Historical views of mental illness

How a society explains mental illness determines how it treats people.

• Supernatural / demonic — possession, witchcraft, sin. Treatment: exorcism, trephination, punishment.
• Somatogenic — Hippocrates' humours; later, physical causes in the body and brain. This leads towards the medical model.
• Moral treatment (Pinel, Tuke, 18th-19th century) — the insane are ill, not wicked, and should be treated humanely. Asylums grew, then became overcrowded custodial institutions.
• Deinstitutionalisation (from the mid-20th century) — antipsychotic drugs and civil rights arguments emptied the asylums into 'care in the community', which was frequently underfunded.

Defining abnormality: deviation from social norms (but norms are cultural and change — homosexuality was in the DSM until 1973), statistical infrequency (but rare is not the same as ill, and some disorders are common), failure to function adequately, and deviation from ideal mental health (Jahoda — but almost nobody meets every criterion).

Categorising disorders: the DSM (American Psychiatric Association) and the ICD (World Health Organization). Classification enables communication, research and treatment — but it also labels.

Key research: Rosenhan (1973), On being sane in insane places

• Study 1: eight sane pseudopatients presented at 12 psychiatric hospitals across the United States, each reporting a single symptom — hearing an unfamiliar voice saying 'empty', 'hollow' or 'thud'. Everything else they said was true, and once admitted they behaved entirely normally.
• Findings: all were admitted. All but one were diagnosed with schizophrenia, and were discharged with schizophrenia in remission — never as sane. Stays ranged from 7 to 52 days (mean about 19 days). Ordinary behaviour, such as note-taking or queuing early for lunch, was reinterpreted as symptomatic. Many fellow patients — but no staff — suspected they were not ill.
• Study 2: a teaching hospital that doubted the results was warned that pseudopatients would present over three months. Of 193 genuine patients, 41 were judged by at least one staff member to be a pseudopatient. Rosenhan had sent none.

Conclusions: psychiatric diagnosis at the time lacked validity; the label, once applied, was sticky and coloured every subsequent interpretation of the person's behaviour; and depersonalisation was routine on the wards. Application: know the characteristics of an affective disorder (e.g. depression), a psychotic disorder (e.g. schizophrenia) and an anxiety disorder (e.g. phobia) — and be able to say why misclassifying between them matters so much.

Rosenhan

The medical model

The medical model treats mental illness as an illness like any other, with a physical cause, a diagnosis, and a physical treatment.

• Biochemical explanation — imbalances in neurotransmitters. Excess dopamine activity is linked with the positive symptoms of schizophrenia; low serotonin activity with depression. Evidence comes from the drugs: antipsychotics block D2 receptors, and SSRIs block serotonin reuptake.
• Genetic explanation — vulnerability is inherited. Family, twin and adoption studies show that risk rises steeply with genetic relatedness; MZ concordance greatly exceeds DZ concordance for schizophrenia — but is well below 100%, so genes alone are not sufficient.
• Brain abnormality — structural differences, e.g. enlarged ventricles and reduced grey matter in some patients with schizophrenia; reduced prefrontal activity in some violent offenders.

Strengths: objective, scientific, testable; it removes blame from the individual and their family; and it has produced treatments that work for many people. Weaknesses: reductionist and determinist; correlation is repeatedly mistaken for cause (the drugs raise or lower a transmitter, which does not prove the transmitter caused the disorder); and it can ignore the person's life circumstances entirely.

Which model of mental health?

Tap a statement, then tap the model it belongs to.

Key research: Gottesman et al. (2010)

Severe mental disorders in offspring with two psychiatrically ill parents.

• Method: a very large-scale study using Danish national registers — a population sample, using secondary data gathered from psychiatric and civil registration records over decades. It is a natural, correlational design, not an experiment.
• Design: the researchers identified couples where both parents had been admitted with schizophrenia, or both with bipolar disorder, and compared the risk to their children with the risk to children with one affected parent and with neither.
• Findings: risk of schizophrenia in the offspring was dramatically higher when both parents had schizophrenia than when one parent, or neither, was affected — and the same pattern held for bipolar disorder. Even so, the majority of children with two affected parents did not develop the disorder.
• Conclusion: strong support for a genetic contribution to severe mental disorder — but genetics is clearly not deterministic, which is why a diathesis-stress interpretation is required.

Evaluate it: huge sample, objective register data, excellent population validity, no risk of demand characteristics. But shared environment is confounded with shared genes (two ill parents also make for a very different upbringing), registers only capture people who were admitted, and the findings are socially sensitive — they can be used to advise people about having children.

Gottesman

Alternatives to the medical model

OCR requires the behaviourist and cognitive explanations, plus one of humanistic, psychodynamic or cognitive neuroscience.

• Behaviourist: abnormal behaviour is learned like any other — a phobia is a conditioned association (as in Little Albert), maintained by the negative reinforcement of avoidance. Depression can be framed as learned helplessness. Treatment follows directly: systematic desensitisation, flooding, token economies.
• Cognitive: the disorder lies in faulty thinking — Beck's negative triad (negative views of self, world and future) and Ellis's ABC model (activating event → irrational belief → consequence). Treatment: CBT, which identifies and challenges the irrational belief.
• Humanistic: distress arises from incongruence between the self and the ideal self, often caused by conditions of worth imposed by others. Treatment: client-centred therapy offering unconditional positive regard, empathy and genuineness.
• Psychodynamic: unresolved unconscious conflict from childhood. Cognitive neuroscience: maps faulty thinking onto brain function using scanning — an attempt to bridge the cognitive and the biological.

Key research: Szasz (2011), The myth of mental illness: 50 years later

Szasz revisits and defends the argument he first made in 1960. His case is conceptual, not empirical — this is a review/theoretical article, not a study with participants, and you should say so when evaluating it.

• Illness requires a bodily lesion. Disease, properly speaking, is a demonstrable physical abnormality of the body. Mental 'illness' is diagnosed from behaviour and speech — from a person's conduct, not from a lesion.
• 'Mental illness' is therefore a metaphor, and treating a metaphor as literal fact is a category error. What we call mental illness is really problems in living — difficulties with conflict, responsibility and meaning.
• The critical consequence: the label licenses coercion. Psychiatry, uniquely among medical specialisms, can detain and treat people against their will. Szasz argues this makes psychiatry an instrument of social control, and that involuntary psychiatric intervention is an abuse of the language of medicine.

Evaluate it: Szasz's argument fits Rosenhan's evidence about labelling and its power, and it has been enormously influential in patients' rights and anti-psychiatry. But it is a polemic with no data; brain-imaging and genetic evidence (Gottesman) suggest at least some disorders do have physical correlates; and denying that mental illness is real risks withholding effective treatment from people who are suffering severely.

Match the key research to its topic

Tap a study on the left, then the topic it is the key research for.

Szasz

Applying the models to treatment

The application for each topic is a treatment, and you must be able to apply it to a novel case.

• Biological treatment (from the medical model) — e.g. antipsychotics for schizophrenia (typical drugs are D2 antagonists; atypical drugs such as clozapine also act on serotonin, with fewer movement side effects but a need for blood monitoring), or SSRIs for depression. Effective for many, cheap, requires no effort — but side effects, high relapse on stopping, and it treats symptoms rather than circumstances.
• Non-biological treatment (from the alternatives) — e.g. CBT (identify the irrational belief, test it against evidence, replace it; homework and behavioural activation), systematic desensitisation for a phobia, or client-centred therapy. Lower relapse rates and it addresses the cause of the thinking — but it takes time, motivation and a skilled therapist, and it is not suitable for everyone in acute crisis.

The strongest answers refuse the false choice: the evidence supports a combined approach for many disorders (medication to stabilise, therapy to change the thinking and prevent relapse). Say so, and justify it.

Which model?

Debates

Method spotlight

How Component 03 is structured

How Component 03 is assessed

Component 03: Applied psychology — 105 marks, 2 hours, 35% of the A level.

• Section A — Issues in mental health is compulsory for everyone.
• Section B — you answer on TWO of the four applied options: child psychology, criminal psychology, environmental psychology, sport and exercise psychology. You do not answer on the other two.
• For every topic you must know the background, the key research, and the application — and be able to apply all three to a novel situation.
• The methodological issues and debates (nature/nurture, freewill/determinism, reductionism/holism, individual/situational, usefulness, ethics, socially sensitive research, psychology as a science, ethnocentrism, validity, reliability, sampling bias) run through every topic.

Two options, not one. Plan your revision accordingly — Section A plus two full options is a large body of key research, and each piece of key research must be describable and evaluable.

The big ideas to know

Issues in mental health is compulsory — you then choose TWO of the four applied options. Press Finish to see your score.