clinical psychology

What does ideal mental health look like?

Marie Jahoda (1958) suggested that we are in good mental health if we meet the following criteria:

We have no symptoms or distress

We are rational and can perceive ourselves accurately

we self actualise

We can cope with stress

We have a realistic view of the world

We have good self-esteem and lack guilt

We are independent of other people

We can successfully work, love and enjoy our leisure.

The main feature of this definition is that it’s positive because it focuses on ideal mental health.

A strength of deviation from ideal mental health: comprehensive definition

One strength of the ideal mental health criterion is that it’s highly comprehensive.

Jahoda’s concept of ideal mental health covers most of the reasons why we might seek help with mental health.

An individual’s mental health can be discussed with a range of professionals who might take different theoretical views; for example, a medically trained psychologist might focus on symptoms, whereas a humanistic counsellor might be more interested in self-actualisation.

This means ideal mental health provides a checklist against which we can assess ourselves and others and discuss psychological issues with a range of professionals.

Limitation of deviation from ideal mental health- may be culture bound

One limitation of the ideal mental health criterion is that its different elements are not equally applicable across a range of cultures.

Some of Jahoda's criteria for ideal mental health are firmly located in the context of the US and Europe generally.

The concept of self-actualisation would be considered self-indulgent in much of the world.

This means it’s difficult to apply this concept of ideal mental health to all cultures.

Variations from social/ cultural norms

Social and cultural norms may be different for each generation and different in every culture, so there are relatively few behaviours that would be considered a universal sign of poor mental health on the basis that they breach social/cultural norms.

For example, homosexuality was once considered a mental health condition.

Whilst this view has been widely discredited, it still remains illegal in some countries.

Example: antisocial personality disorder

A person with antisocial personality disorder is impulsive, aggressive and irresponsible.

According to DSM-5-TR, one important symptom of antisocial personality disorder is failure to conform to lawful or ethical behaviour.

In other words, we are making the social judgement that people with antisocial behaviour disorder are considered to have a mental health condition because they don’t conform to our moral standards.

Their behaviour would be considered undesirable in a range of cultures.

Strength of deviation from social/cultural norms- real world application

One strength of deviation from social/ cultural norms is its usefulness.

Deviation from social/ cultural norms is used in clinical practice; for example, antisocial personality disorder is characterised by a failure to conform to culturally accepted behaviour.

These signs show deviations from social/ cultural norms.

Such norms also play a part in the diagnosis of schizotypal personality disorder.

Individuals have trouble in relationships as they assume the other person is having negative thoughts about them; this is deemed “odd” or “eccentric”.

This shows that deviation from social/cultural norms has value in psychiatry.

Limitation of deviation from social norms- love of the familiar

One limitation of deviation from social/cultural norms is that it allows people to impose a narrow range of acceptable behaviours on others.

Zsuzsanna Chappel and Sofia Jeppeson (2023) suggest that people are reassured by “typical behaviour” and disturbed by deviances.

It is problematic if clinicians impose their own social/cultural norms on clients because of their own love of the familiar and fear of weirdness.

The clinician is then disregarding that person’s own judgment of their wellbeing and imposing other people’s standards on their client.

This means that the concept of deviation from social/cultural norms as a criterion for judging mental health may limit personal freedom.

When is someone failing to function adequately?

David Rosenhan and Martin Seligman (1989) have proposed some additional signs that can be used to determine whether someone is not coping:

When a person no longer conforms to standard interpersonal rules, for example maintaining eye contact when speaking or not respecting personal space.

When a person experiences severe personal distress.

When a person’s behaviour becomes irrational or dangerous to themselves or others.

Strength of the failiure to function criterion- represent a threshold for help

One strength of the failure-to-function criterion is that it represents a sensible threshold for when people need professional help.

Most of us show symptoms typical of one or more mental health conditions to some degree at some point.

25% of people in England will experience a mental health problem in any given year.

People tend to seek professional help, or be noticed and referred for it by others.

This criterion means that treatment and services can be targeted at those who need them most.

Limitation of failiure to function adequately- discrimination and social control

One limitation of failure to function adequately is that it is open to abuse.

In practice, it can be very hard to say when someone is really failing to function adequately and when they simply choose to deviate from social/cultural norms.

For example, people who favour high-risk activities, or people with alternative lifestyles who choose to live “off grid”.

This means that people who make unusual choices are at risk of being diagnosed with a mental health condition, and their freedom of choice may be restricted.

Statistical infrequency

Perhaps the most obvious way to define anything as mentally healthy or a mental health condition is according to how often we come across it.

Statistical infrequency: relatively usual behaviour can be thought of as being healthy, and any unusual behaviour can be seen as unhealthy.

Statistical infrequency- example

This statistical approach comes into its own when we are dealing with characteristics that can be reliable measure, for example, intelligence.

The majority of people’s scores will cluster around the mean, and the further we go below that mean, the fewer people will attain that score; this is called a normal distribution.

The average IQ is set at 100. In a normal distribution, 68% of people have a score from 85-115.

Only 2% of people have a score below 70 and are very unusual and possibly labelled as having intellectual disability disorder (IDD).

Strength of statistical frequency- real-world application

One strength of statistical infrequency is its usefulness.

Statistical infrequency is used in clinical practice, both as part of formal diagnosis and as a way to assess the severity of an individual’s symptoms.

A diagnosis of intellectual disability disorder requires an IQ of below 70.

An example of statistical infrequency used in an assessment tool is Becks depression inventory (BDI). A score of 30+ is widely interpreted as indicating severe depression.

This shows the value of statistical infrequency in diagnosis and assessment processes.

Limitation of statistical infrequency- unusual characteristics can be positive

One limitation of statistical infrequency is that infrequent characteristics can be positive.

For every person with an IQ below 70, there is another with an IQ above 130, yet we do not think of someone negatively for having an IQ above 130.

Similarly, we would not see someone who received an extremely low depression score on a BDI test as having poor mental health.

This means that although statistical infrequency can form part of assessment and diagnostic procedures, it is never sufficient as the sole basis for defining mental health.

DSM-5-TR categories of phobia

All phobias are characterised by excessive fear or anxiety, triggered by an object or situation.

The extent of the fear is out of proportion to any real danger presented by the phobic stimulus

Specific phobia- phobia of an object or situation; almost anything can become a phobic stimulus.

behavioural characeristics of phobias

We respond to things or situations we fear by behaving in particular ways.

We respond by feeling high levels of anxiety and trying to escape.

The level of fear is irrational out of all proportion to the phobic stimulus.

PANIC- a person with a phobia may panic in response to the presence of the phobic stimulus. Panic may involve crying, screaming or running away. Some people may react by freezing, clinging, or getting angry.

AVOIDANCE-unless a person is making a conscious effort to face their fear, they tend to go to a lot of effort to prevent coming into contact with the phobic stimulus. This can make it hard to go about daily life. For example, a person having a fear of rain will find it hard to leave the house.

ENDURANCE-this occurs when the person chooses to remain in the presence of the phobic stimulus in order to keep an eye on it rather than leaving it. For example, arachnophobia.

Emotional characteristics of phobias

ANXIETY: Phobias are classed as anxiety disorders. By definition, they involve an emotional response of anxiety, an unpleasant state of high arousal. This prevents a person from relaxing and makes it difficult for them to experience a positive emotion. Anxiety can be long-term.

FEAR: Fear is the immediate and extremely unpleasant response we experience when we encounter or think about a phobic stimulus. It is usually more intense but experienced for shorter periods of time than anxiety.

EMOTIONAL RESPONSE IS UNREASONABLE: The anxiety or fear experienced is disproportionate to any threat posed.

Cognitive characteristics of phobias

SELECTIVE ATTENTION TO THE PHOBIC STIMULUS: If a person can see the phobic stimulus, it is hard to look away from it. Keeping our attention on something really dangerous is a good thing, as it gives us the best chance of reacting quickly to a threat, but this is not useful if the fear is irrational.

IRRATIONAL BELIEFS: A person with a phobia may hold unfounded thoughts in relation to phobic stimuli- don’t have any basis in reality and can’t be easily explained.

COGNITIVE DISTORTIONS: The perceptions of a person with a phobia may be inaccurate or unrealistic.

Explaining phobias- the two process model- process 1

Orval Hobart Mowrer (1960) proposed the two-process model based on the behavioural approach: phobias are acquired by classical conditioning and continue because of operant conditioning

Process 1: Classical conditioning involves learning to associate something of which we initially have no fear with something that already causes a fear response.

John Watson and Rosalie Rayner (1920) created a phobia in a 9-month-old baby called ”Little Albert”

Albert showed no unusual anxiety at the start of the study, and when shown a white rat, he tried to play with it.

In the experiment, the researcher made a loud, frightening noise by banging an iron bar close to Albert's ear whenever the rat was presented.

This noise was an unconditioned stimulus which produced an unconditioned response of fear.

When the rat (neutral stimulus) and UCS are encountered close in time, the NS becomes associated with the UCS, and now they both produce the fear response; The rat is now a conditioned stimulus that produces a conditioned response.

This conditioning generalised to similar objects such as a non-white rabbit, a fur coat, wagon wearing a Santa Claus beard made out of cotton balls. Little Albert displayed distress at the sight of all of these.

Explaining phobias- the two process model- process 2

Operant conditioning takes place when our behaviour is reinforced (rewarded) or punished.

Reinforcement tends to increase the frequency of behaviour.

In the case of negative reinforcement, an individual avoids a situation that is unpleasant; such behaviour results in a desirable consequence, which means the behaviour will be repeated.

Mowrer suggested that when we avoid a phobic stimulus, we successfully escape the fear and anxiety that we would have experienced if we remained there.

This reduction in fear reinforces the avoidance behaviour so the phobia is maintained.

Strength of the two process model - real world application

One strength of the two-process model is its real-world application in exposure therapies (such as systematic desensitisation)

The distinctive element of the two-process model is the idea that phobias are maintained by avoidance of the phobic stimulus.

This is important in explaining why people with phobias benefit from being exposed to the phobic stimulus.

Once the avoidance behaviour is prevented, it ceases to be reinforced by the experience of anxiety reduction and avoidance and therefore declines.

This shows the value of the two-process approach because it identifies a means of successfully treating phobias.

A limitation of the two proess model- incomplete explanation

One limitation of the behavioural approach is that it’s an incomplete explanation.

The central behaviour in phobias is avoidance- a person with a phobia avoids the phobic stimulus.

However, phobias are not simply avoidance responses.

Sophie Li and Bronwyn Graham (2021) asked phobic and control group participants to approach a spider.

The phobic group estimated the size of the spider to be significantly larger than the control group, suggesting that cognitive factors such as distorted perceptions or heightened fear can influence how phobic individuals experience and interpret stimuli.

The two-process model cannot easily explain this finding.

This means that the two-process model is not a full explanation for the development of phobias.

Strength of two process model- phobias and traumatic experiences + counterpoint

One strength of the two-process model is evidence for a link between a bad experience and phobias.

The Little Albert study illustrates how a frightening experience involving a stimulus can lead to a phobia of the stimulus.

Ad De Jongh (2006) found that 73% of people with a fear of dental treatment had experienced a traumatic event, mostly involving dentistry.

This can be compared to a control group of people with low dental anxiety, where only 21% had experienced a traumatic event.

This confirms that the association between stimulus (dentistry) and an unconditioned response (pain) can lead to the development of the phobia.

COUNTERPOINT

Not all phobias appear following a bad experience.

Some common phobias, such as snake phobiations where very few people have any experience of snakes, let alone a traumatic experience.

Also, not all frightening experiences lead to phobias.

This means that the association between phobias and frightening experiences is not as strong as we would expect if behavioural theories proved to be a complete explanation.

systematic desensitisation

Systematic desensitisation is a behavioural therapy designed to gradually reduce phobic anxiety through principles of classical conditioning.

If a person can easily relax in the presence of a phobic stimulus, they will be cured.

A new response to the phobic stimulus is learned.

This learning is a different process called counterconditioning; there are three processes involved in SD:

The anxiety hierarchy: Put together by a client with the phobia and therapist. This is a list of situations related to the phobic stimulus that provoke anxiety, arranged from least to most frightening.

Relaxation: The therapist teaches the client to relax as deeply as possible. It is impossible to be afraid and relaxed at the same time, so one emotion prevents the other; this is called reciprocal inhibition. The relaxation may involve breathing exercises or mental imagery techniques (asking them to imagine themselves in a relaxing place); an alternative is using drugs such as valium.

Exposure- Finally, the client is exposed to the phobic stimulus while in a relaxed state. This takes place over several sessions, starting at the bottom of the anxiety hierarchy; the client moves up to the next level when they can stay relaxed at the current level and thus progress through the hierarchy. Treatment is successful when the client can stay relaxed in situations high on the anxiety hierarchy.

Strength of systematic desensitisation- supporting evidence

One strength of systematic desensitisation is its evidence base.

Katarzyna Odgers (2022) carried out a meta-analysis of studies into the effectiveness of exposure therapies for treating specific phobias.

Exposure in general was found to be very effective, with no differences in effectiveness for different kinds of exposure.

This means that systematic desensitisation is likely to be helpful for people with phobias.

limitation of systematic desensitisation- limited application

One limitation is that systematic desensitisation is less effective for people with particular cognitive characteristics.

A systematic review by Joscha Bohnlein (2020) looked at 111 studies of exposure therapies and found evidence to show that exposure is less effective for certain groups of people, such as people with low self-efficacy and high trait anxiety.

This means that exposure, part of systematic desensitisation, may not work.

flooding

Flooding involves immediate exposure to a very frightening experience.

Flooding sessions typically last 2-3 hours; sometimes only one long session is needed to cure a phobia.

Flooding stops phobic responses very quickly.

Without the option of avoidance behaviour, the client learns quickly that the phobic stimulus is harmless.

In classical conditioning terms, this process is called extinction.

A learned response is extinguished when the conditioned stimulus is encountered without the unconditioned stimulus.

The result is that the conditioned stimulus no longer produces the conditioned response (fear)

In some cases, the client may achieve relaxation in the presence of the phobic stimulus simply because they become exhausted of their own fear response.

Ethical safeguards

Flooding is not unethical, but it is an unpleasant experience so clients must give fully informed consent to this traumatic procedure.

A client would typically be given the choice of systematic desensitisation or flooding.

Strength of flooding- cost effective

One strength of flooding is that it is highly cost-effective.

A therapy is cost effective if they are clinically effective and not expensive.

Flooding can work in as little as one session, as opposed to 10 sessions for SD to achieve the same result.

Even allowing for a longer session would mean it’s more cost-effective.

This means that more people can be treated at the same cost with flooding than with SD or other therapies.

Limitation of flooding- traumatic

One limitation of flooding is that it is a highly unpleasant experience.

Cnfronting ones phobic stimulus in an extreme form provokes tremendous anxiety.

Sarah Schumacher (2015) found that participants and therapists rated flooding as significantly more stressful than SD.

This raises the ethical issue for psychologists of knowingly causing stress to their clients, although this is not a serious issue provided they obtain informed consent.

The traumatic nature of flooding means that attrition (drop-out rates) are higher than for SD.

This suggests that overall therapists may avoid using this treatment.

DSM-5-TR categories of depression

major depressive disorder- severe but short-term depression

Persistent depressive disorder- long-term but recurring depression, including sustained major depression.

Disruptive mood dysregulation disorder- outbursts of temper in childhood

premenstrual dysphoric disorder- disruption to mood before or during menstruation.

Behavioural characteristics of depression

ACTIVITY LEVELS: people with depression have reduced levels of energy. People then tend to withdraw from work, education and social life. It can be so severe that they can’t get out of bed.

Depression can also lead to psychomotor agitation- agitated individuals may struggle to relax and end up pacing up and down a room.

DISRUPTION OT SLEEP OR EATING BEHAVIOUR: depression is associated with changes to sleeping behaviour. A person may experience reduced sleep (insomnia) or increased need to sleep (hypersomnia). Similarly, appetite or eating may increase or decrease, leading to weight gain or weight loss.

AGGRESSION AND SELF-HARM: people with depression are often irritable and in some cases can become verbally or physically aggressive. Depression can lead to physical aggression directed against the self. This includes self-harm, often in the form of cutting, or suicidal attempts.

Emotional characteristics of depression

LOWERED MOOD- feeling sad and lethargic- people with depression often describe themselves as worthless or empty.

ANGER- People with depression can frequently experience anger. This can be directed at themselves or others. These emotions can sometimes lead to agression of self harming behaviour.

LOWERED SELF-ESTEEM- Self-esteem is the emotion of how much we like ourselves. People with depression tend to report reduced self-esteem- they like themselves less than usual. Experiencing a sense of self-loathing (hating yourself).

cognitive characteristics of depression

POOR CONCENTRATION- depression is associated with poor levels of concentration; the person may find themselves unable to stick to a task as they usually would or find it hard to make a decision. Poor concentration and poor decision-making are likely to interfere with the individual’s work.

ATTENDING TO AND DWELLING ON THE NEGATIVE- when experiencing a depressive episode, people are inclined to pay more attention to negative aspects of a situation and ignore the positives. They tend to see a glass half empty rather than a glass half full. A bias to recalling unhappy events rather than happy ones.

ABSOLUTIST THINKING- depressed person often thinks in a way that situations are either all good or all bad. This is sometimes called “black and white thinking”, which means when a situation is unfortunate, it is seen to be an absolute disaster.

Becks negative triad

Aaron Beck (1967) used the cognitive approach to explain why some people are more vulnerable to depression.

Faulty information processing:

People with depression tend to focus on the negative aspects of a situation and ignore the positives. May tend towards “black and white thinking”- absolutist thinking.

Negative self schema:

A schema is a package of ideas and information developed through experience- acts as a mental framework in the interpretation of sensory information. People with depression often have a negative self schema, so they negatively interpret all information about themselves.

The negative triad:

Negative view of the world- believing there is no hope anywhere

Negative view of the future- reduces hopefulness and enhances depression

Negative view of themselves- enhances existing depressive feelings because they confirm existing emotions of low self-esteem.

Strength of Beck’s negative triad- research support

One strength of Beck’s cognitive model of depression is supporting research.

David Clark and Aaron Beck (1999) concluded that faulty information processing and negative self-schema of the cognitive triad are not only cognitive vulnerabilities common in depression, but they also preceded the depression.

Confirmed by study conducted by Joseph Cohen(2019) tracked development in 473 adolescents, regularly measuring the study of cognitive vulnerability, showing that cognitive vulnerability predicted later depression.

This shows there is an association between cognitive vulnerabilities and depression.

Limitation of Becks negative triad- inconsistent research findings

One limitation of Beck’s cognitive model of depression is that some research doesn’t support Beck’s findings.

Beck’s theory would predict that high levels of low self-esteem and self-criticism would lead to depression in the future.

Catherine Gittins and Caroline Hunt (2020) found self-criticism and depression were unrelated. They also found that although low self-esteem and depression were related, depression occured beofre low sself esteem, suggesting low self-esteem was not the cause of depression.

This means cognitive vulnerability may not actually lead to depression as Beck believed.

Ellis ABC model

Albert Ellis (1962) proposed good mental health as the result of rational thinking; conditions like anxiety and depression result from irrational thoughts (thoughts that interfere with us being happy and free from pain)

Ellis used the ABC model to explain how irrational thoughts affect our behaviour and emotional state.

A- ACTIVATING EVENT- According to Ellis, we get depressed when we experience negative events, and these cause irrational beliefs. Events such as failing a test or ending an important relationship might cause such irrational beliefs.

B- BELIEFS- Ellis identified a range of irrational beliefs. “Musturbation” is the belief that we must always succeed; “i-can’t-stand-it-itis” is the belief that it is a major disaster whenever something doesn’t go smoothly.

C- CONSEQUENCES- When an activating event creates irrational beliefs, there are emotional and behavioural consequences. For example, if a person believes they must always succeed, then fails, this can cause depression.

Strength of Ellis ABC model- real world application

One strength of the Ellis ABC model is its real-world application in the psychological treatment of depression.

Ellis's approach to cognitive therapy is called rational emotive behavioural therapy (REBT)

The idea of REBT is that by vigorously arguing with a depressed person, the therapist can alter the irrational thoughts that are making the person unhappy.

David (2018) suggested there is evidence to support the idea that REBT can both change negative beliefs and relieve symptoms of depression.

This means REBT has real-world value.

Limitation of Ellis ABC model- reactive and endogenous depression

One limitation of the Ellis ABC model is that it only explains reactive depression and not endogenous depression.

Ellis calls activating events as what it is to be triggering depression reactive depression.

However, many cases of depression are not traceable to life events and are not obvious what leads the person to become depressed at a particular time- endogenous depression.

Ellis model is less useful for explaining endogenous depression.

This means the Ellis model can only explain some cases of depression and is therefore only a partial explanation.

Cognitive behaviour therapy

Most commonly used psychological treatment for depression and other mental illnesses. It is an example of a cognitive approach but also includes behavioural elements.

Cognitive element- assessment in which the client and therapist work together to clarify clients pr’s problems. The task is to identify where there might be negative or irrational thoughts that can be challenged.

Behaviour element- CBT then involves working to change negative and irrational thoughts and finally put more effective behaviours into place.

Becks cognitive therapy

The idea is to identify the automatic thoughts about the world, self and future- the negative triad.

Once identified, the thoughts must be challenged.

Cognitive therapy aims to help clients test the reality of negative thoughts- the client is set homework to record when they enjoyed an event or when people were nice to them (client as scientist).

In future sessions, if the client says no one is nice to them, the therapist can present evidence to show the client’s statements are incorrect.

Ellis rational emotive behaviour therapy

D stands for dispute

E stands for effect

The central technique of REBT is to identify and dispute irrational thoughts.

A client might talk about how unfair things seem, and a therapist would challenge these irrational thoughts through vigorous argument.

The intended effect is to change the irrational belief and so break the link between negative life events and depression.

Empirical argument- dispute whether there is actual evidence to support the negative belief

Logical argument- dispute whether the negative thoughts logically follow from the facts.

Behavioural activation

As individuals become depressed, they increasingly avoid difficult situations and become isolated, which maintains or worsens their symptoms.

The goal of behavioural activation is to work with individuals with depression to gradually decrease their avoidance and isolation and increase their engagement in activities that have been shown to improve mood.

The therapist aims to increase such activity.

Strength of CBT: Evidence for effectiveness

One strength of CBT is the large body of evidence supporting its effectiveness for treating depression.

John March (2007) compared CBT with antidepressant drugs and also with a combination of CBT and/or drugs when treating 327 adolescents with depression.

After 36 weeks, 81% of the CBT group, 81% of the antidepressant group and 86% of the CBT plus antidepressant group were significantly improved.

So CBT was just as effective as antidepressants when used on its own and more so when used alongside antidepressants.

CBT is usually a fairly brief therapy- 6-12 sessions, so it is also cost-effective.

This means CBT is considered the first-choice treatment in public healthcare systems such as the National Health Service.

Limitation of CBT- less useful for depression following trauma