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Psychology, Mental Health and Distress

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PART CONCEPTS

1 From disorder to experience 3

2 History 19
3 Culture 55
4 Biology 75
5 Diagnosis and formulation 101
6 Causal influences 118
7 Service users and survivors 139
8 Interventions 158

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 PROOF

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 PROOF

CHAPTER 1 FROM DISORDER TO EXPERIENCE

Bess’s story

Bess is a 19 year old African Caribbean woman. She was referred to clinical
psychology services after being admitted to a psychiatric hospital, because
her medication had not lessened the voices she heard nor altered the unusual
beliefs she held. Before her admission she had been living with her mother,
brothers and sisters in a large industrial town.
Bess is the oldest of four children. Since the age of 9 she had been largely
responsible for taking care of her siblings, whilst her mother worked long
hours to support the family. Nevertheless, Bess did well at school, although she
sometimes experienced racist bullying. Often, her father drank heavily and was
physically and verbally abusive – towards his wife, but occasionally towards
Bess. Then, when Bess was 12, her father came home drunk and pressured her
for sex. He threatened to hurt her brothers and sisters if she didn’t comply, and
Bess reluctantly agreed. She hated the sexual contact, but relished the affec-
tion she received from him. After two years of this sexual abuse, Bess’s father
left to begin a new relationship. Bess was devastated. She deeply resented her
mother’s anguish at losing him, and their relationship deteriorated.
After her father left, Bess was confused. She resented the way he had treated
her, and wondered why he didn’t contact her. She continued to work hard at
school and did extremely well in her exams. When she was 16, Bess noticed
that although the bullying had mostly stopped she still felt like an outsider. She
began finding it difficult to concentrate, and became preoccupied with the belief
that one day she would meet someone who would take her away to a new life.
Around this time she had a new boyfriend who wanted to turn their relationship
into a sexual one, but Bess refused. When she eventually explained to him what
had happened with her father, he ended the relationship. Bess felt that everyone
she loved would abandon her. She was deeply shamed by what her father had
done to her, judging it to be her own fault.
Bess began to spend more time alone, praying. She believed she was receiv-
ing messages from God, and began listening to loud music to block out the
voices she increasingly heard. She drank large quantities of alcohol, and slowly
became convinced she had a personal relationship – with sexual overtones –
with one of the pop stars she listened to. This made her feel ashamed, but the
pop star told her that one day he would take her to heaven where she would find
peace. She heard his voice often, especially when she felt lonely and miserable.
Increasingly, though, she also heard her father’s voice, commenting critically on
her actions and morals.
Eventually, Bess told her mother about these experiences. Her mother became
angry and contacted a doctor, who referred Bess to psychiatric services. This led
to a violent confrontation between Bess and her mother; Bess was then forcibly
admitted to hospital.

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 4 CONCEPTS
PROOF
Learning outcomes What is distinctive about this book?

After you have read this chapter, you will be able to: The approach taken by this book is somewhat different from
those of other books in this area. One very obvious difference
1 Explain why terminology is especially important in is that, unlike many others, we do not use the term ‘abnormal
relation to mental health psychology’ to describe what our book is about (later, we offer
2 Explain what is meant in this book by ‘distress’ a detailed explanation for this). But in fact this book has several
3 Describe some of the problems associated with everyday distinctive features, so it will be useful to emphasize some of
definitions of normality them here.
4 Explain the problem of thresholds in relation to First, in this book we take a consistently psychological
psychiatric diagnosis approach to mental health. Usually, psychology books on
5 Define key terms, including: service user, distress, mental health are already pre-structured in terms of psychi-
madness, psychosis, neurosis, hallucination and delusion atric diagnostic manuals such as the Diagnostic and Statistical
Manual of the American Psychiatric Association – the DSM
(see Box 1.1). Chapter titles are usually based upon diagnostic
Introduction labels, and explanations are typically directed at ideas of mental
illness that have already been formulated within psychiatry or
This book is about people like Bess. People distressed by life, medicine. Instead, in this book we offer a perspective that is
their relationships, and their position in the social world. It is more suitable for students from non-medical backgrounds
clear from Bess’s story that her distress is far from straightfor- who might want to train as (for example) clinical psycholo-
ward. Do her difficulties arise from her unstable relationships, gists, social workers or CBT practitioners. We have already
from the way she thinks about the world, or the ways in which suggested that we will do this by starting with experience
she has learned to cope? Whilst there are no easy answers to rather than notions of disorder, and there is more discussion
these questions, we hope that this book will provide some of what this means later in the chapter.
ways of thinking psychologically about the kinds of issues Second, most other books of this kind pay relatively little
facing Bess and others who have had experiences like hers. attention to recent psychological research – much of it from
In this chapter, we first of all explain what is distinctive the UK – which has focused on particular kinds of experience,
about this book and why we approached this topic in the way such as ‘hearing voices’, rather than diagnostic categories,
that we did. We discuss the importance of terminology and such as schizophrenia. This research has shown that it is
describe why language is important: both because it provides possible to make significant progress in understanding and
the concepts we use when thinking, and because of its links responding to people’s difficulties without having to endorse
to stigma and discrimination. We explain how in this book we psychiatric diagnoses. Of course, this does not mean that we
will focus on distress (which for now you can simply read as don’t consider psychiatric diagnoses in this book – just that
meaning ‘mental illness’ or ‘psychopathology’), and how we we don’t treat them as necessarily explaining people’s mental
will treat distress as a form of experience – something that health difficulties.
happens within the life and the subjective awareness of a Third, many other textbooks claim that dimensional
person – rather than as a form of illness. models are less clinically useful than psychiatric diagnoses.
Then we give some of the reasons why we decided not to Dimensional models do not presume a sharp dividing line
call this a book about ‘abnormal psychology’. Approaches to between mental health and mental illness, and recognize that
mental health and illness that do not endorse simple notions all of us, sometimes, have distressing and unusual experiences
of abnormality are often described as anti-psychiatry: this in our lives. They are usually contrasted with categorical
is the collective term for a set of disparate work, published models, where mental illness is clearly distinguished from
mostly in the 1960s, which rejected the view that mental mental health and is thought to fall into specific, separate
health problems are illnesses or diseases. We explain why we categories: psychiatric diagnosis exemplifies this approach.
do not call our approach anti-psychiatry; consider the issues But in the UK, at least, the vast majority of clinical psycholo-
raised by a focus on distress as something that is perhaps ‘in gists use dimensional models in their clinical practice, so this
the mind’; and briefly describe some of the ways in which book frequently takes a dimensional approach.
mental health professionals have modelled and conceptual- Fourth, most other mental health textbooks contain a series
ized their field. of chapters, each focused on a particular psychiatric diagno-
These discussions are followed by a short overview of the sis. But although they present extensive information about
rest of the book, and a guide explaining how to get the most each diagnosis, they rarely try to explain the associations
out of reading it. and connections between them. Typically, textbooks claim
to promote a biopsychosocial model of mental health – an
Guiding questions approach within which biological, psychological and social
influences are all considered or modelled together. But because
As you read this chapter, you should bear in mind these they don’t usually contain very much discussion of the links
two questions: between ‘bio’, ‘psycho’ and ‘social’, the model actually tends to
remain relatively obscure. Moreover, because these textbooks
1 Why might we question the notion of abnormal
are invariably structured around psychiatric diagnoses, they
psychology?
also tend to be reductive – in other words, they tend to treat
2 What are the implications of rejecting psychiatric
biological influences as foundational, or as more important
diagnoses in mental health?
than others. By contrast, in this book we try to consider the

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 PROOF FROM DISORDER TO EXPERIENCE 5

links between ‘bio’, ‘psycho’ and ‘social’ in a more nuanced mental health and illness, so that you can come to your own
and conceptually sophisticated manner. conclusions.
Finally, in these textbooks, the discussion of critics of psychia- Of course, in attempting to write about mental health in a
try, and of the controversies associated with its diagnoses and different way we had to think carefully about the language we
assumptions, almost always seems to stop at the end of the 1960s. used. There are many reasons for this, but perhaps the most
If one were to judge by such books, one might almost believe important is that language contains concepts that structure
that all of the problems that these critics had raised were now our thinking. If we use concepts that are inconsistent or
solved. But this is not the case, and in the five decades since the unhelpful, our thinking can become muddled. This meant that
1960s there have been many more critiques of, and alternatives we needed to ensure that our approach was internally consist-
to, psychiatry. These critiques and alternatives have come from ent, so it is to the issue of terminology that we turn next.
clinical psychologists and from those who use mental health
services, as well as from psychiatrists themselves. In recognition
of this, our book is also distinctive because it includes a chapter Terminology
written entirely by mental health service users.
In writing this book we have therefore made a number of One of the first challenges in learning about the psychology of
assumptions: for example, that psychiatric diagnosis does not mental health is the wide variety of terms and concepts used.
necessarily provide the best way to approach mental health Like the language used in relation to any other real-world
problems; that a more sophisticated psychological account of phenomenon, none of these terms is neutral or value-free.
mental health problems will be useful; that mental health service All of them seem to imply something about the nature or the
users have valuable things to tell us about mental health difficul- causes of the phenomena they describe, and all of them are
ties and interventions. All authors have an assumptive frame- more closely associated with certain disciplines and perspec-
work – a worldview within which certain things are implicit tives than with others. The term mental illness, for example,
and simply taken for granted. These assumptive frameworks clearly suggests that our talk will be of matters related to health
are rarely made explicit, but we thought it would be helpful for and sickness, that it will have a medical character but that it
you to have a sense of our starting points and assumptions so will also take a mentalistic or psychological focus. Another
that you can take them into account as you read the book. widely used term, psychopathology, makes exactly the same
Importantly, we have not written this book as a polemic assumption because it adds the concept of disease – pathol-
and we accept that you may agree or disagree with some of ogy – to the prefix ‘psycho-‘, which is short for ‘psychological’.
our judgements. Throughout the book we will be presenting In both cases, then, the terminology already assumes that our
evidence for and against different ways of conceptualizing perspective upon these phenomena should be a fundamentally

BOX 1.1 a-theoretical, instead of depending

upon concepts derived from theories.
Another concern frequently raised
by critics is that the DSM has promoted
What is the DSM? This means that it does not use earlier the medicalization of everyday life: in
concepts such as neurosis: a collective other words, it encourages us to see
‘The DSM’ is The Diagnostic and term for forms of distress that involve everyday difficulties and stresses (for
Statistical Manual of the American exaggerations of everyday responses example, shyness) as ‘symptoms’ of
Psychiatric Association. It contains (e.g. excessive worrying) but do not ‘illness’ that then require ‘treatment’.
the diagnostic criteria that American involve distorted perceptions or Certainly, the number of separate
psychiatrists use in their practice. In unusual beliefs. Whereas the concept of diagnoses within each version of the
Europe and the UK, psychiatrists most neurosis was originally derived DSM has tended to increase with each
often favour the slightly different from psychoanalytic theory, the DSM revision, as the table shows. However,
psychiatric diagnostic criteria set out purports to be no more than a set of advocates of diagnosis argue that
in The International Classification of descriptions of the disorders the system is simply becoming more
Diseases (ICD), produced by the World frequently observed by clinicians. These accurate and refined over time, and
Health Organization. However, although disorders are proposed by panels of that the changing numbers reflect this
they may use these criteria in their experts, and are subject to a consulta- process of development.
practice, for research purposes UK and tion process and approval by a central
European psychiatrists also tend to use committee before they can be included in TITLE YEAR DIAGNOSES
the DSM. the manual. DSM 1952 106
Both the ICD and the DSM have been Despite this, critics argue that the
subject to frequent revisions. The ICD is DSM-II 1968 182
DSM is far from value-free and neutral.
currently on version 10, whilst the current They suggest that in practice the DSM-III 1980 265
DSM is known as DSM-IV-TR: version IV, DSM furthers the interests, not just of DSM-III-R 1987 292
text revision. As we went to press, both psychiatry, but also of the pharmaceutical DSM-IV 1994 297
DSM-5 (the APA seem to have changed and insurance industries (because, under
their numbering system) and ICD 11 were DSM-IV-TR 2000 297
America’s insurance-based healthcare
expected shortly. system, a diagnosis is needed in order to Chapter 5 contains a lengthy discussion
At least in its current version, the reclaim the cost of treatments such as of psychiatric diagnosis and the issues
DSM claims to be purely descriptive and medication). that are frequently associated with it.

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 6 CONCEPTS
PROOF
severe forms of distress. These include experiences such
as hearing voices, which is an example of a hallucination:
a general term for the perception of a stimulus that is not
present. They also include advocating the unusual beliefs that
clinicians call delusions: beliefs that can be shown to be either
impossible or false, but which are sometimes proclaimed
strongly by service users. These experiences are primarily
associated with psychiatric diagnoses such as schizophrenia
and bipolar disorder, and are sometimes collectively referred to
as psychosis. There has been a recent debate in the UK about
terms like psychosis and schizophrenia, and a ‘Campaign
against the Schizophrenia Label’, which has received signifi-
cant media attention. As with the other terms we favour in this
book, we have used madness rather than psychosis because it
mostly avoids the many connotations of illness or disease that
accompany the alternatives.
You will probably be familiar with discussions about termi-
nology from other areas of your studies. Because language
supplies the concepts that structure our thinking and debat-
ing – sometimes very subtly, in ways we don’t necessarily
realize – it is vital to ensure that we are using appropriate
terms. However, it’s also important to realize that, in relation to
distress, these discussions are often particularly contentious.
Because distress touches the lives of so many people, and
because the ways we understand it have very real implications
for the ways that we respond to it, there are often very strong
feelings about the terminology that is used.
For example, there is extensive disagreement about the
term we should use to refer to people who experience distress.
In recent years, the dominance of the medical perspective
associated with psychiatry has meant that the term patient is
How we see or represent the world depends on how we choose to very often used. Over the last 20 or 30 years, however, some
frame it, as well as upon what there is in the world for us to see of those who experience distress have organized themselves
into activist groups and campaigned strongly for a change of
medical one, and that at its most basic level our concern is terminology. They have argued that the term ‘patient’ implies
with people who are diseased or sick. a passive position where someone puts themselves in the
We think that this assumption is incorrect. In our view, when hands of experts to be fixed. Some also object that the term
people are given diagnoses such as schizophrenia or depres- inappropriately focuses almost exclusively on the medical and
sion it is neither accurate nor helpful to think of them as being biological aspects of care (e.g. medication), rather than adopt-
medically ill or diseased. So in this book we will use the terms ing a more holistic approach. As a result of these objections,
‘psychopathology’ and ‘mental illness’ very infrequently, and some professionals now refer to those who use their services
even then only when they are already being used by the people as clients. However, some groups have argued instead that
whose work we are drawing upon. In their place, we will use they should be referred to as consumers (popular in the
the term distress. When we use this term, we use it to refer to USA, Australia and New Zealand) or service users (popular
just the same kinds of phenomena that textbooks of this kind in the UK), and many professionals have also taken up this
usually call mental illness or psychopathology. We use distress language.
to mean all of the different kinds of difficult or unusual experi- But these terms have also been challenged. Some suggest
ences associated with the hundreds of psychiatric diagnoses that they obscure the fact that many people are not always will-
currently employed. Distress is our term for the core subject ing consumers of mental health services, unlike the consum-
matter of this book: the experiences associated with diagnostic ers of other goods and services: some, for example, will be
categories such as schizophrenia and depression, and with the receiving compulsory treatment. Such critics have sometimes
work of professions such as clinical psychology, psychiatry, suggested that the term recipient is more accurate. And yet
social work and nursing. others have argued that, because they have had to cope not
However, to reduce repetitive language, we will occasionally only with their distress, but also with psychiatric interventions
draw on other phrases like ‘mental health problem’. This termi- which they have experienced as negative or unhelpful, the
nology is also open to challenge, because by locating these term psychiatric system survivor is most appropriate.
experiences in relation to health it also implies a link to illness. In short, then, there is no ‘right’ term to use and people in
However, it is more ambiguous than ‘mental illness’, carries distress, like everyone else, have their own preferences and
less conceptual baggage, and is easily understood because it understandings. In this book we will usually use the term ‘serv-
is widely used. ice user’, since this is one of the terms most widely used in the
Similarly, we will sometimes use the term madness to UK. But we will also sometimes use other terms, where other
collectively describe experiences associated with the more people have used them or where the context demands it.

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 PROOF FROM DISORDER TO EXPERIENCE 7

Stigma and discrimination these illnesses are what psychiatric diagnoses describe. The
second assumption is that this will result in less discrimina-
Language and terminology are important because of how they tion, because people will be more tolerant if they think that an
affect our thinking. However, they also matter in relation to unusual behaviour is caused by a medical illness or disease;
service users and their experiences of distress because of the otherwise, they might hold the person morally responsible.
widespread discrimination to which such people are subject. Another problem noted by some critics of these campaigns is
The UK government regularly surveys public attitudes about that stigma is seen as caused by problematic attitudes located
‘mental illness’: a survey (Office for National Statistics, 2010b) inside individuals, rather than as a product of, or reaction
of 1,745 people revealed that to, discrimination at a societal level – in a similar manner to
sexism and racism (Sayce, 1998).
• 78% of people agree that ‘people with mental illness have
for too long been the subject of ridicule’
• 75% agree that ‘people with mental health problems should
have the same rights to a job as anyone else’
• 87% agree that ‘we need to adopt a more tolerant attitude
towards people with mental illness’ (a fall from 92% in 1994)

At the same time, however, only 26% of people agreed that

‘most women who were once patients in a mental hospital can
be trusted as babysitters’. Only 34% agreed that ‘less emphasis
should be placed on protecting the public from people with
mental illness’, and only 33% agreed that ‘mental hospitals are
an outdated means of treating people with mental illness’.
This survey suggests that the public have ambivalent
feelings about service users and distress. One way of under-
standing this ambivalence is to see negative attitudes as an
example of stigma. This approach draws upon sociologist
Erving Goffman’s (1963) work Stigma: Notes on the manage-
ment of spoiled identity, where he described the process of
If only it were this simple. The fact is, millions of people will suffer from some form of
stigmatization as involving being viewed as socially deviant mental health problem during their lives. We can’t promise a quick fix, but we can offer
support and sound, practical advice for a better life. Talk to us.
and linked with negative stereotypes. Since then, a number
of researchers have drawn on this paradigm to suggest that
experiencing distress or being given a psychiatric diagnosis
can lead to one being stigmatized. Drawing on this insight,
there has been a considerable amount of research into why
mental distress is linked to negative attitudes.
Research suggests that the development of negative attitudes
begins early in life. Rose, Thornicroft, Pinfold and Kassam (2007)
asked 472 14-year-old school students ‘What sorts of words or
phrases might you use to describe someone who experiences
mental health problems?’ They reported that around 250 words This poster was part of an advertising campaign by a UK mental health
were mentioned by the young people, including terms such charity. What does it make you think? Does it stigmatize people with
mental health problems, or does it challenge their stigmatization? What
as nuts, psycho, loony, weird, freak, spastic and demented.
does it suggest to you about the causes of distress?
In their interview study of 1,737 adults, Crisp, Gelder, Rix,
Meltzer and Rowlands (2000) reported that their respondents
commonly perceived people who had been given a diagnosis A number of studies have reported that, whilst the public may
of schizophrenia as unpredictable and dangerous, even though use medical terminology, they place a ‘greater emphasis on
about half of them knew someone with a mental health prob- psychosocial than biogenetic explanations of schizophrenia’
lem. Unfortunately, research also shows that such prejudiced (Read et al., 2006, p. 311). Moreover, contrary to the assump-
views are even reported amongst doctors (Mukherjee, Fialho, tions of the anti-stigma paradigm, biomedical explanations
Wijetunge, Checkinski & Surgenor, 2002) and may be made are associated with more negative attitudes and behaviour
worse by some nurse training (Sadow, Ryder & Webster, 2002). than psychosocial models, in which mental health problems
Despite a huge amount of money spent on ‘anti-stigma’ are seen as psychological in nature and caused by adverse
campaigns the effects on public attitudes have been modest, life events and circumstances (Lam, Salkovskis & Warwick,
leading some to suggest that attitudes about mental health 2005; Mehta & Farina, 1997; Read & Harré, 2001; Read et al.,
may be different from other attitudes (Crisp et al., 2000). 2006). Why might this be? One possibility is that, if unusual
However, in a recent review, Read, Haslam, Sayce and Davies experiences or behaviours are seen as biomedical in origin,
(2006) suggest that it may be the underlying assumptions of they become more mystifying and unpredictable. Conversely,
the anti-stigma paradigm which are the reason for the lack of if they are seen as the result of someone’s life experiences,
change. These approaches are typically based on two assump- they are perhaps more understandable. So public education
tions, the first of which is that the public need to be taught to programmes focusing on psychosocial explanations may well
adopt a biomedical model of distress – to assume that distress fare better than those that endorse biomedical approaches (see
is caused by diseases or illnesses of the brain or mind, and that Figure 1.1).

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 8 CONCEPTS
PROOF
Biomedical approach Psychosocial approach
Sees the person’s mental health problems as the main problem Sees barriers in society as the main problem
Sees problems as a symptom of an underlying disease process and Sees problems as an understandable response to adverse life
illness events
Sees societal reactions as due to the stigma attached to having a Sees societal reactions as due to discrimination against a
mental health problem marginalised group (like racism, sexism etc)
Aim of public education is to remove perceived blame attached to Rejects the relevance of notions of ‘blame’ and aims to promote
the individual by ‘blaming’ the illness rather than the person diversity, reduce fear and increase empathy and understanding
Key public education slogan ‘Mental illness is an illness like any other’ Key public education slogans: ‘I’m crazy: so what?’ ‘It’s normal
to be different’

Figure 1.1 Contrasting biomedical and psychosocial approaches to public education about mental health

Discrimination reported that reliance on fictional television was associated

Although many people experience mental health problems, with higher ratings of unpredictability.
there is now substantial evidence that mental health service Rose (1998) compared UK TV news coverage in the summer
users experience significant discrimination across all areas of and winter of 1986 with TV news and other programmes
their lives (Sayce, 2000). For example, only 24% of people with between May and July 1992. Although she found variety in TV
long-term mental health problems were in work in England in genres like soap operas and comedies, the category of danger
2003 – the lowest employment rate of any of the main groups was very frequent. For example, a third of all camera shots in
of people with disabilities (Social Exclusion Unit, 2004). Almost her collection of TV news relevant to mental health dealt either
half (47%) of Read and Baker’s (1996) respondents said that they visually or verbally with danger, violence and crime. Moreover,
had been abused or harassed in public. Berzins, Petch and on the news, nearly two thirds of all stories involving those
Atkinson (2003) reported that people with mental health prob- with psychiatric diagnoses fell into the category of crime news,
lems suffered much higher rates of verbal abuse and physical although crime news accounts for only 10% of news coverage.
harassment than the general public, with much of it commit- As well as increasing the general public’s fear, negative media
ted by teenagers and neighbours. representations have an impact on people with mental health
Sadly, discrimination intrudes into even the most intimate problems themselves. Half the respondents of a UK mental
relationships and can lead to many people with mental health health charity’s survey of mental health service users said that
problems feeling isolated (Mind, 2004) and being wary about their mental health had been negatively affected and a third
telling other people about their own or another’s distress said others had reacted negatively towards them as a result of
(Mental Health Foundation, 2000). There has also been an such reports (Mind, 2000).
increase in community opposition to nearby mental health The media bias against mental health service users is
facilities. Research suggests that residents’ fears are fuelled by especially unhelpful because it largely ignores the available
media reporting, and are associated – on occasion – with both evidence. A UK study found that murders by mental health
vandalism and assaults (Repper, Sayce, Strong, Willmot and service users are infrequent and occur less than once a week
Haines, 1997). (Large, Smith, Swinson, Shaw & Nielssen, 2008). Whilst this
Another domain within which mental health service users might sound alarming at first, it should be seen in the context
experience discrimination is the media. Headlines such of other statistics. First, only 10% of people convicted of murder
as ‘Schizophrenic Given Life for Murder’ (Daily Express, 24 in the UK are thought to have any mental health difficulties
March 2009), and terms such as ‘Psycho Cabbie’ (The Sun, 4 at the time of their crime (Department of Health, 2001), and
June 2010), serve to associate mental health service users with 95% of all murders are committed by people who have never
violence and fear and help to spread negative attitudes. Indeed, been given a psychiatric diagnosis (Institute of Psychiatry,
many commentators see disproportionate media report- 2006). Second, the number of people experiencing mental
ing as an important maintaining factor in more widespread health difficulties at any one time is large – typically around
discrimination. In one study of a range of print and broadcast one in six of the population, or – in the UK – roughly 7 million
media, stories about homicides and crimes accounted for 27% people. These figures show that the vast majority of murders
of all coverage of mental health (Care Services Improvement are committed by people without mental health problems, and
Partnership/Shift, 2006). Messages about the risks of violence that the proportion of people with mental health problems
posed by people with mental health problems were present in who commit murder is extremely small. Other violent attacks
15% of stories, most of which implied the risk was high. by mental health service users (i.e. those not causing death) are
News and entertainment media focus primarily on violence similarly much less frequent than media reporting suggests,
against others when addressing issues relating to mental and when they do occur they are frequently also associated
illness, with these items receiving ‘headline’ treatment (Philo, with the use of alcohol or other drugs (Fazel, Langstrom, Hjern,
1994). These findings are robust (e.g. CSIP/Shift, 2006; Philo, Grann & Lichtenstein, 2009).
1996; Pinfold & Thornicroft, 2006) and influence the public’s In fact, contrary to public fears, people with mental health
fear of unpredictability and violence (Philo, 1996). Levey and problems are far more likely to be victims of violence than
Howells noted (1995) that perceived dangerousness was not perpetrators; for example, they are six times more likely than
as important as the perceived difference and unpredictability the general population to die by homicide (Hiroeh, Appleby,
of people with a diagnosis of schizophrenia. Moreover, they Mortensen & Dunn, 2001). A US study of people experiencing

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 PROOF FROM DISORDER TO EXPERIENCE 9

psychosis found that they were 14 times more likely to be the From our perspective, however, experiences of distress are
victims of violent crime than to be arrested for committing part and parcel of the other experiences of everyday life. They
violence themselves (Walsh et al., 2003). They are also far more do not form a separate, unitary category of symptoms that can
likely to be a danger to themselves than to other people; for be understood separately from everything else. Experiences
example, one influential study found that 90% of UK suicides associated with distress – just like every other experience – are
involve people with mental health problems (Barraclough, bound up with social and material conditions, personal biog-
Bunch, Nelson & Sainsbury, 1974). raphies, life events and relationships. And, just like every other
How might we change stigmatizing attitudes and discrimi- experience, they are influenced by our biological capacities, by
natory behaviour? As we have seen, promoting psychosocial the many, variable potentials produced by our nature as living,
rather than biomedical explanations may help. In addition, organic beings.
activists like Sayce (1998, 2000) have argued that lessons can be But if distress is not separate from other aspects of experi-
learned from broader disability campaigns. Here, campaigners ence, and does not form a unitary category all to itself, how can
argued that it was not a person’s disability which was the prob- we know where it starts and ends? How can we reliably and
lem (as might be expected from an individualistic biomedical validly draw an objective line between distress – the province
approach), rather it was the way in which society unintention- of services such as clinical psychology and psychiatry – and
ally created barriers by organizing the environment in a way more everyday experiences of being unhappy, worried and so
which was convenient only for people without a disability. In on?
the same way, rather than focusing on individual experiences Simply put, our answer is that we cannot draw such a line.
of stigma, we might see public attitudes to service users – We do not believe that it is possible to produce a set of criteria
fuelled by inaccurate media reporting – as socially-created or definitions that transcend history, place and culture and
barriers to their acceptance by others. that can be used objectively to discriminate between those
who are clinically distressed and those who are not. In the
DSM, the existence of a distinct line between normal and
What is distress? abnormal is taken for granted – even though it is recognized
that only appropriately trained expert psychiatrists might be
Throughout this book, then, we use ‘distress’ as a generic able to determine exactly where it lies. By contrast, we believe
term to refer to all the phenomena and experiences that are that there is no value-free distinction between behaviours and
sometimes called ‘psychopathology’ or ‘mental illness’. But, experiences that are considered normal and those that are
as we have suggested, this is not just about a preference for a considered abnormal. Neither is there any universal standard
different way of describing these experiences: it also signals a against which people’s emotions, thoughts and actions can
different way of conceptualizing them. We will now describe be judged, and by reference to which they can be categorized
in more detail how we conceptualize distress, and how – as as deviant. On the contrary, the identification of distress as
a concept – it differs from concepts of mental illness or distress will always be entwined with prevailing cultural norms
psychopathology. of emotionality, behaviour and morality.
When we talk about distress, we are talking about a highly However, this does not mean that cultural norms are the sole
variable and heterogeneous set of experiences. These experi- criteria against which distress might be identified. Sometimes
ences can include a person’s ways of acting or experiencing can make it difficult
for them to live their lives as they would like, or can have a bad
• strong or overwhelming emotional states, of various
effect upon their physical health. When this happens, their
kinds, that disrupt everyday life and prevent people from
behaviour is never somehow floating free of cultural norms:
functioning
what we want to do in our lives, for example, is continuously
• habitual and repetitive patterns of acting – for example,
influenced by the precepts, norms and values of our time and
in relation to personal hygiene, or to do with safety and
culture.
security – that create anxiety if they are not carried out
Nevertheless, there are patterns of activity and experience
• experiences of seeing and hearing things that other people
which would be unhelpful or damaging in most circumstances.
do not see or hear, or of holding beliefs that are considered
Gradually starving yourself – perhaps because you have come
by others to be unusual and extreme.
to believe that only by doing so can you begin to meet all of
In this book, we take these kinds of experiences as problems the many expectations placed upon you – will damage your
in their own right. This contrasts with the approach frequently physical health, no matter where or when you live. Similarly,
taken in psychiatry, where service users’ talk of these kinds being so profoundly miserable that you are unable even to get
of experiences can very quickly get re-interpreted as nothing out of bed is likely to prevent you from achieving your goals,
more than symptoms of an illness. In psychiatric settings, whatever those goals are. In the same way, experiencing angry
doctors are frequently listening out for particular patterns and abusive voices that no-one else can hear is likely to make
of difficulty in order to match the person’s experience with you frightened, confused and distracted, and this will probably
a pre-defined diagnostic category. However, this might occur to some extent even in cultures where voice-hearing
mean that they miss some of the complexity and fluidity of is not as thoroughly stigmatized as it is in the West. So, whilst
people’s actual experiences of distress: in attentively looking these dysfunctional or damaging consequences are definitely
for patterns of symptoms, they may fail to notice the ways in not separate from wider cultural norms and values, they do not
which people’s distress is linked to the circumstances of their arise solely because of them: they are also a product of specific
situations. As a consequence, rich accounts of distress that patterns of experience and activity.
engage with its meaning and detail in a person’s life may be To some extent, distress can also be identified with respect
difficult to achieve from within a psychiatric framework. to the extent to which a person’s actions and experiences

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 10 CONCEPTS
PROOF
are unusual and inexplicable. Again, cultural norms play an like these those norms are either mediated by other people’s
important role here, and in two ways. First, almost by defini- experiences, or codified in legal or other requirements. These
tion, norms refer to the ways of acting and experiencing examples show how the identification of distress can be a
displayed by the majority. However, there are difficult issues compassionate move, perhaps by attempting to keep safe
involved in trying to agree the threshold at which an experi- someone who might otherwise be a danger to themselves. But
ence becomes seen as clinically significant (see Box 1.2 for a they also show how distress is always bound up with the wider
discussion). Second, norms are relevant because we are far structures of power that organize our lives, and by which
more ready to ascribe distress to people when their ways of interventions might be imposed against our will.
being in the world do not make sense to us. When what people To summarize: distress is always conceptualized with respect
say or how they act is not only unusual but also seems to lack to cultural norms, but these norms are not the sole criteria
any obvious explanation, we are more likely to conclude that against which distress is understood. One consideration is
they are experiencing distress of some kind. In other words, it that distress always has a subjective component, regardless of
is not just the frequency or rarity of someone’s acts and expe- its location within culture. Another is that, intersecting with
riences that counts – it is also the sense or the meaning that cultural norms, we also have
we are able to give to them.
• Judgements about the extent to which a person’s actions
Another issue is that there are significant numbers of people
and experiences are harmful or dysfunctional
who receive treatment from psychiatric or clinical psychologi-
• Judgements about the extent to which they are unusual
cal services but who do not want these interventions. Some
• Judgements about the meaning of actions and
might be experiencing the transient states of extreme euphoria
experiences
and intense energy that psychiatrists call mania; others might
• The influence of power relations
be hearing voices that are friendly and supportive, rather than
angry or abusive; yet others might be very unhappy, worried None of these judgements is simply objective, just as the
or confused, but have nevertheless come to believe that the operation of hierarchical power relations cannot simply be
treatments are not working, or that they produce as many seen as ‘objectively’ correct. But whilst these judgements and
difficulties as they solve. Some such people might end up influences do not escape the influence of cultural norms, they
receiving services, not because they themselves are distressed, are not identical to them, either. Instead, they point to numer-
but because their behaviours and experiences are distressing ous ways in which the contexts, consequences and meanings
to others around them. Others may end up receiving services of experience are part of its conceptualization as distress. They
because their behaviour leads them to fall foul of the law. make it clear that distress is always socially and culturally
Again, cultural norms are highly relevant here: but in cases positioned, that it will vary according to the specifics of time

BOX 1.2 anxiety, finding that 61% of respondents

reported being much or somewhat
experience a DSM-defined disorder at
least once during their life-times, and
The problem of thresholds more anxious than others in at least one what this prevalence means for etiologi-
of the seven social situations surveyed. cal theory, the construct validity of the
We have seen that one criterion for However, if the threshold at which DSM approach to defining disorder,
identifying experiences as mental health a person’s distress was considered service delivery policy, the economic
problems is how unusual they are. But clinically significant was moved, the burden of disease, and public percep-
what is the threshold beyond which an prevalence of ‘social anxiety syndrome’ tions of the stigma of mental disorder’
experience is considered so unusual varied from 1.9% to 18.7%. Many diagnos- (p. 907).
that it is significant? This question is tic criteria are formulated without any Because there are cultural norms
important, because research shows empirical investigation of base rates in about what might be regarded as
that some phenomena associated with the general population. This may explain grounds for distress, where the
distress are far more common than is why there is a frequent disparity between threshold for distress is set will have
usually supposed. numbers of people seen by mental a considerable impact. One US study
Of a random sample of 7, 076 health services and numbers of people in has suggested that ‘about half of
Dutch people, Van Os, Hannsen, Bijl community surveys who meet diagnostic Americans will meet the criteria for a
and Ravelli (2000) reported that, whilst criteria. DSM-IV disorder sometime in their life’
3.3% had ‘true’ delusions (i.e. meeting all Moffit et al. (2010) have suggested (Kessler et al., 2005, p. 593). If half of the
diagnostic criteria) an additional 8.7% an that many estimates of prevalence in population experiences something, is it
additional 8.7% had delusions that were community surveys undercount because unusual? To some extent, this depends
‘not clinically relevant’ – that is, they they rely on retrospective accounts. on one’s worldview. For example,
were ‘not bothered by it and not Their prospective study, which followed Sigmund Freud, one of the founders
seeking help for it’ (van Os et al., 2000, participants between the ages of 18 of psychoanalysis, did not see it as his
p. 13). Similar findings have been and 32 and interviewed them four times job to make people happy: instead he
reported in relation to hearing voices (see during this period, found prevalence simply argued that ‘you will see for
Chapter 11). rates for DSM diagnoses that were twice yourself that much has been gained if
Stein, Walker and Forde (1994) those of other national surveys. They we succeed in turning your hysterical
conducted a telephone survey in Canada conclude by suggesting that ‘researchers misery into common unhappiness’
to ask about experiences of social might begin to ask why so many people (Freud & Breuer, 1895/2004, p. 306).

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 PROOF FROM DISORDER TO EXPERIENCE 11

and place, and will be patterned according to broader socio- culture (Hebdige, 1979). Social definitions recognize the cultur-
logical variables such as socio-economic status, gender and ally normative dimension of distress that we described above,
ethnicity. Conceptualized in this way, distress is quite different but when we try to formalize them it becomes apparent that
from mental illness or psychopathology, both of which imply we also have to invoke other (typically unspecified) criteria
objective disease states that can be identified in ways that are to decide which social norms, when, and where, to use as the
distinct from cultural norms. basis of our decisions.
So concepts of normality and abnormality do not provide
an objective basis for the identification of mental illness or
psychopathology, and this in part explains why we have not
Why not abnormal psychology?
relied upon these concepts in this book. But the term ‘abnormal
psychology’ is nevertheless widely used, and seems acceptable
Our claim that there are no objective criteria by which distress
to the majority of psychology lecturers and students. Despite
can be distinguished from other kinds of experience is a chal-
this, there are other reasons why we choose not to describe
lenge to the idea that some kinds of experience – and perhaps
this as a book about abnormal psychology.
even some kinds of person – are simply abnormal. But this
is such a taken-for-granted idea that it even lends its name
to the most commonly used title for textbooks like this one, Abnormal psychology is confusing
which are typically described as books on abnormal psychol- and unclear
ogy. This term is very widely used, perhaps because classifying One reason we haven’t used the term ‘abnormal psychology’
some kinds of experience as abnormal makes it reasonable to is that it is ambiguous: is it the psychology itself that is abnor-
describe them as expressions of psychopathology or mental mal, or does the term refer to the psychology of abnormality?
illness. Since abnormal psychology is such a common term, Common sense would suggest that it is the second of these
we should explain why we do not use it in this book. options that most people have in mind; if so, this only leads to
Whilst the notion that trained professionals can use objec- a second, thornier set of confusions.
tive criteria to distinguish between normality and abnormality As we have already discussed, there is no straightforward,
is perhaps comforting, it is nevertheless mistaken. Speaking objective way to distinguish abnormal behaviours and experi-
very generally, formal definitions of abnormality can be ences from normal ones. Even more fundamentally, though,
classed as medical, as statistical, or as social – but whichever it is impossible to easily identify a body of psychological
kind of definition we use, we encounter contradictions and theory and practice that is both exclusive to abnormality and
problems. Each kind of definition excludes some phenomena unconnected with other topics. Psychological explanations in
we might intuitively want to define as psychologically abnor- abnormal psychology tend to draw upon just the same kinds of
mal, includes some we would not want to define as abnormal, paradigms and theories as other psychological explanations –
or smuggles elements of subjective opinion into what are biological, cognitive, behavioural, social, developmental and so
ostensibly objective judgements. on. It does not seem necessary to assume that the psychologi-
For example, if we use a medical definition of normality, cal processes that occur in distress are fundamentally differ-
we will tend to class as normal those activities which contrib- ent or abnormal in comparison to those that occur in other,
ute to health and wellbeing, and class as abnormal those that supposedly normal, experiences. There are many successful
endanger life or wellbeing or which cause harm to bodily psychological models of distress that draw upon established
organs or tissues. But this means that many highly prevalent psychological theories and concepts such as learning theory,
everyday activities – such as smoking, drinking alcohol, diet- attribution theory, schema and so on.
ing, extreme sports, body-piercing and tattooing – would be
classed as abnormal, because they all involve actual or poten-
tial damage to the body.
Abnormal psychology is not consistently
If we use a statistical definition of normality, we will class
psychological
as abnormal those activities, behaviours and characteristics A further way in which abnormal psychology is confusing is
that are, numerically, relatively unusual in a given population. that it is not consistently psychological. Frequently, abnormal
Statistical definitions of normality derived from psychology psychology entirely abandons psychology and turns instead
sometimes use psychometric instruments, normal distribu- to psychiatry. This is clearly demonstrated in the overall struc-
tions and similar procedures by which to distinguish those ture of most textbooks, which typically follow, more or less
who are abnormal from those who are not. But without also faithfully, the diagnostic categories associated with one of the
drawing on cultural values and norms (for example, in decid- major psychiatric diagnostic systems such as the DSM or ICD.
ing which experiences to include in psychometric scales) But this necessarily means that the inconsistency also runs
statistical definitions will always generate contradictions, deeper: even where psychological explanations are offered,
because some highly valued attributes – being a member of they are directed at problems already defined in psychiatric
the royal family, perhaps, or excelling at sport – are statistically terms. So in abnormal psychology there is an unresolved
highly abnormal. tension between psychiatry and psychology, and frequent
If instead we use a social definition of abnormality, this will shifts from one to the other. Moreover, when this happens,
reflect the specific kinds of activities and experiences approved abnormal psychology typically offers no rationale for this shift
or disapproved of in that time and place, so will inevitably be from a psychological mode of explanation and description to a
subject to marked variation. This variation operates within as medical, psychiatric one.
well as between cultures: groups and subcultures have their In this textbook, we try to avoid these confusions by present-
own norms of behaviour and conduct that sometimes differ ing consistently psychological accounts of distress. This does
significantly from those of the dominant or mainstream not mean, of course, that we entirely ignore psychiatry: this

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 12 CONCEPTS
PROOF
would be impossible, given that so much of the evidence we will tend to possess a limited and restrictive set of conceptual
have about distress is associated with it. Nor does it mean that frameworks when they themselves, or people in their lives,
we ignore any of the multiple facets of distress, such as its encounter mental health problems. These limitations, and
biological, cognitive or developmental aspects. the assumptions of abnormality which they reproduce, may
However, it does mean that we treat psychological explana- act as barriers to people’s ability to understand difficulties and
tions of distress as sufficient in their own right. Rather than respond to them appropriately.
subordinating them to psychiatry by applying them only to Of course, all teaching and learning starts from a set of
problems defined in the first instance as medical and psychiat- assumptions about what we imagine to be the nature of the
ric, we also use psychology to define the nature and character topic and what students need to learn about it. We do not imag-
of people’s distress. ine that by avoiding the term ‘abnormal psychology’ we have
somehow written a textbook that is free from any assumptions –
far from it. We simply hope that the assumptions we started
Abnormal psychology is unhelpful from will prove more helpful and appropriate for psychologists
A third reason we haven’t used the term ‘abnormal psychol- and many others who wish to engage with this topic.
ogy’ is that it is likely to be particularly unhelpful for many
of the people who will be expected to study it. As we note
throughout this book, distress is very common and it is likely Isn’t this just anti-psychiatry?
that most readers will know someone who has experienced it
(see Box 1.3). Some readers might consider that our arguments so far are
In this context, teaching that is framed from the outset as ‘just anti-psychiatry’. By this, people mean the work of psychi-
being about something abnormal will already import a range atrists and others in the 1960s, like Ronald Laing in the UK and
of assumptions that, for many readers, are likely to be difficult Thomas Szasz in the USA, both of whom were critical of the
or unhelpful. It is hard to engage constructively with teach- legitimacy of psychiatric claims. As we will see in Chapter 2,
ing that labels you, or the people you love and care for, as the so-called anti-psychiatrists were not a homogenous
abnormal. group, and there were important differences between the key
Even more seriously, this unhelpful aspect of abnormal figures. Moreover, both Laing and Szasz were unhappy with
psychology is not confined to its likely effects upon the learn- the term ‘anti-psychiatry’, and they were clearly not against all
ing and teaching of psychology. Although the majority of ideas and practices in this area, since they both continued to
people who study psychology do not go on to have careers practise psychotherapy.
in the profession, they will nevertheless draw upon what they Many modern abnormal psychology and psychiatry text-
have learned at other points in their lives. This means that they books give the impression that the challenges raised by the

BOX 1.3 such people, and that the people they

knew were most often family members.
in a manner which does not get in the
way of our lives or cause significant
I know someone who has a She observed that taking part in such a difficulties for us or those close to us).
mental health problem class is not ‘simply an abstract academic Thus, if you feel that you are a little
exercise; it is a potential source of obsessive because you like things to be
Many readers of this book will either knowledge and skills that could have a neat and tidy, it does not mean you have
know someone who has had a mental significant impact on students, families a disease called obsessive compulsive
health problem, will have experienced a and friends’ (Connor-Greene, 2001, p. 211). disorder. This self-recognition problem
problem themselves, or may do so in the We take this point seriously. is very common. If you asked the other
future. UK mental health campaigners Throughout the book we have sought to students in the class if they have started
suggest that about one in four people portray people in distress in a respectful to question whether they have a mental
will, at some point in the course of manner, and to avoid an ‘us and them’ health problem, we think it is likely they
their lives, experience clinical levels of attitude. We have tried to investigate will say that they have too!
distress. Elsewhere in this book, we ask and present the evidence behind, for If, however, you do have a problem
whether such figures challenge common example, claims about particular mental that is long-lasting, and that is causing
definitions of mental illness based upon health interventions, so that readers of difficulties that get in the way of your
notions of organic disease and dysfunc- the book can act as informed citizens life and causing you further distress,
tion. For now, all we need to recognize is when helping a family member to then you should consider seeking help.
that such experiences are very common, weigh up the pros and cons of different Most universities and colleges have
so if you have experienced distress – or intervention options. mental health or counselling services,
know someone who has – you are not When reading about mental health, and these can be an appropriate place
alone. one can easily start to recognize oneself to start. For those who are not students,
In a survey of students attending an in the descriptions of certain kinds of local voluntary services in your area can
abnormal psychology class in the US, problem. As we will see in later chapters, usually be identified by searching the
Patricia Connor-Greene (2001) found that studies of the normal population suggest internet. You could also try discussing
almost every student reported knowing that many mental health problems are your difficulties with your GP, who – if it
someone with a mental health problem, normally distributed, such that a lot of is appropriate – will be able to refer you
that quite often students knew several us experience them at a low level (i.e. to more specialist services.

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 PROOF FROM DISORDER TO EXPERIENCE 13

anti-psychiatry movement were addressed with a new edition place since the 1960s. The term ‘anti-psychiatry’ seems to
of the DSM in the 1980s. However, this new manual did not exclude all of this more recent work, is simplistic, and carries far
solve the more fundamental conceptual problems noted by too much historical and conceptual baggage; for these reasons
these critics – for example, that value judgements are neces- we would not use this label to characterize our approach.
sarily involved in definitions of mental illness, and that there
is no clearly evidenced biological basis for mental illness, and
thus no physical tests for (say) schizophrenia in the way that From disorder to experience
there are for infections or viruses. Moreover, there has been
a considerable body of empirical research over the last fifty Most mental health textbooks, then, focus on psychiatric
years which has cast new light on some of the debates which disorders; Box 1.4 shows how disorder is typically defined
began in the 1960s. Throughout the book we will draw on this within psychiatry, and discusses some problems associated
research to demonstrate that there are continuing problems with such definitions. By contrast, in this book we focus on
with the validity and reliability of diagnostic constructs. experience. By this we mean that we will describe and try to
Likewise, we will draw on this research to show that a focus explain experiences of distress without presuming that they
on the experience of forms of distress can yield results that are are always caused by an underlying disorder of some kind.
valuable to service users, researchers and clinicians. We will treat the difficulties themselves as something to be
It may help here to consider some of the debates in other explained, rather than attributing them to an underlying
areas of psychology, for example between different approaches disorder that in fact may not even exist.
to social psychology or between paradigms like learning In the last few years there has been a growing tendency
theory and psychoanalysis. Here, too, there are debates about for psychology to engage directly with the particularities of
assumptive frameworks, key concepts, terminology and experience itself, rather than, for example, engaging with
methodology. In these areas, too, we have had to accept that general biological or cognitive capacities. There have been
research is always, to some degree, a reflection of its time, three recent books on the psychology of experience, each one
affected by cultural norms and so on. Our contention is that taking a slightly different focus. Ben Bradley (2005) empha-
this is also true in mental health, so throughout the book you sizes that experience is always relational and shaped by the
will see debates analogous to those found in other areas of simultaneous experiences of other people. He also discusses
psychology. ways of thinking about the significance of time in relation to
In short, there are some similarities between aspects of our experience. Dave Middleton and Steve Brown (2005) show how
approach and the ideas of the anti-psychiatrists, but there are our experience is made in part from our memories, exploring
also significant differences. This book reflects the findings of how they help give meaning to everything we see, hear and
the nearly fifty years of research and discussion that has taken feel. Niamh Stephenson and Dimitris Papadopoulos (2007)

BOX 1.4 This definition raises many issues that

recur throughout this book: whether
of disorder is inescapably social in
character.
DSM-IV definition of mental or not distress should be seen as a However, as Kirk and Kutchins
disorder medical or biological problem, the (1999) observe, we can only reliably
relationships between individuals and identify a dysfunction if we can say
In DSM-IV each of the mental disor-
their culture, the kinds of reactions with confidence what the function of a
ders is conceptualized as a clinically
we should expect people to show to system or organ is meant to be.
significant behavioural or psychologi-
unpleasant but common experiences But in relation to human minds and
cal syndrome or pattern that occurs
in an individual and that is associated such as bereavement, and so on. brains, our knowledge of these
with present distress (a painful Notably, however, the definition also functions is still remarkably limited. For
symptom) or disability (impairment displays a continual concern with example, we know that many neural
in or more areas of functioning). This notions of dysfunction, and this raises systems frequently serve more than
syndrome or pattern must not be some complex issues. one function, that most basic abilities
merely an expectable and culturally For example, Wakefield (1992) are enabled by multiple neural systems
sanctioned response to a particular distinguishes between disorder and working in parallel, and that there
event, for example the death of a dysfunction. He argues that a disorder are frequently many different neural
loved one. Whatever its original is a harmful dysfunction, and that what pathways by which the same
cause, it must currently be consid- is considered harmful will be judged (or a similar) behavioural or cognitive
ered a manifestation of a behavioural, according to prevailing social norms. goal can be reached. They argue
psychological or biological dysfunc- By contrast, a dysfunction – for example, further that many forms of distress
tion in the individual. Neither deviant of a cognitive mechanism designed to are probably not dysfunctional in any
behaviour nor conflicts that are conduct a specific function – might be simple sense: for example, that it may
primarily between the individual and identified objectively, so is not subject to well be ‘natural’ and a sign that your
society are mental disorders unless the same kinds of influences or biases. neural systems are working as they
the deviance or conflict is a symptom This suggestion is insightful: it avoids should if you end up feeling deeply
of dysfunction in the individual. many of the difficulties associated with miserable because you have lost your
Reproduced in Stein et al. definitions of normality and abnormality job and have no immediate prospect of
(2010, p. 1760) whilst also recognizing that the notion getting another.

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 14 CONCEPTS
PROOF
focus mainly on the ways in which experience is shaped by Like all of the other examples in this book, these are fictional –
the wider power relations of society, relations which regulate they are not descriptions of real people. Nevertheless, they are
our experience and – at the same time – create contradictions fictions closely informed both by clinical practice and by the
that can put us somewhat at odds with their requirements. research literature describing mental health difficulties. This
These different perspectives on experience begin to show means that we can use them to draw out important issues that
how it always spreads in two directions: ‘outside’ ourselves, are relevant to our understandings of distress – for example,
into the social and material circumstances that give experi- how people are socially positioned. Dave is a middle-class
ence its character and content, and ‘inside’ ourselves, by way professional, whereas Ellie and Mark are less wealthy and have
of the many thoughts, feelings and memories it consists of. fewer resources. Studies show that the incidence of psychiatric
In this book we will try to explore experience from both of diagnoses varies with wider economic and social conditions
these directions, in the hope that by doing so we can make and is patterned according to sociological variables such as
even superficially baffling experiences more open to expla- class or socio-economic status, gender and ethnicity. Similarly,
nation. The alternative – attributing what we cannot readily there is much evidence that women are more likely to be
understand to the effects of an underlying disorder – tends given some psychiatric diagnoses than men, and that overall
to produce unsatisfying, circular explanations: we know that they are more likely to experience distress. Nevertheless, as
Jenny has schizophrenia because she hears voices, and the our examples illustrate, at the individual level these influences
reason she hears voices is because she has schizophrenia. appear complex and uneven.
Whilst the kinds of experiences we will consider are quite Ultimately, each of our examples is an attempt to reduce the
varied, they are all of the kinds that mental health profession- messy complexity of a lived experience, in all its uncertainty
als might encounter in the course of their work. At the start of and ambiguity, to a single narrative told from a specific point
this chapter we presented Bess’s story and suggested that her of view. Inevitably, doing this raises issues. For example, there
experiences are fairly typical of those that clinicians encoun- are always other stories that could have been told: even though
ter. Here are some more examples: we have tried to illustrate something of the great diversity of
distressing experiences, it is impossible to encapsulate the
Dave is a 45 year old man who is frustrated with his career.
variety of experiences being lived out around us all the time. So
Although he has a well paid, highly respected job and a
we could have told many other stories; but we could also have
comfortable home, he is dissatisfied with other aspects of
told the stories we did tell in different ways. Mark’s stepfather,
his life and his negative feelings have recently started to
for example, might have told a story that emphasized Mark’s
become overwhelming. At work, Dave feels that his talents
unreasonable behaviour, and described how he frequently
are not being recognized, and that his manager is a bully
becomes aggressive without any apparent justification.
who does not take his suggestions seriously. In recent
months, this situation has begun to preoccupy Dave’s
thoughts. He has frequent trouble sleeping, and has started
experiencing pains in his neck and back. His GP can find
no physical cause for these pains, but since Dave recently
began experiencing panic attacks he has referred him to
a counsellor attached to the practice. Together with the
counsellor, Dave has begun exploring how his responses to
his manager are shaped by other experiences in his life.
Ellie is a 19 year old woman who got pregnant when
she was just 15, although she has not seen her son’s father
since then. She has tried to provide her son with a stable
home, but despairs that she is only surrounding him
with the same kinds of instability and confusion that she
experienced herself when she was growing up. For a long
time now Ellie has felt very miserable, but she has come
to believe that if only she had cosmetic surgery to make
her body look ‘younger’, more attractive to men, she would
feel much better. When her doctor would not refer her
for cosmetic surgery of this kind, Ellie attempted suicide.
Since then she has been taking anti-depressant medica-
tion and receiving cognitive-behavioural therapy.
Mark is a 25 year old unemployed man who lives with his
mother and stepfather in a poor suburb. He never knew his
own father, who left home when he was small. His mother
remarried and had a daughter with her new partner, and
Mark grew up feeling that he always took second place to
his sister. Following a long and angry argument with his
stepfather, Mark has been lonely and miserable and has
started locking himself into his room. Alone at night, he Both psychiatry and psychology are imbued with interests – for example,
those of commerce and professional status. Although the problems
has begun to hear angry male voices criticizing him. Mark
associated with these interests may be more acute in respect of
is terrified by these experiences, but has not told anyone psychiatry, psychology does not provide a neutral ground from which to
about them because he fears that people will laugh. approach distress

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 PROOF FROM DISORDER TO EXPERIENCE 15

This suggests that there will often be tensions between what

people say about distress according to how they have experi-
enced it, how they have been exposed to it, and how they have
been encouraged to understand it. Moreover, these tensions will
often have moral, ethical or political dimensions to them. This is
only to be expected: partly because distress often first becomes
a matter for intervention when people flagrantly breach every-
day moral codes and expectations, partly because distress is
associated with inequality, disadvantage, discrimination and
prejudice, and partly because the stigma associated with it can
be used to discredit or denounce the actions and pronounce-
ments of individuals. Stories about distress (like all stories, in
fact) are never neutral: they are always told from a point of view,
and that point of view always reflects a set of interests.
We have no definitive solution to these problems. We
certainly cannot claim that the account we give in this book
is somehow neutral, or that it fails to reflect our interests as
academic and clinical psychologists. Instead, we have adopted
two strategies to take account of these problems. First, we will
continually emphasize the importance of all kinds of evidence
when considering, weighing and assessing the claims made Anything that is ‘in the mind’ is also a state of the brain and body
for different explanations of distress. And second, we have
included in this book some of the views and perspectives of
don’t understand it in these dismissive terms because there
people who actually experience distress, so that our profes-
is a clear and visible explanation for its severity. Those who
sional perspectives can be balanced by perspectives from
experience chronic back pain, by contrast, may also fall prey
those who have actually received mental health services.
to such discrimination: having a visible cause for pain – or for
distress – helps.
All in the mind? Third, the experiences of distress that are categorized by
psychiatric diagnoses are, in any case, overwhelmingly psycho-
By rejecting psychiatric disease categories we might appear logical in character. There are no reliable biological markers for
to be denying the reality of people’s distress: if the categories different diagnoses, no blood tests or scans that can be used to
aren’t real, are we saying that the distress isn’t real, either? make diagnoses of depression or schizophrenia. Instead, there
This is not the case. We have not based this book upon are reports – usually verbal – of various kinds of experience:
psychiatric diagnoses because of the extensive evidence unusual beliefs, profound unhappiness, extreme agitation,
regarding their lack of validity, poor reliability, dubious empiri- hearing voices and so on. These experiences may well also have
cal grounding and much-discussed conceptual difficulties (we aspects that are visible in the person’s bearing and manner:
discuss this evidence in much more detail throughout the people who are deeply unhappy, for example, often talk more
book, especially in Chapters 4 and 5). slowly than other people, and sometimes more quietly. They
In place of psychiatric diagnoses, we advocate consistently may have difficulty thinking of words or concentrating on the
psychological explanations, but from a psychological perspec- flow of conversation, and may find it hard to motivate them-
tive, people’s distress is just as ‘real’ as it is from a psychiatric selves. But the existence of these bodily elements does not
one. The pejorative term ‘it’s all in her mind’ is sometimes necessarily mean that there is a physical disease called depres-
used to imply that psychological distress should be something sion, although it does demonstrate, again, that psychological
we can simply overcome by an effort of will. It is a moral states are simultaneously states of the body and brain.
judgement which ultimately implies that only those of weak Fourth, we should always keep in mind that even when
character fall prey to psychological disorders. In this book we people’s own actions seem to be unhelpful and self-defeating,
need to avoid such unjustified moralizing, whilst holding on this does not mean that they are simply responsible for their
to the idea that distress is fundamentally psychological. We own distress. Putting this another way, just because how we
can do so in a number of ways. respond to our distress can make a difference to the outcome,
First, we should recall that nothing is simply ‘all in the this doesn’t mean that individuals should be held personally
mind’. Mind, body and brain are intimately joined together, responsible for failing to respond in what, from an outsider’s
and anything that is ‘in the mind’ is simultaneously a state perspective, is the ‘correct’ manner. In actuality, most people’s
of the body–brain system. The denigration of psychological room to manoeuvre is far more limited than it might at first
distress as being ‘all in the mind’, in other words, relies for its appear, and many simply do not have the resources to deal
force upon the cultural commonplace of mind–body dual- with their situation in ways that are markedly different.
ism. Mind–body dualism – also sometimes called Cartesian Moreover, just like everyone else, when people experiencing
dualism – refers to a tendency, common in Western distress make choices, they always do so with limited knowl-
cultures and associated historically with the philosophy of edge of their consequences: we can know what we do, but
René Descartes, to treat mind and body as distinct, separate cannot so readily know all of the effects of what we do.
substances with no necessary links between them. Far from denying the reality of people’s distress, then,
Second, we should recall that pain, such as that from a psychological explanations begin with this reality and attempt
broken leg, is just as much ‘in the mind’ as distress, but we to understand how it has been constituted. In our view,

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 16 CONCEPTS
PROOF
only the existence of a cultural prejudice against psycho- focus of study will be what occurs inside the brain and body of
logical explanations for distress prevents this from being more someone experiencing distress; other influences will only be
obvious. important to the extent that they make a difference to the body
and brain.
Models also supply a mode of representation – an analogy
Models of distress or set of metaphors that is useful for communication and
conceptualization. In the cognitive model, for example, the
In science, models are often used as an aid to thinking about analogy is that the mind works like a computer, so we conceive
and researching problems. Formal scientific models are of distress as caused by faulty information processing. In this
derived from theories and bear a systematic relationship to way, models also organize events and phenomena into (possi-
them. There are also more ‘informal’ models that are most ble) causal chains. If distress is cognitive and arises because of
accurately located within a paradigm rather than a theory, faulty information processing, the causal chains will implicate
and these are the kind of models typically used in relation psychological mechanisms and strategies (attributions, percep-
to distress. We have already mentioned biopsychosocial, tions etc.); if distress is biological, the causal chains will depend
biomedical and psychosocial models of distress, but in the on biological phenomena such as features of the brain.
literature many more are described. Figure 1.2 shows some of However, these benefits can also become limitations.
the most commonly-cited models of distress, together with Because models are analogies or metaphors for distress, rather
their most frequently used synonyms. than actual distress, they can easily be over-extended. Once
Whilst for convenience we have named these models as we begin to think of distress in terms of (for example) a cogni-
though they were separate and distinct entities, you need to tive model, we might be tempted to keep on thinking of it this
be aware that in actual practice things are far more confusing. way even when we encounter aspects that might be better
For example, it is possible to conceive of the diathesis-stress explained in other ways. For example, although some aspects
model as a variant of the biopsychosocial model, because it of being extremely sad can be conceptualized cognitively (in
attempts to unite biology, in the form of an organic vulnerabil- terms of a set of negative cognitive biases), other aspects are
ity or diathesis, with the psychological and social influences probably better explained by reference to biological or social
that cause stress. processes. This might seem to imply that a biopsychosocial
However, it is equally possible to conceive of the diathesis- model is what is needed, and whilst in a superficial sense this
stress model as a variant of the medical or psychiatric model, is obviously true, in practice most biopsychosocial accounts
because it posits that clinical distress only arises in people who are inadequate (we discuss this issue in Chapter 4, especially
are medically (biologically) vulnerable. Likewise, some family in Box 4.5).
systems models are also psychoanalytic; and many psycho- Another possible disadvantage of using models is that, in
logical models are cognitive as well as behavioural. Similarly, simplifying distress by focusing on what is most relevant from
many people would see the biological model as being the a given perspective, they might actually leave out what is most
same as the medical or psychiatric one, whereas some would important, but we will never know this unless we start from
differentiate these. the actual phenomena (the experience of being distressed, in
Using models to understand distress can yield a number of all of its complexity and confusions) rather than from within
advantages. Models simplify complex issues, making it easier the bounds of a model to which we have already made an
to think about them and to generate ways of researching them intellectual or professional commitment.
empirically. They do this largely by selecting some aspects A final disadvantage is that models of distress can be
of distress as most relevant to enquiry, and others as less misleading with respect to causality because they might imply
relevant: this assists with both theory and empirical research. sets of relations that, in actuality, do not exist. For example,
Using a biological model of distress, for example, the primary a biological model of distress that emphasizes the role of
hormones might give the impression that these hormones
only interact with each other, and lose sight of the fact that
Biomedical (biological) levels of hormones also fluctuate according to external influ-
ences such as social and relationship status.
Medical (psychiatric, illness) There are also deeper conceptual issues with most
commonly used models of distress because for the most part
Diathesis-stress (stress-diathesis, stress-vulnerability)
they accept boundaries that we might wish to question. For
Behavioural example, biological and social influences tend to be either
kept apart or – when they are brought together – mediated by
Cognitive psychology. Whilst there is some sense in this, it then makes it
Humanistic (existential) very difficult to consider situations where biological and social
influences might interact directly, without necessarily being
Psychodynamic (psychoanalytic) psychologically mediated, such as in the development of an
embryo in the womb, or in the very early days of a human
Family systems
infant’s life.
Psychosocial (sociocultural) Throughout this book we will sometimes have to make
reference to models of distress, and you can use the table in
Biopsychosocial this section to orient yourself toward them. However, whilst
they can be useful, you should always bear in mind that they
Figure 1.2 Models of distress can also be misleading.

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 PROOF FROM DISORDER TO EXPERIENCE 17

Overview of this book diagnosis is not valid and reliable enough to provide a firm
scientific basis for understanding distress. It then sketches an
This book is in two parts. The first part provides a foundation alternative, consistently psychological approach to classifying
for the second by systematically setting out key concepts, distress.
debates and evidence. The aim of the first part is to supply a Causal Influences: In some instances, the causes of a
detailed account of distress that describes its character, identi- person’s distress might seem quite obvious; in others, they
fies causal influences, and discusses responses to it. In the may seem mysterious or obscure. This chapter provides a
second part, we apply this account of distress to a subset of the detailed discussion of the notion of causality in relation to
most common kinds of mental health problems encountered distress, showing how it is often more difficult to ascertain and
by professionals in clinical psychology, psychiatry, social work understand than we imagine. We describe and evaluate the
and related disciplines. research methods used to establish causality in distress, and
then review evidence showing that – regardless of the specific
form that distress takes –it is associated time and again with a
Part 1
common set of causal influences.
This part contains eight chapters which, read together, provide Service Users and Survivors: Mental health service users
a consistently psychological account of distress. Although we sometimes describe themselves as experts by experience. This
frequently discuss psychiatric diagnoses in this part, we do chapter draws upon some of that expertise and describes how
not use them as explanations. Instead, we offer explanations the service user movement in the UK has mounted a series of
that draw upon psychological theories and concepts, supple- challenges to the treatments offered by services. A discussion
mented where appropriate with evidence and ideas from of the work of the ‘Hearing Voices Network’ shows how serv-
disciplines including neuroscience, anthropology, sociology, ice users are continuing to challenge conventional services
epidemiology and other relevant disciplines. In this way we by organizing themselves to provide viable alternatives to
provide an account of distress that avoids ‘jumping ship’ and conventional therapies.
uncritically importing wholesale a set of concepts and theories Interventions: Here we describe the kinds of interventions
from psychiatry. Part 1 has eight chapters: for distress typically offered by Western mental health services.
We describe psychiatric medication, psychotherapy, and
Introduction (this chapter)
community psychology interventions, using these to show
History
how each offers different potential sources of help to people
Culture
experiencing distress. A number of different mental health
Biology
professionals are involved in offering interventions to people
Diagnosis and Formulation
in distress – in the appendix to the book we describe some of
Causal Influences
the key professional groups and the kinds of settings within
Service Users and Survivors
which they work.
Interventions

History: To understand why we have the ideas we do today it

Part 2
is vital to look at how those ideas were developed, so in this
chapter we provide a survey of the different ways that distress Part two of the book contains five chapters. In each one
has been understood and treated over the centuries. Our we discuss in detail one of the major kinds of distress that
history shows how there have always been competing strands contemporary Western mental health services encounter.
of explanation and treatment for distress, some primarily We had to make some difficult choices about how we should
implicating the body and its organs and some primarily impli- present this material. On the one hand, we did not want to
cating experiences, meanings, thoughts and feelings. organize the material around psychiatric diagnoses. On the
Culture: This chapter describes how distress differs between other hand, we knew that many mental health modules are
cultures. It discusses some of the great variability in the forms structured in this way. This meant that we needed to present
of distress, the variability in the ways that it gets linked to other our material in a way that was useful to as many people as
aspects of experience, and the variability in the outcomes possible.
associated with it. As we have already suggested, distress is We have done this by structuring these chapters around
thoroughly bound up with culture, and this chapter illustrates broad forms of distress where there is some commonality in
the extent and consequences of this. the underlying phenomenology of an experience. In psychol-
Biology: Our approach to biology treats it as an inescapable ogy, phenomenology refers to exactly what an experience is
part of distress, but does not make the unfounded psychiatric like – what kinds of characteristics, features and subjective
assumption that it is always the ultimate cause of people’s qualities it has. Reflecting some of its links with philosophy
difficulties. In this chapter we explain why there are problems (phenomenology is also an important branch of philosophy),
with biopsychosocial accounts of distress, and in their place this usually means that efforts are made to include the bodily
offer an alternative view of the role of biology. We summarize or embodied aspects of experience, as well as those usually
evidence that supports our approach, drawing upon studies described as mental or cognitive.
of attachment as well as upon recent work in psychology and What does this look like in practice? Well, for example, it
neuroscience. means that Chapter 9, ‘Sadness and Worry’, deliberately treats
Diagnosis and Formulation: Textbooks of ‘abnormal together aspects of experience that are usually treated sepa-
psychology’ are usually organized around systems of psychi- rately in books organized according to the DSM classification.
atric diagnosis, such as one of the versions of the DSM. In other books, these experiences are likely to be addressed
This chapter presents some of the evidence that psychiatric in two separate chapters, one focused upon ‘Depression’ and

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 18 CONCEPTS
PROOF
the other focused upon ‘Anxiety Disorders’. Similarly, Chapter will get a lot more out of reading all of them if you first read the
11 on ‘Madness’ includes experiences that, in other textbooks, chapters in Part 1.
would be addressed separately in relation to psychiatric diag-
noses such as schizophrenia and bipolar disorder. Questions
Although the number of different kinds of distress we
Each of the chapters has a set of questions associated with it.
discuss in this way is fairly small, they will account for the vast
You can use these questions to check your own learning and
majority of the referrals received by UK mental health services.
make sure that you understand the material in the book in the
The chapters are
way that we intend. There are guiding questions at the start of
Sadness and Worry each chapter that will alert you to recurrent themes to keep in
Sexuality and Gender mind as you read. There are also summary or revision ques-
Madness tions at the end, which you can use to check that your learning
Distressed Bodies and Eating is proceeding adequately.
Disordered Personalities

Each of these five chapters is structured in a similar way, and Boxes

each one builds upon the concepts and evidence laid out in All through the book we use boxes to introduce additional
Part 1 of the book. Within each of these chapters there are material alongside the main text. Some of the boxes simply
sections on history and culture, a summary of the psychiatric contain material that, although linked to the main text, is easier
diagnoses typically given to people experiencing this form of to explain separately. Other boxes contain discussions of key
distress, a review of the evidence regarding causality, and a theories, concepts or issues which will recur throughout the
description of the kinds of treatments and interventions avail- book.
able for this kind of distress.
Key terms and concepts
How to use this book You have probably already noticed that whenever we use
any specialist terms or language for the first time, the term is
Sequence printed in bold and a definition or explanation appears very
close by – mostly immediately afterwards, occasionally just
Because most ‘abnormal psychology’ textbooks are structured beforehand.
around the diagnostic categories of the DSM, they often do not
make a sequential, structured argument. This means that it is
Stories and experiences
usually quite easy to dip into them, regardless of the order of
the chapters, in order to read about specific diagnoses. Almost all of the chapters in this book start with a story about
This book is a little different. In Part 1, especially, all of the someone’s experience. As we have already explained, these
chapters are linked so that together they provide a systematic stories are all fictional but, at the same time, they are informed
argument that explains our approach to distress. The chapters by clinical practice and by close readings of the mental health
in Part 2 are more like the chapters in other textbooks, in that literature. You can read them as a very quick and accessible
it does not especially matter in which order you look at them. way of orienting yourself to the concerns and issues that each
However, whilst these chapters can be read in isolation, you chapter raises.

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