed that most conflicts originate as a result of sexual aggression or aggression-related, unresolved unconscious conflicts originating during an individual’s childhood years. These conflicts lead to tension, developmental disruption, and mental illness, particularly anxiety spectrum disorders. Freud’s theory is often labeled the “will to pleasure” theory. He developed psychoanalysis as the means to unlock the unconscious and resolve these childhood conflicts.

Other Psychodynamic Theorists

Alfred Adler and Carl Jung knew and became students of Freud. Adler, Jung, and Viktor Frankl were among the early psychoanalytic leaders. However, each of them branched out from Freud’s initial precepts, identifying other theoretical constructs and strategies for understanding etiology and effective treatment of mental health conditions. Additionally, other psychodynamic leaders like Erik Erikson and Karen Horney broke off from traditional Freudian psychoanalytic concepts, veering away from the belief that sexual desires and conflicts in childhood were the major causes of later conflicts and mental illnesses. Table 10-2 summarizes the major beliefs for each of these theorists.

Although these theorists maintained a largely psychodynamic orientation, each built on his or her background in psychoanalytic theory and developed his or her own new theories. Some of these theorists could be included in more than one category of grand psychological theory, as they incorporated theoretical concepts and constructs from behavioral, social, and/or biological theory into their theories.

Psychoanalysis is conducted one or more times a week over several years. Techniques such as free association (spontaneously saying whatever comes to mind), introspection, and sometimes dream analysis are used to facilitate insight into repressed conflicts. The therapy is believed to reduce tension and anxiety, resolve conflict, and restore mental health.

Behavioral Theories

Behavioral theory, also called behaviorism, assumes that only observable, measurable, and objective criteria are important to understand human behavior and effect behavioral change. It attempts to explain an individual’s actions, that is, how a person acts. According to behavioral theory, a person’s behavior is the result of learning that has occurred in response to a stimulus. Behavioral theory does not include the concept of the unconscious in explaining mental health and illness.

Ivan Pavlov is credited with discovering the behavioral theory of classical conditioning. Other individuals have been credited with the title “father of behavioral psychology.” They include Edward L. Thorndike, John B. Watson, and B. F. Skinner.

Ivan Pavlov

Ivan Pavlov is a Nobel prize–winning physiologist who discovered the phenomenon of associative stimulus-response behavior while studying digestive processes in dogs. He noticed a curious association occurring during his experiments. The dogs in his sample began to salivate before food was placed in their mouths by the assistants. The dogs began drooling (an unconditioned response) at the sight of food or on hearing the sound of food being prepared (an unconditioned stimulus). These observations led him to conduct experiments to understand these curious, unexplained behaviors. During those experiments, Pavlov discovered that after several trials of ringing a bell (conditioned stimuli) just before putting food into the dogs’ mouths, the dogs began associating the sound of the bell with the food. Subsequently, the dogs began to drool (a conditioned response). Continued experiments revealed that the dogs salivated with just the bell ringing, even without the presence of food. The learned associative behavioral stimulus-response discovered by Pavlov (1927), called CLASSICAL CONDITIONING, was later applied to human learning involved in the etiology and treatment of mental illnesses.

John B. Watson

John B. Watson, a psychologist and theorist pioneer of radical behaviorism, rejected the existence or influence of the then-dominant psychodynamic theory concepts of “consciousness” and the “mind.” Around the same time as Pavlov was conducting his experiments, Watson began to introduce his behavioral theory in the United States. He viewed learning and animal behavior (not differentiating human from other animal behavior) as dependent on three things—muscles, organs, and glands. Watson also believed that the more often a response to a stimulus occurs (principle of frequency) and the more recently a response is made (recency), the chances are that the response will be repeated.

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