Theories on mental health and illness

Chapter 8 Theories on mental health and illness

Patricia Barkway

• Mental health and mental illness are complex, distinct entities that are not necessarily mutually exclusive.

• Various subjective factors influence whether human behaviour is perceived as normal or abnormal.

• Community attitudes about mental health and mental illness contribute to stigma.

• Although personality and human behaviour theories provide explanations for the way in which individuals think, feel and behave, no theory has universal applicability.

• Personality and human behaviour theories underpin psychotherapeutic interventions for mental illness.

• Psychological and sociological theories have influenced the development of nursing theories.

• The answer to the nature versus nurture debate is not simply either/or. A more plausible explanation is that personality develops as a consequence of the interaction between nature and nurture.

• biomedical model

• mental health

• mental illness

• nature versus nurture debate

• nursing theories

• psychological theories

• sociological theories

Learning outcomes

Introduction

Who are you? How have you come to be who you are? What influences how you think, feel and act? Are your personality and behaviour determined by your genetic make-up and biological events, by thoughts and feelings, by your experiences in the world, or by an interrelationship between some or all of these? Why are some people seemingly more vulnerable to mental illness, while others are resilient despite adversity? Most of us, at one time or another, have pondered these questions. Through attempting to understand why humans behave as they do, a further question arises: are personality and human behaviour determined by genetics and biology (nature) or shaped by one’s upbringing, experiences and environmental factors (nurture)? This question has long engaged the interest and passion of philosophers, healers and health professionals and, in more recent times, scientists. Investigation of these questions has resulted in various theories being proposed to explain normal and abnormal behaviour, and mental health and mental illness. These concepts, the theories that attempt to explain them, and proposed interventions will be examined in this chapter. The nature versus nurture debate will also be explored.

What is mental health?

A succinct, universally applicable definition of mental health has long been elusive. Although contemporary definitions encapsulate the breadth of factors that contribute to mental health, they are wordy and jargonistic. See, for example, the definition proposed by the Australian Health Ministers (2003, p 5), which states that:

Mental health is a state of emotional and social wellbeing in which the individual can cope with the normal stresses of life and achieve his or her potential. It includes being able to work productively and contribute to community life. Mental health describes the capacity of individuals and groups to interact, inclusively and equitably, with one another and with their environment in ways that promote subjective wellbeing, and optimise opportunities for development and the use of mental abilities.

In the 1980s, Doona suggested that the problem of defining mental health was derived from the fact that the concept of health is not a measurable scientific term; she concluded that ‘health is probably a value judgement and more amenable to philosophical analysis’ (Doona 1982, p 13). Her comment remains pertinent today. Two decades later, Sainsbury (2003) draws a parallel between mental health and happiness. Although this is a seemingly simplistic comparison, Sainsbury does not see happiness as an individual pursuit, but rather, a consequence of political and social factors that, in the main, remain outside the direct control of the individual.

Defining mental health

Initial attempts to define mental health have focused on the individual’s ability to incorporate external factors. Kittleson cited four major components, namely high self-esteem, effective decision-making, values awareness and expressive communication skills (1989, pp 40–1). Kittleson’s depiction of mental health as a positive construct separate from mental illness was welcome but limited. It was welcome because it enabled mental health to be viewed as more than merely the absence of the symptoms of mental illness. It was limited because a focus on individual factors implies individual responsibility, which may lead to victim blaming (McMurray 2007; Talbot & Verrinder 2005). Furthermore, a definition in terms of the individual fails to acknowledge the contribution of social factors and the environment to mental health.

In 1993, Raphael drew attention to contextual and social issues that affect mental health, namely workplace factors, education, macro-economic and other forces. These social forces are acknowledged as contributors to mental health, as are personal qualities such as resilience, coping, physical health and wellbeing (Raphael 1993). Contemporary definitions of mental health include social determinants such as social connectedness, acceptance of diversity, freedom from discrimination, and economic participation (Vic Health 2003; Wilkinson & Marmot 2003). Recognition of social determinants is evident in the United Kingdom Health Development Agency’s guidelines for mental health promotion, which aim to:

• develop people’s coping and general life skills

• promote social support networks—for example, to tackle bullying, support bereaved families, facilitate self-help groups and increase opportunities to participate in the community

• address structural barriers to mental health in areas such as education, employment and housing (Health Development Agency 2003).

The emergence of a definition of mental health that encompasses positive constructs, not just the absence of symptoms, is important because it enables mental health and mental illness to be viewed as distinct from each other, and not as two points at opposite ends of a continuum. Significantly, it means that the two states are not mutually exclusive. A person can enjoy mental health regardless of whether or not they are diagnosed with a mental illness if they have a positive sense of self, personal and social support with which to respond to life’s challenges, meaningful relationships with others, access to employment and recreation activities, sufficient financial resources and suitable living arrangements.

‘Mental health’ as a euphemism for ‘mental illness’

Health professionals and the health literature have adopted the practice of using the terms mental health and mental illness interchangeably. In 1989 Kittleson drew attention to this phenomenon following an examination of undergraduate mental health texts. He found that ‘personality development and emotional illness make up the bulk of mental health coverage in the texts’ (1989, p 40). A recent perusal of contemporary mental health literature found that this practice is still prevalent in texts and journals (Fontaine 2004; Forster 2001; Meadows, Singh & Grigg 2007; Morrison-Valfre 2005; and journals such as the International Journal of Mental Health Nursing and Issues in Mental Health Nursing). Although these publications include ‘mental health’ in their titles, in the main they contain chapters or articles concerning assessment of, and treatments for, mental illness or mental health problems.

The substitution of the term ‘mental health’ when referring to ‘mental illness’ is a twentieth-century phenomenon that has been carried forward into the new millennium. The first references to ‘mental health’ being used as an alternative to ‘psychiatry’ occurred in the United Kingdom and the United States from the 1920s. Momentum was gained after the Second World War, when proponents such as Caplan advocated a shift from treatment of mental illness to prevention (Evans 1992, p 55). In the United States, Szasz (1961) argued that mental illness was a societal ill and not an individual sickness. Amid this debate, legislators worldwide changed the term ‘mental illness’ in the names of legislation to ‘mental health’. However, this change is nominal because the content of worldwide legislation continues to be concerned with mental illness (Ministry of Health New Zealand 2000; New South Wales Government 2006, United Kingdom Department of Health 2007). The Queensland Mental Health Act 2000, for example, identifies the purpose of this legislation as ‘providing treatment and protection of persons who have a mental illness’ which is [vaguely] defined as ‘any illness or disorder of the mind’ (Queensland Government 2000). Despite the title of the Act, it contains no reference to mental health as a positive concept.

Following legislative name changes, organisations that provided treatment and rehabilitation services to individuals with mental illness also changed their names, replacing words like ‘psychiatric’ and ‘mental illness/disorder’ with ‘mental health’—hence the emergence of organisations with titles like ‘Southern Area Mental Health Service’. Nevertheless, despite the change of name there has been little shift in the focus of the services provided, as they continue to address the needs of the mentally ill, with minimal focus on mental health. This is not to suggest that mental illness services should not be provided; clearly there is a demonstrated need for them and they are not under scrutiny here. Rather, the assertion is that to call them mental health services is a misnomer.

A further consequence of using the euphemism ‘mental health’ when referring to mental illness is that this practice may in fact be contributing to the perpetuation of stigma. Implicit in the avoidance of the term ‘mental illness’ is the notion that mental illness is something to be avoided, hidden or shameful. Ironically, calling mental illness by another name has not reduced stigma; instead, it has broadened the application of stigma to now include mental health.

Critical thinking challenge 8.1

What is mental health? How does it differ from mental illness?

Theories of personality

Personality theories that develop models to explain human behaviour have long been sought. In addition to curiosity and philosophical enquiry, particular emphasis is placed on identifying the causes of abnormal behaviour so as to develop models for understanding prevention or treatment of mental illness. Explanations can be broadly divided into three paradigms:

• biomedical or biological/physical models

• psychological models, including psychoanalytic, behavioural, cognitive and humanistic approaches

• sociological models.

Within these paradigms the following are the major viewpoints to offer a theory of personality development or an explanation of human behaviour:

• biomedical model—proposes that behaviour is influenced by physiology, with normal behaviour occurring when the body is in a state of equilibrium, and abnormal behaviour being a consequence of physical pathology

• psychoanalytic theory—asserts that behaviour is driven by unconscious processes, and influenced by childhood/developmental conflicts that have either been resolved or remain unresolved

• behavioural psychology—presents the view that behaviour is influenced by factors external to the individual. Behaviours are learned, depending on whether they are rewarded or not, by association with another event or by imitation.

• cognitive psychology—acknowledges the role of perception and thoughts about oneself, one’s individual experience and the environment in influencing behaviour

• humanistic psychology—focuses on the development of a concept of self and the striving of the individual to achieve personal goals

• sociological theories—shift the emphasis from the individual to the broader social forces that influence people. This model challenges the notion of individual pathology.

Each of these seemingly disparate perspectives makes a substantial contribution to the understanding of how and why humans think, feel and behave as they do, and thereby identifies opportunities for prevention and treatment of mental illness. Nevertheless, as a comprehensive theory of human behaviour, each also has major shortcomings. Let us now look at these theories in more detail.

Biomedical model

Also known as psychobiology or the neuroscience perspective, the biomedical model asserts that normal behaviour is a consequence of equilibrium within the body and that abnormal behaviour results from pathological bodily or brain function. This is not a new notion—in the fourth century bc the Greek physi cian Hippocrates attributed mental disorder to brain pathology. His ideas were overshadowed, however, when throughout the Dark Ages and later during the Renaissance, thinking and explanations shifted to witchcraft or demonic possession (Alloy, Riskind & Manos 2005; Davison, Neale & Kring 2004). In the nineteenth century, a return to biophysical explanations accompanied the emergence of the public health movement.

In recent times, advances in technology have led to increased understanding of organic determinants of behaviour. Research and treatment have focused on four main areas:

• nervous system disorders, in particular neurotransmitter disturbance at the synaptic gap between neurons—over fifty neurotransmitters have been identified, four of which are implicated in mental illness. These are acetylcholine (Alzheimer’s disease), dopamine (schizophrenia), norepinephrine (mood disorder) and serotonin (mood disorder).

• structural changes to the brain—perhaps following trauma or in degenerative disorders such as Huntington’s disease

• endocrine or gland dysfunction, as in hypothyroidism—this has a similar presentation to clinical depression, and hormonal changes are considered to be a contributing factor in postnatal depression

• familial (genetic) transmission of mental illness—twin studies reviewed by Gottesman found the following lifetime risks of developing schizophrenia: general population 1%, one parent 13%, sibling 9%, dizygotic twin 17%, two parents 46%, monozygotic twin 48% (Alloy et al 2005; Cando & Gottesman 2000).

Although genetic studies demonstrate a correlation between having a close relative with schizophrenia and the likelihood of developing the disorder, a shared genetic history alone is not sufficient. If genetics were the only aetiological factor, the concordance rate for monozygotic twins could be expected to be 100%. Gottesman’s research is important because it supports the diathesis-stress model, a widely held explanation for the development of mental disorder which proposes that constitutional predisposition combined with environmental stress will lead to mental illness (Alloy et al 2005).

Critique of the biomedical model

Among treatments that emerge from the biomedical model are medications that alter the function, production and reabsorbtion of neurotransmitters in the synaptic gap. However, evidence that a particular intervention is an effective treatment is not proof of a causal link with the illness. Consider a person with insulin-dependent diabetes mellitus, for example. Because this person lacks insulin to metabolise glucose, the condition is managed with regular insulin injections. However, the lack of insulin is a symptom of the disease, not the cause. Whatever caused the pancreas to cease producing insulin is not known, despite the treatment being effective. Similarly, with schizophrenia the relationship between the use of antipsychotic medications, dopamine levels and symptom management is correlational, not causal. Therefore, although antipsychotic medication affects dopamine levels and can be an effective treatment to manage the symptoms of schizophrenia, this does not provide evidence that elevated dopamine levels caused the disorder.

Psychoanalytic theory

Sigmund Freud developed the first psychological explanation of human behaviour—psychoanalytic theory—in the late nineteenth century. He placed strong emphasis on the role of unconscious processes in determining human behaviour. Central tenets of the theory are that intra-psychic (generally unconscious) forces, developmental factors and family relationships determine human behaviour. Mental illness is seen as a consequence of fixation at a particular developmental stage or conflict that has not been resolved.

Sigmund Freud (1856–1939)

Freud was an Austrian neurologist who, in his clinical practice, saw a number of patients with sensory or neurological problems for which he was unable to identify a physiological cause. In the main these patients were middle-class Viennese women. It was from his work with these patients that Freud hypothesised that the cause of their maladies was psychological. From this assumption he developed a personality theory, which he called psychoanalytic theory.

According to Freud the mind is composed of three forces:

• the id—the primitive biological force comprising two basic drives, sexual and aggressive. The id operates on the pleasure principle and seeks to satisfy life-sustaining needs such as food, love and creativity, in addition to sexual gratification.

• the ego—the cognitive component of personality which attempts to use realistic means (the reality principle) to achieve the desires of the id.

• the superego—the internalised moral standards of the society in which one lives. It can be equated to a conscience.

Freud’s theory proposes that personality development progresses through four stages throughout childhood. At each stage the child’s behaviour is driven by the need to satisfy sexual and aggressive drives via the mouth, anus or genitals. Failure of the child to satisfy these needs at any one of the stages will result in psychological difficulties that are carried into adulthood. For example, unresolved issues at the oral stage can lead to dependency issues in adulthood, and problems in the anal stage may lead to the child later developing obsessive-compulsive traits. Freud’s stages of psychosexual development are:

• oral—from birth to about eighteen months, where the primary focus of the id is the mouth

• anal—from approximately eighteen months to three years, where libido shifts from the mouth to the anus and primary gratification is derived from expelling or retaining faeces

• phallic—from approximately three to six years, where gratification of the id occurs through the genitals

• genital—once the child passes through puberty, sexual urges re-emerge, but now they are directed towards another person, not the self as they were at an earlier stage of development

• latent—Freud proposed that from approximately six to twelve years, the child goes through a latency phase in which sexual urges are dormant (Alloy et al 2005; Bond & McConkey 2001; Davison et al 2004).

Defence mechanisms

An important contribution of psychoanalytic theory to the understanding of behaviour has been the identification of defence mechanisms and the role they play in mediating anxiety. Defence mechanisms were first described by Freud and later elaborated on by his daughter Anna (Freud 1966). They are unconscious processes whereby anxiety experienced by the ego is reduced. Commonly used defence mechanisms include:

• repression—the primary defence mechanism and an unconscious process whereby unacceptable impulses/feelings/thoughts are barred from consciousness (e.g. memories of sexual abuse in childhood)

• regression—the avoidance of present difficulties by a reversion to an earlier, less mature way of dealing with the situation (e.g. a toilet-trained child who becomes incontinent following the birth of a sibling)

• denial—the blocking of painful information from consciousness (e.g. not accepting that a loss has occurred)

• projection—the denial of one’s own unconscious impulses by attributing them to another person (e.g. when you dislike someone but believe it is the other person who does not like you)

• sublimation—an unconscious process whereby libido is transformed into a more socially acceptable outlet (e.g. creativity, art, sport)

• displacement—the transferring of emotion from the source to a substitute (e.g. a person who is unassertive in an interaction with a supervisor at work and ‘kicks the cat’ on arriving home)

• rationalisation—a rational excuse is used to explain behaviour that may be motivated by an irrational force (e.g. cheating when completing a tax return, with the excuse that ‘everyone does it’)

• intellectualisation/isolation—feelings are cut off from the event in which they occur (e.g. after an unsuccessful job interview the person says, ‘I didn’t really want the job anyway’)

• reaction formation—the development of a personality trait that is the opposite of the original unconscious or repressed trait (e.g. avoiding a friend’s partner because you are attracted to that person).

Critique of psychoanalytic theory

Although the notions of unconscious motivations and defence mechanisms are helpful in interpreting behaviours, Freud’s version of psychoanalytic theory has not been without its critics. Fellow psychoanalyst Erik Erikson disagreed with Freud’s theory of psychosexual stages of development and proposed instead a psychosocial theory in which development occurred throughout the lifespan, not just through childhood as in Freud’s model (Erikson 1963; Santrock 2007).

The unconscious nature of Freud’s concepts and stages renders them difficult to test and therefore there is little evidence to support Freudian theory. Feminists, too, object to Freud’s interpretation of the psychological development of women, arguing that there is scant evidence to support the hypothesis that women view their bodies as inferior to men’s because they do not have a penis (Alloy et al 2005).

Behavioural psychology

Behaviourism is a school of psychology founded in the United States by J B Watson in the early twentieth century with the purpose of objectively studying observable human behaviour, as opposed to examining the mind, which was the prevalent psychological method at the time in Europe. The model proposes a scientific approach to the study of behaviour, a feature that behaviourists argue is lacking in psychoanalytic theory (and in humanistic psychology, which developed later).

Behaviourism opposes the introspective, structuralist approach of psychoanalysis and emphasises the importance of the environment in shaping behaviour. The focus is on observable behaviour and conditions that elicit and maintain the behaviour (classical conditioning) or factors that reinforce behaviour (operant conditioning) or vicarious learning through watching and imitating the behaviour of others (modelling).

Three basic assumptions underpin behaviour theory. These are that personality is determined by prior learning, that human behaviour is changeable throughout the lifespan and that changes in behaviour are generally caused by changes in the environment. The following were prominent figures in the development of behaviourist psychology.

Ivan Pavlov (1849–1936)

Russian physiologist Ivan Pavlov was the first to describe the relationship between stimulus and response. Pavlov demonstrated that a dog could learn to salivate (respond) to a non-food stimulus (a bell) if the bell was simultaneously presented with the food. His discovery became known as classical conditioning.

John B Watson (1878–1958)

Watson, who is attributed with being the founder of behaviourism, changed the focus of psychology from the study of inner sensations to the study of observable behaviour. In his quest to make psychology a true science, Watson further developed Pavlov’s work on stimulus–response learning and experimented by manipulating stimulus conditions. Watson believed that abnormal behaviour was the result of earlier faulty conditioning and that re-conditioning could modify this.

B F Skinner (1904–1990)

Skinner formulated the notion of instrumental or operant conditioning in which reinforcers (rewards) contribute to the probability of a response being either repeated or extinguished. Skinner’s research demonstrated that the contingencies on which behaviour is based are external to the person, rather than internal. Consequently, changing contingencies could alter an individual’s behaviour. This is an underlying principle in treatment using an operant conditioning approach (Bond & McConkey 2001; Skinner 1953).

Critique of behaviourism

Behaviourism provided the first scientifically testable theories of human development as well as plausible explanations of conditions such as depression and anxiety. However, behaviourist explanations are less convincing when applied to psychosis or organic disorders. Furthermore, most behaviourist research has been conducted on animals under laboratory conditions, so to extrapolate findings from this research to humans is mechanistic and does not allow for intrinsic human qualities like creativity or the ability to love, think or solve problems. Finally, behaviourist theory falls short in explaining the success of an individual brought up in an adverse environment, or how mental illness can occur in a person whose environment is apparently healthy and advantaged.

Only gold members can continue reading. Log In or Register to continue

Related

Stay updated, free articles. Join our Telegram channel

Tags: Psychiatric Mental Health Nursing

Feb 19, 2017 | Posted by admin in NURSING | Comments Off

Full access? Get Clinical Tree

Get Clinical Tree app for offline access

Get Clinical Tree app for offline access