2 - causality in mental distress

LO1 - understand what we mean by causality + why it matters

what is causality?

study of factors, mechanisms + relationships between factors + mechanisms that cause mental distress

what are causal attributions?

everyday, common-sense explanations of behaviour + its consequences

why is causality important in clinical psychology?

-clinical psychology is predicated on notions of causality

-most clinical interventions assume that changes in one variable will lead to changes in mental distress

how are causal models used in clinical psychology?

-clinical psychologists develop causal models to explain relationships between variables that could cause mental distress

-these models inform psychological assessment + clinical interventions

what are examples of causal factors in mental distress?

Relational: families, early experiences, trauma + abuse

Biological: neurotransmitters, brain structure + genetics

Social: inequalities/poverty, gender/social orientation, ethnicity/migrant status/disability

how is causality in mental distress probabilistic?

-probabilistic

-there are many possible causes of mental distress + often more than one causal influence

-causality is “over-determined”, mental distress can often be explained in more than one way

-causal influences on mental distress operate contingently, meaning they interact with each other in ways that are difficult to predict + to identify

what four conditions are used to establish causality?

• Covariation: if X causes Y, Y should occur more often than not when X is present.

• Temporal precedence: the cause must occur before mental distress.

• Alternative explanations: alternative explanations for the causal relationship must be excluded.

• Logical connections: it must be possible to explain how X causes Y

what is a sufficient cause (first type)?

Y always occurs after X, but Y can also occur in the absence of X

Example: consumption of carbohydrates + glucose-rich food (X) can lead to raised blood glucose levels (Y) in people with diabetes

-no identified sufficient causes for mental distress

what is a necessary cause (second type)?

-Y never occurs without the prior occurrence of X, but X does not always lead to Y

Example: a sexually transmitted disease (Y) never occurs without prior sexual contact (X)

-no necessary causes for mental distress as not everybody who experiences depression has low serotonin or has experienced bullying, abuse or poverty

what is an insufficient cause?

-Y occurs only after X occurs alongside another variable (Z). Y does not occur when X occurs alone

Example: schizophrenia may develop when someone has a genetic susceptibility (Z) and is exposed to a life stressor (X)

-for mental distress, there are only insufficient causes

→ many insufficient causes that interact with each other

LO2: appreciate why studying causality in mental distress is tricky

why is it difficult to establish causality in mental distress?

-many studies are cross-sectional rather than longitudinal - measure variables at one point in time, making it difficult to establish temporal precedence (which variable came first)

-difficult to prospectively study important influences

→ some influences only become apparent many years later

example: the impact of parenting practices may only become apparent in adulthood

→ many influences occur over different time periods, happen in different places + interact with other variables

-impossible to include all important influences

-practical + ethical limitations in manipulating causal influences, eg SES, ethnicity

what other difficulties affect the study of causality?

-many important influences are sensitive, which can lead to sampling bias

-people may not be aware of all factors contributing to their distress or may find them difficult to articulate

-researchers + clinicians may have unconscious biases influencing measurement + models

-causal attributions are influenced by social + cultural norms + values.

why are diagnostic categories a measurement issue when studying causality?

diagnostic categories may lack validity + people with the same diagnosis can experience different combinations of symptoms

how many unique symptom combinations are possible for major depressive disorder (MDD)?

over 1,000 unique symptom combinations (Fried & Nesse, 2015)

-people can meet the criteria for the same diagnosis through different combinations of symptoms, this makes mental distress difficult to measure as one consistent condition

LO3: understand the strengths + weaknesses of different research methods on causality

what is the deductive approach to studying causality?

tests a theory of causality using pre-determined variables

what is the inductive approach to studying causality?

explores experiences + links them to causal theories, or develops new causal theories

what is the epidemiological approach?

studies determinants + distribution of health - related topics

survey methods - what are survey methods used to study causality?

-ask participants directly about the occurrence of variables associated with distress

-eg clinical interviews + self-report questionnaires

-ps can be sampled via quasi-random sampling  - researchers select ps at regular intervals (eg 5th/ 10th) from list/ population sequence (for example, the electoral register)

-uses predefined range of variables of interest

what are advantages of survey methods?

• useful when large random samples are used alongside valid + reliable clinical instruments

• explore real variation in influences + mental distress

• can be used longitudinally

what are disadvantages of survey methods?

• data depends on the questions asked + researchers' preconceptions

• depends on what participants are able + willing to tell researchers

• some people with relevant mental health experiences may be excluded through quasi-random sampling

what did Word Mental Health International College Student Initiative involve?

• first-year students recruited through convenience sampling from colleges + universities across nine countries

• online self-report questionnaires → measured perceived stress, six forms of mental distress (DSM screening scales) + sociodemographic variables.

• found strong relationships between perceived stress + mental distress

experiments - how do experiments study causality?

-manipulate a variable (X) to explore its effect on another variable (Y)

- participants are sampled randomly

- participants are divided into experimental + control groups

- differences are compared between groups using relevant measures.

eg randomised controlled trials (RCTs)

what are the advantages of experiments?

-can provide the strongest inference of causality.

-high internal validity because they provide a controlled environment

what are the disadvantages of experiments?

-low external validity: findings from a controlled environment may be difficult to generalise to the real world

-cannot control many other confounding variables

-convenience sampling may mean important causal influences in other groups are missed

-ethical + practical constraints

what did hesselle + montag’s 14 day social media abstinence involve?

-students recruited through convenience sampling

-randomly allocated to a control group or abstinence groups.

-14-day intervention using self-report questionnaires.

-measured depression and anxiety symptoms, loneliness + body image

-found small but non-significant increases in anxiety and depression +< a decrease in body image dissatisfaction.

qualitative studies - what are they

-deal with language, images + non-numerical data rather than measures, scales or questionnaires

-don’t test pre-conceived hypotheses

-eg interviews, focus groups + ethnography

what are advantages of qualitative studies?

-explore how the meaning of causal influences impacts people’s experiences

-can help identify causal order/ temporal precedence

-explore how different influences interact in mental distress

-generate new hypotheses for quantitative studies

-useful for studying complex cases

what are the disadvantages of qualitative studies?

-cannot be generalised to entire population

-do not test hypotheses

-can be difficult to relate findings back to quantitative results

what did hermann et al’s study or adolescents’ perceptions of mental health stigma involve?

-recruited 32 adolescents through purposive sampling

-used semi-structured interviews, individually or in focus groups

-conducted inductive analyses of interview transcripts

-identified three or helped

what are the advantages of qualitative studies?

-explores how the meaning of causal influences impacts people’s experiences

-can help identify causal order or temporal precedence

-can tell us something about how different influences interact in mental distress

-good for generating new hypotheses for quantitative studies

-good for studying complex cases

what are the disadvantages of qualitative studies?

-cannot be generalised to entire population

-doesn’t test hypotheses

-can be difficult to relate back to quantitative findings

what are epidemiological studies?

-studies determinants + health- related topics

-frequently uses clinical info gathered by doctors + other professionals

-studies how frequently diseases occur in different populations

-link variations in the prevalence of diseases to other variables eg socioeconomic status lifestyle choices, employment history

what did Global Burden of Disease (GBD) studies include?

-data about over 300 diseases + conditions

-over 80 risk factor in 204 countries

-found global increases in anxiety + depression over time

-increases were particularly pronounced in women + young people

-variations also found across regions + sociedemographic index

what are advantages of epidemiological studies?

-often provide most comprehensive picture of associations between demographic characteristics, lifestyle variables + distress

-can access in patient, clinic + hospital populations as well as as community samples

-can be more effective than survey methods as they have access to clinical info

what are the disadvantages of epidemiological studies?

-data is based on diagnostic categories, which are argued to lack validity

-prone to pre existing biases that are difficult to measure

LO4 - understand how causal explanations influence treatment decisions + outcomes

what is the biomedical model?

-assumes individual differences in biological processes (eg neurotransmitters, genes, brain structure + functioning)

-serotonin: involved in regulating functions such as mood, sleep, appetite, decision making

-serotonin hypothesis - coppen - 1967 - low serotonin as a cause for depression

what did errittzoe et al find?

-compared ps with depression to controls

-measured serotonin release in brain using radio active tracing

-reduced serotonin response in patients with depression

-however, sample limitations

why does the effectiveness of SSRIs not prove that depression is caused by low serotonin?

-SSRI efficacy doesn’t prove that depression is caused by reduced serotonin levels (Lacasse + Leo, 2005)

-(treatment working through a particular biological system does not automatically prove that a problem was originally caused by an abnormality in that system)

why might biological differences in people with mental distress not be necessarily its cause?

biological differences might result from mental distress rather than cause it

what did monctrieff et al 2022 find about serotonin and depression?

no clear evidence of differences in serotonin when results were pooled together

what did schmaal et al find using MRI data?

-used large cross-cultural sample (N greater than 8000)

-found reduced hippocampus volume in ps with depression

-reduction correlated with number of depressive episodes episodes

-this association doesn’t establish whether reduced hippocampal volume causes depression or results from repeated depressive episodes

how can biomedical model influence stigma?

-may reduce blame from others (crisafulli et al) + potentially self blame (larkings et al 2018)

-but this can come at the expense of increased perceptions of dangerousness (walker + read) + immutability (phelan et al)

what is the ‘mixed blessings model’ (harlan + kvaale 2015)

-biomedical explanations may have both positive + negative effects on stigma

-can reduce blame but increase perceptions that people with mental distress are dangerous or that their condition is unchangeable

how can causal beliefs influence treatment preferences?

-can influence preferences for medication, psychotherapy + type of psychotherapy (tompkins et al)

what did read et al (2015) find about causal beliefs + antidepressant preferences

-studied over 1800 ps in new zealand who had been prescribed antidepressants

-found diverse causal beliefs, including chemical imbalance, stress, relationship problems + childhood trauma

-ps with bmm beliefs thought antidepressants more effective

-study had sampling bias

how can biomedical model beliefs influence expectations about recovery?

bmm beliefs are associated with more pessimistic views about recovery

what did kemp et al find about serotonin beliefs + prognosis?

-ps with recurrent depression were told they had either low or normal serotonin levels

-researchers measured their expectations about prognosis + recovery

-ps in low serotonin condition were more pessimistic about their recovery

-similar findings reported for other forms of mental distress (lebowitz et al 2013)

what did larking et (2017) find about causal beliefs in treatment?

-used semi structured interviews with 23 service users

-ps felt causal beliefs were important + frequently thought about them

-causal beliefs were rarely addressed in treatment

-addressing them could increase insight, improve symptom management + reduce self blame

-were important for therapeutic alliance + recovery process

summary of LOs

1: causality is the study of factors, mechanisms/relationships between factors + mechanisms that cause mental distress, there are no necessary or sufficient causes for mental distress, only multiple insufficient causes

2: studying the causality of distress is complicated by many factors, such as the lack of validity of diagnostic categories, difficulties in measurement + establishing timelines, biases

3: deductive, inductive + epidemiological approaches are all valuable, the kind of answers we get depends on the research methods we use, with each method having weaknesses + strengths

4; causal beliefs are important for stigma, treatment choices + outcomes + ultimately recovery. hm explanations can increase access to service + reduce self blame, but do not seem to translate the optimism about treatment efficacy