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"Mental Health issues are not disorders but a transient reaction to accumulated distress in a person's life."(DT 2013)
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Friday, 14 June 2013
" A PSYCHOLOGICAL MODEL OF MENTAL DISORDER," Peter Kinderman, Professor of Clinical Psychology, Division of Clinical Psychology, University of Liverpool, ABSTRACT AND INTRODUCTION TO PAPER - SEE HIM EXPOUND HIS VIEWS AT OLD TRAFFORD ON JUNE 28th
A psychological model of mental disorder Peter Kinderman. MA, MSc, PhD
Professor of Clinical Psychology, Division of Clinical Psychology, University of Liverpool, Whelan Building, Quadrangle, Brownlow Hill, Liverpool, L69 3GB. Tel: +441517945533. Fax: +441517945537. Email: firstname.lastname@example.org
A coherent conceptualisation of the role of psychological factors is of great importance in understanding mental disorder. Academic papers and professional reports alluding to psychological models of the aetiology of mental disorder are becoming increasingly common, and there is evidence of a marked policy shift towards the provision of psychological therapies and interventions. This paper discusses the relationship between biological, social and psychological factors in the causation and treatment of mental disorder. It argues that simple biological reductionism is not scientifically justified, and also that the specific role of psychological processes within the biopsychosocial model requires further elaboration. The biopsychosocial model is usually interpreted as implying that biological, social and psychological factors are co-equal partners in the aetiology of mental disorder. The psychological model of mental disorder presented here suggests that disruption or dysfunction in psychological processes is a final common pathway in the development of mental disorder. These processes include, but are not limited to, cognitive processes. The model proposes that biological and environmental factors, together with a person‟s personal experiences, lead to mental disorder through their conjoint effects on these psychological processes. Implications for research, interventions and policy are discussed. 192 words Key words: psychological processes, biopsychosocial model, biological reductionism
The past few years have seen a massive investment of research and development efforts in the field of mental disorder. It is estimated that in the UK, the National Health Service spends about £219 million per year on mental health research1, and mental disorder has been estimated to cost the state £77 billion per year2. On July 25, 1989, President George Bush designated the 1990s the „Decade of the Brain‟. The European Community Council of Ministers3 swiftly followed. Recent advances in imaging techniques such as computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET) have been hailed as offering great potential for detailed neuroanatomical investigations of many disorders4. Research into biological aspects of mental disorder is welcome. However it is important that this research is properly integrated with psychological and social accounts of mental disorder. Some observers point to a threat of a retrenchment into a reductionist, biomedical approach to mental disorder5. It has been argued that diagnostic and etiological accounts stemming from a simple biomedical approach will be partial and scientifically inadequate6. Ill-informed reductionist accounts may lead readers to an unfortunate perception that mental health care is both lacking in humanistic sensibilities and dehumanising7.
Psychological approaches to mental disorder offer alternative perspectives and can also be integrated with biological perspectives. Indeed, this paper will suggest that a comprehensive psychological model of mental disorder can offer a coherent and assertive alternative to purely reductionist biological accounts that nevertheless incorporates biological research. Most biomedical theories and most biomedical interventions in mental disorder explicitly or implicitly relate to synaptic or intracellular processes8. Thus abnormalities in neurotransmitter functioning are implicated in theoretical models and drug treatments (selective serotonin re-uptake inhibitors etc) target synaptic neurotransmitters in the search for effective treatment. In contrast, psychological approaches focus on associative networks, based in the neural substrate, but developed through learning and relying on theories of conditioning, perception, appraisal and belief-formation, propositional and implicational encoding, mental models of the world, internalised schemas of relationships etc. Psychological models of mental disorder, therefore, address different kinds of mechanisms, but also strive to encompass more than the mere mechanics of any individual system and to look at interactions and interrelationships.
Over the past few years a number of reports by professional bodies, strategy documents from policy makers and proposed changes in legislation all stress the role of psychologists and of psychological perspectives in mental health. As an example, the first national clinical guidance issued by the UK‟s National Institute for Clinical Excellence concerned the frontline treatment of schizophrenia9. Amongst other important comments, this document recommended that “100%” of people in receipt of the diagnosis of schizophrenia should be offered cognitive behavioural therapy (p55). Recent academic reviews of the role of psychosocial influences on mental illnesses and psychotic experiences10 and major grant-funded randomised controlled trials have repeatedly demonstrated the effectiveness of psychological therapeutic approaches in a range of mental health problems11, 12, 13.
Psychological formulation is the summation and integration of the knowledge that is acquired through the assessment process14. Psychological formulations attempt to explain why people are experiencing difficulties. They usually consist of a list of problems and possible psychological reasons for these15. Typically, formulations examine the events of people‟s lives, and how the individuals have interpreted and reacted to these. Formulations are hypotheses about the nature and origin of problems, which are tested out over time16, and therefore tend to change over the course of both assessment and therapy. Psychological case formulations are complex and may comprise a number of provisional hypotheses, based on a large variety of psychological theories, each drawing on scientific research. The use of psychological formulations is not synonymous with being a clinical psychologist, and is certainly not incompatible with being a psychiatrist. Many individual clinical psychologists may fail to provide psychological formulations. Many medically-trained psychiatrists welcome formulation; either as an adjunct to diagnosis – the iconic DSM-IV17 suggests that diagnosis is only a start – or, as some psychiatrists propose, as an alternative to diagnosis18. Psychological models of mental disorder could inform the practice of all workers in the mental health services, but they should be coherent. It is axiomatic that psychologists welcome the inclusion of specifically psychological elements in psychiatric formulations. The questions are how that should be done and what constitute coherent psychological models of mental disorder.
It is worthwhile briefly mentioning the biopsychosocial model in psychiatry. This is primarily associated with the work of George Engel7, who attempted to provide a scientific account of mental disorder that could challenge a reductionist biological account. The biopsychosocial model therefore suggested that mental disorder emerges from a human system that has both physical elements (a biological nervous system) and psychosocial elements (relationships, family, community and wider society)19, 20. The biopsychosocial model was widely adopted21, 22, 23. Inevitable micro-historical pressures such as a professional revolt against so-called antipsychiatrists24, 25, 26 has meant that some of the gloss has worn off the biopsychosocial model. Antipsychiatry remains vocal27, 18, 28 while, conversely, biodeterminist writings are also common8. Wing, in particular, appeared to feel the need to defend diagnosis, to assert the biomedical basis of psychiatric disorders and the utility of a „diagnose and treat‟ approach29. The emphasis within the biopsychosocial model on social and psychological perspectives in addition to biological aspects of mental disorder may be welcome. However, consideration needs to be given to how, in each case, the elements – bio-, psycho-, and social- – relate one to another. The biopsychosocial model is, or should be, more than a simple statement that these three aspects should be included in a formulation. In particular, it has been argued that the biopsychosocial model has been interpreted in practice as reserving a dominant position for biomedical approaches5, where indeed social and psychological factors are acknowledged and given prominence, but are considered to be moderators of the direct causal role of biological processes. This „primacy‟ of biomedical causation30 has been cited as an argument for the professional superiority of one profession over others31. This wider sociological debate over the implications of particular epistemological approaches has, of course, been a source of some tension32.
This paper argues that the role of psychological and social processes in mental disorder requires further attention. The biopsychosocial model does not address the issues of the nature of the interrelationships between elements. Importantly, it fails to address issues related to the different status and nature of the different elements – the unresolved issue of „primacy‟. The nature of psychological factors itself needs further attention. This includes a consideration of the different functions psychological factors can play in different models of mental disorders: as causes, as symptoms and as possible therapeutic factors. Such consideration may, paradoxically, rationalise and contextualise the role of biochemical aspects. The biopsychosocial model fails properly to address biological accounts of mental disorder if it cannot relate, for example, how monoamine abnormalities in depression33 relate to findings of low self-esteem34 and negative thinking patterns35, 36 and findings of greatly increased incidences of mental disorder in disadvantaged groups37. A coherent model of the links between these findings – which should emerge from a coherent psychological model of mental disorder – should also ensure that biological approaches to mental disorder are given proper regard. What, then, is a psychological conceptualisation of mental disorder? Is there a coherent, simple, model of mental health that simultaneously elucidates the psychological perspective and contrasts it with that of other approaches? What would a generic psychological model of mental disorder look like? Could a coherent account of the role of psychological factors in mental disorder also help the development of an integrative model of mental disorder; in which multiple causal factors, different symptomatic markers and different therapeutic elements are all appropriately addressed?
Multiple causes of mental disorder
The biopsychosocial model is based on is the notion of multiple simultaneous causes of mental disorder. Clinical and research evidence supports this assumption, as will be discussed below. Any proposed generic psychological model must acknowledge this. One can imagine something along the lines of a theoretical multiple regression equation, with mental ill health as the dependent (predicted variable). One might even imagine measuring such disorder on a numeric scale ranging from zero to 100 or perfect mental health. One can imagine further three possible independent or predictor variables. The biopsychosocial model, and the model proposed here, includes multitude causes – multitude predictors. Nevertheless, one can imagine for the purposes of this argument three main classes of predictor variables (biological, social and circumstantial) as illustrated in Figure 1a. It is worth noting that these classes of causal or predictor variables are slightly different from the components of the biopsychosocial model. As will be clarified below, this reflects two important modifications to the biopsychosocial model: the distinction between psychological processes and personally significant life events, and the specific status given to the disruption of psychological processes as a final common pathway to mental disorder.
All of these classes of variables are causally related to mental ill health. Clearly, biological factors are important in mental health. Links between genetics, biochemical abnormalities, neuroanatomical abnormalities or merely the structure and functioning of the physical brain and mental disorder have been studied extensively.
Some authors have argued that, while biological variables have explanatory power in cases of mental disorder, psychosocial aspects merely account for human experiences that do not amount to clinically significant disorders30. It is beyond the scope of this paper to discuss all possible biological factors causal in all possible forms of mental disorder. It is worth noting that these cannot be dismissed. As just one example, a variety of problems from unipolar depression38 through bipolar disorder39 to schizophrenia40 have been associated reliably with genetic heritability. In the hypothetical multiple regression equation suggested above, therefore, it is likely that an imaginary predictor variable capturing the population‟s biomedical variance would be a significant predictor of variance in mental ill health. Equally, we have evidence that social and environmental factors contribute to mental disorder. Again, the number of studies is enormous, but there are clear links between poor housing41 and poverty and unemployment42 and environmental stress and the expression of a wide range of mental health problems. In simple terms there is considerable evidence of an association between mental disorder and the experience of poverty and deprivation43, 44, 45. In our hypothetical example, a general and portmanteau measure of disadvantageous social environment would clearly be a significant predictor of variance in mental ill health.
An environmental, or social environmental, causal variable can be seen as occupying the space of psychiatric sociology – examining and contextualising social and environmental causes of mental disorder46. When people refer to psychological issues, they sometimes refer to the effects of potentially life-shaping experiences that impact on mental health – childhood sexual abuse47, bullying48, attachment relations with parents49, assault50 and all other major and minor interpersonal experiences.
Although these are disparate kinds of event, it remains true that life events in general contribute to mental disorder51, 52. Because of the breadth of these experiences, it may be difficult to capture them all on one hypothetical dimension. Nevertheless, in our hypothetical multiple regression equation, again, it is likely that an imaginary predictor variable capturing these potentially damaging cumulative life events would also be a significant predictor of variance in mental disorder. This represents one important meaning of the term „psychological‟ as it is used in this context – as a reference to the causal role of psychosocial factors in the development of mental disorders. A simple statement that biological factors, social factors and life events all contribute to the development of mental ill health does not take us further than the biopsychosocial model. Two further important further points are necessary, reflecting the specific psychological nature of the model proposed here. First, people from different professional and academic backgrounds may well differ as to their hypotheses about the relative importance of the putative predictor variables.
One example of this is the current interest in genetics. As commented above, genetic aspects of mental disorder are important. However, the apparently bare facts themselves appear frequently to be overstated, and the concept of heritability itself can be misleading when applied to psychological phenomena. For example, the heritability of psychotic disorders has been quoted as being as high as .8553. This figure is commonly taken to imply that 85% of the variance in the presentation of the symptoms of psychosis can be statistically attributed to the variance in the population's genome. This may be misleading. Rutter54 cogently argues that psychosocial, environmental and developmental influences on mental disorder are A psychological model of mental disorder Page 11
significant. He points out that some of the assumptions behind molecular genetics research do not translate easily into lay language (for example, genetic effects plus environmental effects do not necessarily sum to 100%). This, Rutter argues, may lead to subtly but important misrepresentations of biological findings when discussed in contexts such as the present discussion. It is not necessarily correct, for instance, to suggest that social background, life events and psychological factors together could explain only the „remaining‟ 15% of the variance in the presentation of the symptoms of psychosis. Biological, social, circumstantial and psychological variables also interact. Personal vulnerability factors such as neuroticism55 may make a person more emotionally responsive to life events. Similarly, the social support buffer hypothesis56 suggests that the level of a person‟s available social support buffers the impact of environmental stressors on mental health. Thus, for two individuals experiencing stressful events, the person with the greatest level of social support will experience lower levels of mental disorder. A similar set of interactions may explain the often commented upon fact that the concordance rates for monozygotic twins for no mental disorder is 100%57. So a biomedical dominance of explanatory models of mental disorder is not inevitable. Social factors and the influence of life events may be just as important.