Welcome to Alternatives to the Medical Model!
In the previous topic, you looked at the Medical Model, which views mental illness as a physical illness of the brain that should be treated with biological methods like medication. But what if mental health issues aren't biological diseases at all? What if they stem from our life experiences, how we learn, how we think, or how society treats us?
In this chapter of Component 03: Applied Psychology (Section A: Issues in Mental Health), we explore alternative, non-biological ways to understand and treat psychological distress. Don't worry if this seems challenging at first — we will break down the entire topic into three simple parts:
• Background: Three psychological explanations of mental illness (Behaviourist, Cognitive, and Psychodynamic).
• Key Research: Thomas Szasz (2011) – The myth of mental illness: 50 years later.
• Application: Non-biological treatments for psychological disorders (such as CBT and Systematic Desensitisation) and their value to society.
Part 1: Background — Psychological Explanations of Mental Illness
Psychologists who reject a purely biological view argue that mental disorders are rooted in psychological processes. The OCR specification focuses on three major approaches:
1. The Behaviourist Explanation
Core Premise: All behaviour is learned through our interactions with the environment (nurture). Maladaptive or abnormal behaviours are acquired in the exact same way as normal behaviours.
The Behaviourist approach explains disorders through three main learning mechanisms:
• Classical Conditioning (Learning through Association): A neutral stimulus becomes paired with an unconditioned stimulus that naturally produces a response. Over time, the neutral stimulus triggers that same response alone. For example, in Watson & Rayner’s classic study on Little Albert, a baby was conditioned to fear a white rat by pairing the rat with a terrifyingly loud noise. This explains how phobias develop.
• Operant Conditioning (Learning through Consequences): Behaviours are shaped by reinforcement and punishment. If a person experiences anxiety in a social setting and leaves immediately, the sudden relief they feel acts as negative reinforcement (the removal of an unpleasant feeling). Because leaving reduces anxiety, the avoidance behaviour is reinforced and repeated, maintaining the anxiety disorder or phobia.
• Social Learning Theory (SLT - Learning through Observation): We observe the behaviours of role models (parents, peers) and imitate them, especially if we see those models being rewarded (vicarious reinforcement). For example, a child who observes a parent reacting with extreme terror to a spider may imitate that fearful behaviour.
2. The Cognitive Explanation
Core Premise: Mental disorders are caused by faulty, irrational, or distorted thought processes, negative schemas, and cognitive biases. It is not the situation itself that causes distress, but how we interpret that situation.
Two essential cognitive models explain conditions like depression:
• Beck’s Negative Triad: Aaron Beck suggested that depressed individuals hold negative core beliefs about three key areas:
1. The Self: "I am completely useless and unlovable."
2. The World / Current Experiences: "Everyone is critical of me and the world is unfair."
3. The Future: "Things will never get better; there is no hope."
These negative automatic thoughts form a continuous cycle that traps the person in a state of low mood.
• Ellis’s ABC Model: Albert Ellis argued that psychological distress occurs through a three-step sequence:
• A (Activating Event): A triggering external situation occurs (e.g., failing a test).
• B (Belief): The person holds an irrational or absolutist belief about the event (e.g., "I must be perfect at everything, or I am a failure").
• C (Consequence): The irrational belief leads to unhealthy emotional and behavioural consequences (e.g., severe feelings of worthlessness, giving up on school).
3. The Psychodynamic Explanation
Core Premise: Mental disorders originate from unconscious psychological conflicts, unresolved developmental issues in early childhood psychosexual stages, and imbalances between the three parts of personality (the id, ego, and superego).
Key psychodynamic mechanisms include:
• Unconscious Conflict & Defence Mechanisms: The ego mediates between the instinctual desires of the id and the moral demands of the superego. When this conflict becomes overwhelming, the ego deploys unconscious defence mechanisms (such as repression, denial, displacement, and projection). If overused or overburdened, these defences lead to neurotic symptoms and mental illness.
• Fixation and Regression: Traumatic experiences or over-gratification/deprivation during childhood psychosexual stages (such as the oral or anal stage) cause an individual to become fixated at that stage or regress to it during adult stress.
• Depression as Anger Turned Inwards: Freud explained that when an individual experiences loss or rejection during the oral stage, they feel unconscious rage toward the lost object/person. Because direct expression of this rage is unacceptable, the ego turns this hostility inward onto the self, resulting in self-blame, self-hatred, and depression.
Key Takeaway for Background:
The Behaviourist approach views mental illness as learned maladaptive behaviour; the Cognitive approach views it as faulty and irrational thinking; and the Psychodynamic approach views it as unresolved unconscious conflict from childhood.
Part 2: Key Research — Thomas Szasz (2011)
Study Overview
• Citation: Szasz, T. (2011). The myth of mental illness: 50 years later. The Psychiatrist, 35(5), 179–182.
• Nature of Study: A theoretical critique / perspective commentary essay (reviewing and reaffirming the provocative arguments first published in his landmark 1960/1961 work, The Myth of Mental Illness).
Core Arguments and Themes of Szasz (2011)
1. Mental Illness is a Metaphor:
Szasz argues that a genuine medical illness or disease requires an identifiable, demonstrable physical lesion, defect, or physiological pathology in the body. While the physical brain can have genuine medical illnesses (such as Alzheimer's disease or neurosyphilis), these are neurological diseases, not "mental illnesses". Calling psychological distress a "mental illness" treats a figure of speech (a metaphor) as a literal physical fact.
2. "Problems in Living" vs. Somatic Disease:
What psychiatry diagnoses as mental illness are not medical diseases, but social, moral, ethical, legal, and personal struggles. Szasz called these problems in living. Life involves suffering, conflict, and difficult adjustments, but labeling these personal challenges as "medical conditions" strips human experience of its moral and social meaning.
3. The Politicisation of Psychiatry and "The Therapeutic State":
Szasz heavily criticises the state-sanctioned legal power granted to psychiatry. When the government and psychiatry combine (creating what he calls the therapeutic state), psychiatry becomes a mechanism of social control to manage non-conformist, inconvenient, or disruptive individuals.
Szasz strongly opposed involuntary commitment (sectioning) and forced psychiatric treatment, arguing that they deprive individuals of basic human dignity, personal responsibility, and constitutional civil liberties.
4. Fifty Years Later (Changes from 1960 to 2010):
In this 2011 review, Szasz observed that over the last 50 years, biological psychiatry had grown even more powerful due to massive funding from the pharmaceutical industry and the expansion of classification systems like the DSM and ICD. He argued that despite sophisticated brain scans and genetic research, modern psychiatry still commits the error of "reification" — treating abstract, metaphorical concepts as if they were concrete physical diseases.
Common Exam Mistakes to Avoid with Szasz (2011)
• Mistake 1: Treating this paper as an empirical experiment.
Correction: Szasz (2011) is an essay / commentary. It does NOT have a sample size, independent/dependent variables, control groups, or numerical/statistical data.
• Mistake 2: Thinking Szasz believed suffering is "made up" or fake.
Correction: Szasz never denied that people experience profound emotional distress, suffering, and disturbed behaviour. He argued that these are real problems in living, but not physical diseases.
Key Takeaway for Szasz (2011):
Szasz argues that mental illness is a medical metaphor used by the "therapeutic state" for social control. True diseases require physical bodily lesions; psychological distress consists of human "problems in living".
Part 3: Application — Non-Biological Treatments
Under Section A, you must be able to describe and evaluate at least one non-biological treatment for a specific mental disorder, directly linking it to its underlying psychological model.
Option A: Cognitive Behavioural Therapy (CBT) for Depression
Underlying Approach: Cognitive approach (Beck and Ellis).
How CBT Works:
CBT focuses on the present and aims to identify, reality-test, and alter irrational thoughts and maladaptive behaviours.
1. Identifying Automatic Negative Thoughts: The therapist and client work collaboratively to identify negative automatic thoughts relating to the self, world, and future (Beck's triad). Clients may keep a thought diary to record situations that trigger feelings of despair.
2. Cognitive Restructuring / Disputing: The therapist challenges irrational core beliefs (Ellis's disputing technique). The client is asked to provide concrete evidence for their beliefs (e.g., "What evidence do you have that nobody likes you?").
3. Behavioural Activation & Homework: Clients are given behavioral assignments to reality-test their assumptions (e.g., joining a social club or going for a daily walk). When the client experiences success and enjoyment, it directly disproves their negative cognitive schemas.
Option B: Systematic Desensitisation (SD) for Specific Phobias
Underlying Approach: Behaviourist approach (Classical conditioning).
How SD Works:
Systematic Desensitisation aims to replace a learned fear response with a state of calm through counterconditioning and reciprocal inhibition (the biological principle that you cannot be relaxed and terrified at the exact same moment).
1. Relaxation Training: The client is taught deep muscle relaxation and breathing techniques.
2. Constructing an Anxiety Hierarchy: The client and therapist create a stepped list of feared situations from least frightening (e.g., looking at a small photo of a spider) to most frightening (e.g., holding a tarantula).
3. Gradual Exposure: The client works up the hierarchy step-by-step, only moving to the next level once they can remain completely calm at the current stage.
Contribution to the Economy and Society
Non-biological psychological treatments provide massive benefits to wider society:
• Economic Productivity: Mental disorders like depression and anxiety lead to high rates of workplace absenteeism and loss of productivity. By equipping individuals with lifelong coping mechanisms, psychological therapies help people return to work and pay taxes.
• Reduced NHS Burden: While psychological therapies have an upfront cost, they teach self-management skills that reduce long-term relapse rates, ultimately lowering the ongoing costs of repeat prescriptions and hospital admissions.
Quick Revision & Memory Aids
Memory Mnemonic for Beck's Negative Triad:
Remember SWiFt: Self, World, Future.
Memory Mnemonic for Ellis's Model:
ABC: Activating event \(\rightarrow\) Belief (irrational) \(\rightarrow\) Consequence (emotional/behavioural distress).
Quick Summary Checklist:
• Behaviourist: Disorders are learned (Classical = association, Operant = reinforcement, SLT = imitation).
• Cognitive: Disorders stem from faulty thinking (Beck's triad, Ellis's ABC).
• Psychodynamic: Disorders stem from unconscious conflicts, defence mechanisms, and childhood psychosexual stages.
• Szasz (2011): Mental illness is a metaphor, not a disease; distress = problems in living; psychiatry acts as social control in the therapeutic state.
• Application: CBT for depression or Systematic Desensitisation for phobias (non-biological therapies that benefit individual wellbeing and economic productivity).