Critical Introduction to Clinical Psychology

Question 1

what is clinical psychology?

Answer 1

• Clinical psychologists deal with a wide range of mental and physical problems including addiction, anxiety, depression, learning difficulties and relationship issues (issues that impact a persons ability to function in every day life)
  
  • They may undertake a clinical assessment to investigate a clients situation
    ○ Work of a clinical psychologist includes formulation, assessment and diagnosis through interviews, observations and psychometric tests
    ○ This leads to referrals, advice, counselling or therapy
  • They are not involved in the prescription of drugs instead they look at the person in context and their wider needs for support
  • Clinical psychologists work largely in health and social care settings including hospitals, health centres, community mental health teams, CAMHS and social service’s
    They often work as part of a team with other health professionals to make sure plans are constantly reviewed for patients

Question 2

importance of terminology

Answer 2

• There are many terms for mental health problems, and most terms are linked to different perspectives on mental health problems
  
  • As a discipline we need to avoid over labelling individuals with mental health problems and understand how ti makes them feel and how it affects our responses to them
  • The language is part of the system- need a way of diagnosing people so they can receive the right treatment (need to call it something)
  • The problem comes when you imply that someone is ‘sick’ or diseased- evokes an organic basis like a physical illness but this does not apply to mental health all the time
    ○ This is the legacy of a predominantly biomedical approach- tend to move away from words such as mental illness due to this
  • Terms like mental health problem scope the problem better because it is less contentious and suggests that these symptoms come and go- no permeance
  • Weakness of these words:
    ○ Not a fair representation as a lot of what we experience is co-morbid and includes physical symptoms
    ○ Assumes that people will always be like this and there is no getting better (implies permeance and becomes part of their identity when it is not a true reflection of their character)
  • Similar debates exist around the terminology to describe those who experience mental distress
  • These terms depersonalise the experience for people with mental health problems- personalisation agenda is needed
  • Gone back to viewing individuals as passive recipients of predominantly medical treatment- times when some individuals need to be on a hospital ward but more often than not they live a normal life
  • Term ‘clients’ in the psychotherapy world is used when people pay- they have more agency and the treatment is active not passive.
    ○ This does not define them by their mental health, instead they are just accessing treatment
    ○ This is tended to be used more in academic publications
  • Recipients are when they have no active choice in treatment e.g. being sectioned
    Psychiatric system survivors- advocacy groups who call themselves this when they have experience side effects from medication

Question 3

why does language matter?

Answer 3

• Government regularly undertake population surveys- for depression the results are positive but it is not the same for schizophrenia
  
  • Mental distress is associated with stigma and discrimination in social and personal settings
  • Negative stereotypes associated with mental distress
    ○ Lots of ambivalence around mental health when dealing with it at a superficial level e.g. brief encounters however when these interactions deepen people are more reluctant
  • Low employment rates
  • At increased risk for verbal abuse, physical harassment and victimisation
  • Subject to negative media portrayals
    E.g. people with mental health problems are more likely to commit crime (violent crime and schizophrenia) but this is just a fallacy

Question 4

understand and criticise definitions of abnormality

Answer 4

• Mental distress refers to the ‘experiences associated with diagnostic categories ad with the work of professions such as clinical psychology, psychiatry, social work and nursing’ (Cromby et al)
  
  • No clear cut dichotomy between people who are well and unwell
    Should not focus on calling it abnormal- realise people will experience this and focus on when it becomes problematic

Question 5

medical definition of abnormality

Answer 5

• Something that makes your health and wellbeing worse
  
  • Many things should not be classified as abnormal e.g. depression and grieving can be very protective
  • Depression can be normal e.g. some people view it as a heightened state of realism
  • This provokes questions such as how much depression is too much- usually define by when it gets too much for someone to cope with
  • Depression is a very normal response to stressful situations
  • Everyone will experience a bereavement in one point of their life- depression is a normal reaction to this
  • Complicated grief is diagnosable within the DSM
  • Persistent complex bereavement disorder (PCBD)
    ○ The patient experienced the death of a loved one at least 6 months previously
    ○ At least one of the following symptoms has been present longer than expected taking into account the persons social or cultural environment
    ○
    ○ Some of the requirements for the diagnosis- should not be a disorder as it is a natural process
    ○ Drawing on what is a very normal and adaptive healthy response- over medicalised something that is normal and claimed it is abnormal
    ○ At least two of the following have been recorder for at least one month:
    ○
    ○ Symptoms cause substantial distress for the sufferer or impact significantly on areas of functioning and cannot be attributed to other causes
    Medical definitions of abnormality even within our own diagnostic manuals are problems

Question 6

statistical definition of abnormality

Answer 6

• Something that is unusual within the population
  
  • However mental health problems are not unusual- many people experience a DSM-defined disorder at least once during their lifetime (Kessler et al., 2005)
  • Moffit et al (2010)
    ○ Prospective study (looking at people through time) in a large cohort of New Zealand ppts (N=1037)
    ○ Measured diagnoses of anxiety, depression, alcohol and cannabis dependence
    ○ Compared to national surveys
    ○ Study yielded 2x higher prevalence rates for all DSM diagnoses compared to national surveys
    Cannot define abnormality through mental health because when we look at the figures we are defining normality

Question 7

social definitions of abnormality

Answer 7

• Something is disapproved in specific times and places (it needs to be changed)
  
  • Organise ourselves through a social construct
  • Ideas about what constitutes mental distress are always influenced by cultural and social norms
    ○ Varies across time and place
    ○ Relates to broader sociological variables, such as socioeconomic status, gender and ethnicity
  • Every psychologist has their own ideas about what are normal or abnormal behaviours
  • These ideas reflect views on human nature and social order inculcated by our social, economic, educational and religious backgrounds
    Our westernised understanding over medicalises and we do not have a good enough understanding of other cultures to understand what normality is globally e.g. sometimes socially acceptable to hear voices vs us diagnosing it as schizophrenia

Question 8

Our psychology is WEIRD

Answer 8

• Most psychological research is based on participants from WEIRD societies (Henrich et al., 2010)
  ○ Western
  ○ Educated
  ○ Industrialised
  ○ Rich
  ○ Democratic
  
  • Not representative of the population in general
  • Limits our understanding of adverse experiences and mental distress because we have not looked in the appropriate way
  • Individualistic orientation:
    ○ The discipline still largely sees the behaviour of abstract individuals as the response to a given environment
    ○ Conceptualises causes of mental distress within an individual rather than outside forces
  • Some diagnostic categories may be more related to social issues than mental disorders
    ○ Leslie Camhi (1993) argued that the diagnosis of kleptomania originated in parallel with the invention of large department stores
    ○ Lower class women who stole- thieves
    ○ Higher class women who stole- mentally ill
    Notions of mental health are socially and temporally dependent

Question 9

biomedical model

Answer 9

• A model is a theory or heuristic for understanding and explaining something
  
  • Useful to help direct research but can be limiting
  • What defines a model is what they are focussing in on what they see as being the sole cause for that phenomena- use viewpoint and research to back this up
  • Within mental health there are a number of models
    Biomedical model suggests that genetics, hormones, brain, neurotransmitters as the sole cause of depression
  • Position paper approach in this journal
  • Starts with the position of Applebaum- strong biomedical function and promoted biomedical model as the causal model for mental illness
    ○ Pharmaceutical companies also sponsored these events
  • View that brains are biological organs so everything has a biological basis in the brain- should be able to give someone a drug in the same way you do with an infection and the problems of mental distress will be alleviated
    ○ However this does not stand up to empirical tests
    Focus purely on biology so very reductive

Question 10

chemical imbalance theory

Answer 10

• Mental disorders are caused by an imbalance of neurotransmitters in the brain
  ○ Important cultural uses
  ○ Reduces uncertainty about the cause of mental distress
  
  • No evidence to say this is the mechanism through which mental illness is caused
  • It has overpromised and underdelivered
  • Short, routinised and cheap mental health treatments (drugs) are often limited to superficial improvements, but they are a quicker and cheaper solution than in depth longer term therapy
  • This relates to the growing intrusion of drug companies in the field of mental health
    ○ Promotion of psychotropic medication
    ○ Research funding
    ○ Selective reporting on research results
  • Growth in drug companies in relation to mental health- very little incentive to change the drug basis as they fund research
  • Global annual sales forecast of drugs for psychiatric indications 2020-2025
  • Expensive effort to market products
    ○ Leads to over optimistic expectations
    ○ Encourages taking medication for minor difficulties
    ○ Promotes the idea that most psychological problems are caused by brain or bodily malfunctions
    ○ Discourage from investing time and effort in psychotherapy
    More diagnoses being out in the DSM- by having more diagnostic categories more people will be on these drugs as there is no other answer

Question 11

understand differences between categorical and dimensional models for mental distress

Answer 11

• Categorical models for metal distress assume that there is an objective difference between mental health (abnormal experiences) and mental illness (abnormal experiences)
  
  • Mental illness is seen as a separate category from mental health- diagnostic categories can be reliably identified by trained professionals
  • Typically based on diagnostic manuals which outline criteria for mental illness
  • Promised there would be science to support it but they have never provided it- created a system that is hard to get away from the chemical basis of mental health
    ○ Has not found the causes/mechanisms related to depression
  • Some people say the diagnosis alleviates stress as it can give them access to services and help
  • Lack of ethics- focussed on the desires of pharmaceutical companies not the individuals
  • Have different ways of diagnosing mental health and the DSM is used in Western societies- have a categorical approach but assumes abnormal and normal do not overlap which can be problematic
  • Most Western mental health professionals classify and diagnose disorders using the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), a publication by the APA
  • DSM consists of 3 major components
    ○ Diagnostic classification
    ○ Diagnostic criteria sets
    ○ Descriptive text
    The categorical system seems quite objective- gives the illusion of the medical sciences where you can find more biological evidence for causal mechanisms

Question 12

categorical model

Answer 12

• Diagnostic manuals take a disease perspective which captures abnormalities within categories
  
  • Benefits for clinical practice and research:
    ○ Permits the accumulation and synthesis of knowledge and experience
    ○ Provides professionals with a common language (lingua franca)
  • Reflects the social prejudices of the predominantly white, male persons responsible for its writing and update
  • Influenced by the pharmaceutical industry:
    ○ Emphasis on biological and heritable aspects
    ○ Psychiatric conditions defined by a list of symptoms that mimic the style of biomedical diagnostic categories and even in the terms (disease, symptom, patient, syndrome, relapse etc)
  • The growing number of diagnostic categories reflects that more and more behaviours formerly regarded as eccentricities, sins, crimes, or ordinary life worries are being regarded as diseases or conditions
  • Move to a dimensional perspective- focusses on vulnerabilities
    ○ This will take something like hearing voices as an experience and looks at how much it varies
    Many practicing clinical psychologists use a dimensional model alongside the ICD