Welcome to Alternatives to the Medical Model
Welcome! In this chapter of Component 03: Applied Psychology (Section A: Issues in Mental Health), we look at how psychology explains and treats mental distress without relying purely on biology. If you have ever wondered whether calling emotional distress an "illness" is the best way to help people, this chapter explores exactly that question.
Don't worry if this seems tricky at first—we will break down the entire topic using OCR's three-part structure:
1. Background: Psychological explanations of mental illness (Behaviourist, Cognitive, and Psychodynamic).
2. Key Research: Thomas Szasz (2011) – "The Myth of Mental Illness: 50 Years Later".
3. Application: Non-biological treatments (CBT/REBT and Behavioural Therapies).
Part 1: Background – Psychological Explanations of Mental Illness
The medical model claims that mental disorders are biological illnesses caused by genes, brain chemistry, or physical damage. However, psychological explanations argue that our thoughts, learning, and early life experiences shape our mental health.
1. The Behaviourist Explanation
Core Idea: Mental disorders are not physical illnesses; they are maladaptive behaviours that have been learned through environmental interactions and conditioning.
Behaviourists explain mental illness using three main learning mechanisms:
• Classical Conditioning (Learning by Association): A neutral stimulus gets paired with an unconditioned stimulus that naturally produces fear or distress. Over time, the neutral stimulus becomes a conditioned stimulus triggering a conditioned response (e.g., developing a phobia of dogs after being bitten).
• Operant Conditioning (Learning by Consequences): Behaviours are shaped by rewards and punishments. For example, in anxiety or phobias, avoiding the feared object brings immediate relief. This relief acts as negative reinforcement (removing an unpleasant feeling), which strengthens the avoidance behaviour. In depression, a lack of positive reinforcement from the environment can maintain social withdrawal.
• Social Learning Theory (SLT - Learning by Observation): People can acquire maladaptive behaviours by observing role models and imitating them, especially if they see the model receive vicarious reinforcement.
2. The Cognitive Explanation
Core Idea: Mental illness is caused by faulty, irrational, or maladaptive cognitive processes and information processing.
Two key cognitive models explain how thinking errors lead to psychological distress:
• Beck's Cognitive Triad: Aaron Beck suggested that depression is maintained by negative automatic thoughts across three key areas:
1. Negative views about the Self ("I am completely useless").
2. Negative views about the World ("Everyone is against me").
3. Negative views about the Future ("Things will never get better").
• Ellis's ABC Model: Albert Ellis argued that it is not an event itself that causes emotional distress, but the irrational belief held about that event:
A = Activating Event (e.g., failing a mock exam).
B = Belief (Rational: "I need to revise more" vs. Irrational: "I am a failure at everything").
C = Consequence (Emotional and behavioural outcome: despair, withdrawal, or proactive revision).
• Cognitive Biases & Distortions: People with disorders often show systematic errors in logic, such as catastrophising (expecting the absolute worst outcome), overgeneralisation (drawing a sweeping negative conclusion from a single event), and all-or-nothing thinking (seeing things in black-and-white terms).
3. Alternative Explanation: The Psychodynamic Approach
Core Idea: Mental illness stems from unconscious conflicts between the personality structures (the Id, Ego, and Superego), unresolved early childhood psychosexual conflicts, and the overuse of maladaptive ego defence mechanisms.
Memory Aid for Explanations
• Behaviourist = Behaviours learned from environment.
• Cognitive = Conscious thoughts and irrational beliefs.
• Psychodynamic = Past childhood and unconscious conflicts.
Key Takeaway for Background
Psychological models view mental illness as rooted in learning (Behaviourist), faulty thinking (Cognitive), or unconscious conflicts (Psychodynamic), offering direct alternatives to physical/biological explanations.
---Part 2: Key Research – Szasz (2011)
Study Details
• Author & Year: Thomas S. Szasz (2011).
• Article Title: "The Myth of Mental Illness: 50 Years Later".
• Publication: The Psychiatrist (Bulletin of the Royal College of Psychiatrists).
• Nature of Study: An essay/critique and theoretical review revisiting his original 1960/1961 landmark paper.
Core Arguments & Findings
1. Mental Illness as a Metaphor ("Problems in Living")
Szasz argues that a real physical illness requires identifiable physiological, anatomical, or biochemical lesions/pathologies in the body or brain. Because mental disorders lack these physical lesions, calling them "illnesses" is simply a metaphor. What psychiatry labels as mental illness are actually "problems in living", moral dilemmas, personal difficulties, and social conflicts.
2. Psychiatry as a Pseudoscience
Szasz states that psychiatry miscategorises social, ethical, and behavioural deviance as medical pathology. Crucially, he points out that if an underlying biological or physical cause is ever found for a psychiatric symptom, it ceases to be a mental illness and becomes an established neurological disease (such as neurosyphilis).
3. The Pharmacological and Economic Shift (1960 vs. 2011)
Szasz reflects on how the mental health system changed over 50 years:
• In 1960, coercive power was visible in state mental hospitals where patients were physically locked away (institutionalised).
• By 2011, institutionalisation had largely been replaced by outpatient medicalisation, driven by pharmaceutical companies and state-mandated psychiatric medication.
4. Legal and Social Control
Szasz argues that mental illness is primarily a legal concept rather than a medical fact. Psychiatry acts as an arm of the state to control socially unacceptable behaviour, depriving individuals of their liberty, moral accountability, and criminal responsibility under the guise of "medical care".
5. Human Rights and Personal Responsibility
Szasz advocates that individuals diagnosed with mental illness should be treated as moral agents with full free will, personal responsibility, and autonomy. They should have the right to self-determination—including the right to refuse involuntary detention and psychiatric treatment.
Important Exam Pitfalls to Avoid!
• Mistake 1: Writing that Szasz believed people do not experience suffering. Correction: Szasz fully acknowledged human emotional pain; he objected to medicalising that distress as a bodily disease.
• Mistake 2: Describing Szasz (2011) as an experiment. Correction: There were no participants, IVs, DVs, or lab controls. It is a theoretical essay/review.
• Mistake 3: Confusing Szasz with other Section A studies. Keep them distinct:
- Rosenhan (1973): Validity and reliability of diagnosis (pseudo-patients).
- Gottesman et al. (2010): Medical model genetics study.
- Szasz (2011): Critique of the medical model (anti-psychiatry essay).
Key Takeaway for Szasz (2011)
Szasz argued that mental illness is a metaphor for "problems in living" used as a tool for social control, and that patients should be granted full human rights and moral responsibility rather than forced medical treatment.
---Part 3: Application – Non-Biological Treatments
Candidates must be able to describe and evaluate at least one psychological, non-biological therapy applied to a specific disorder.
Option A: Cognitive Behavioural Therapy (CBT) & REBT for Depression
• Underlying Theory: Grounded in Beck's and Ellis's cognitive models—changing irrational thinking patterns leads to changes in emotions and behaviours.
• Key Procedures:
1. Identifying Irrational Thoughts: The therapist and client work collaboratively to identify automatic negative thoughts and cognitive distortions using thought diaries.
2. Empirical Disputing: The therapist challenges irrational beliefs by asking for objective evidence (e.g., "Where is the proof that nobody likes you?").
3. Behavioural Activation: The client is encouraged to schedule positive, rewarding, or mastery activities (e.g., going for a walk, completing a task) to break the cycle of withdrawal and depression.
4. Homework Tasks: Clients test their negative beliefs in real life as "behavioural experiments".
Option B: Systematic Desensitisation for Specific Phobias
• Underlying Theory: Grounded in classical conditioning. Uses counter-conditioning to replace the conditioned fear response with a relaxation response, based on reciprocal inhibition (the idea that one cannot be relaxed and afraid at the same time).
• Key Procedures:
1. Relaxation Training: The client learns deep breathing and progressive muscle relaxation techniques.
2. Anxiety Hierarchy: The client and therapist construct a stepped list of feared situations from least frightening (e.g., looking at a picture of a spider) to most frightening (e.g., holding a spider).
3. Gradual Exposure: The client works through the hierarchy step-by-step (either in vivo/real-life or in vitro/imagination), practicing relaxation at each stage until anxiety is extinguished.
Key Takeaway for Application
Non-biological therapies directly target the psychological mechanisms of disorders—CBT targets irrational thought schemas in depression, while Systematic Desensitisation breaks conditioned fear responses in phobias.
---Part 4: Linking to Core OCR Debates
In Section A extended-response questions, you must evaluate psychological explanations, Szasz, and therapies against key psychological debates:
• Reductionism vs Holism:
- Psychological explanations (e.g., SLT, Psychodynamic) are generally more holistic than the medical model because they consider social contexts, past relationships, and thought processes.
- However, pure Behaviourism can be seen as reductionist because it reduces complex human emotions down to basic stimulus-response associations.
• Determinism vs Free Will:
- Szasz strongly advocates for Free Will: he argues individuals have personal agency and moral accountability.
- The medical model and behaviourist models are deterministic, viewing individuals as passive victims of their biology or conditioning.
• Individual vs Situational:
- Cognitive theories focus on the individual (faulty internal schemas).
- Behavioural theories and Szasz highlight situational factors (environmental conditioning, family dynamics, and social/economic conflicts).
• Psychology as a Science:
- Behaviourist learning mechanisms and systematic desensitisation can be empirically and objectively tested in lab settings.
- Szasz's theoretical essay is philosophical and qualitative, challenging whether psychiatry should claim to be a hard natural science.
Quick Revision Checklist
✔ Can you describe the Behaviourist (conditioning) and Cognitive (Beck/Ellis) models of mental illness?
✔ Can you explain why Szasz refers to mental illness as a "metaphor" and "problems in living"?
✔ Do you know the 50-year shift Szasz identified (institutionalisation to pharmacological control)?
✔ Can you outline the step-by-step procedure of CBT or Systematic Desensitisation?
✔ Can you evaluate Szasz and psychological alternatives using the Free Will vs Determinism debate?