Diagnosis special issue - Part 6

Don't jump ship!
New approaches in teaching mental health to undergraduates

We hope that the articles in this special issue have convinced you of the need to move beyond diagnosis. Peter Campbell and Rufus May have outlined some alternative approaches in practice with service users; in this final article our emphasis is on another good place to start in effecting change, namely our students.
Mental health teaching on undergraduate psychology courses is often structured according to psychiatric diagnoses and categorisations (Cromby et al., 2007). Here, we question the value of this approach to teaching and propose an alternative to the tendency for psychology educators to 'jump ship' by giving psychiatric rather than consistently psychological explanations of mental distress. We discuss recent theoretical and empirical advances within psychology; review some of the policy developments which might bear upon mental health teaching; and offer pointers to a range of resources which teachers might find helpful.

Psychiatric assumptions

The relationship between psychiatry and psychology is often presented in overly simplistic ways in existing texts on 'abnormal psychology'. The assumption tends to be that the biological precedes the psychological, despite some acknowledgement of an interaction.

However, researchers have found strong associations between ethnicity, gender, social class, sexual abuse and many forms of distress (Johnstone, 2000; Rogers & Pilgrim, 2003; Tew, 2005), which suggests that the brain–body is an open system that cannot be comprehensively understood outside of its social context. Psychiatric diagnoses ignore such research in favour of the individualisation of distress, forcing it into categories of dubious validity, and then implicitly associating it with underlying biomedical pathologies (Bentall, 2004; Boyle, 2002).

Despite these shortcomings, it seems that many psychology educators import psychiatric assumptions. Indeed, the very notion of an 'abnormal psychology' implies that the psychology of mental health requires a leaving behind of the principles and theories of 'normal' psychology. 

New theoretical perspectives

Thankfully, some British psychologists from a broadly critical tradition have offered both a resounding critique of the dominant paradigm and some possible ways forward (Bentall, 2004; Boyle, 2002; Johnstone, 2000; Newnes et al., 2001; Pilgrim, 2000). And many have noted the need to broaden the scope of enquiry to examine the instances of unusual experiences and psychological distress in the 'normal' population, rather than confining the investigation to individuals who have already received a psychiatric diagnosis. Here we will highlight some additional conceptual resources which those involved in teaching about mental health may find useful.

Community psychology

Community psychology (Nelson & Prilleltensky, 2005) offers a means both of investigating the social context of mental health problems and of offering interventions at a community level. The UK Community Psychology website contains some very useful material including links to community psychology centres around the UK and worldwide.

Social perspectives

Workers in this tradition (e.g. Sayce, 2000; Tew, 2005) try to counter the individualising emphasis of traditional approaches. The recovery model – promoting more hopeful views of mental health problems – has also been influential (Turner-Crowson & Wallcraft, 2002). Recently the Social Perspectives Network (www.spn.org.uk) has been founded by academics, practitioners and service users in order to develop research and promote the incorporation of social perspectives within modern mental health services.

Post-structuralism and social constructionism

Traditionally, psychologists have, quite rightly, argued that a psychiatric concept should be evaluated within its own paradigmatic assumptions (i.e. whether it meets realist standards like reliability and validity). However, some professionals and academics have drawn on alternative frameworks to examine those very assumptions – to ask questions about how we come to view mental health experiences in the way we have and to consider whether there are alternatives (Parker et al., 1995). There are now exciting and innovative conceptualisations of experiences like hearing voices (Blackman, 2001), 'delusions' (Harper, 2004) and difficulties related to sexual abuse (Reavey & Warner, 2003). Psychiatrists interested in these ideas have set up the Critical Psychiatry Network (www.critpsynet.freeuk.com) and have argued for the need to move towards a 'post-psychiatry' paradigm (Bracken & Thomas, 2005).

Experimental cognitive psychology and cognitive behaviour therapy

Those working in the tradition of experimental cognitive psychology have noted how individuals with mental health problems do not necessarily have a deficit in thinking, rather a bias (Bentall, 2004). The origins of mental health problems, even ones as 'severe' as the psychoses, can thus be located in normal cognitive processes (as Richard Bentall's article in this issue demonstrates). Cognitive-behavioural approaches attempt to understand the individual's active attempt to make sense of the experience (e.g. perceptual bias, misattribution, shallow processing) in order to understand the cognitive and emotive processes driving it (e.g. protection of self-esteem, defence against negative evaluation).

Neuroscience

Aspects of contemporary neuroscience (e.g. Damasio, 1994) emphasise how the brain–body system is functionally open to experience and its effects, such that toxic life experiences can become quite literally embodied to create forms of distress. Damasio's work has been invoked to explain the phenomena addressed by diagnoses such as depression (Cromby, 2004).

Mental health policy and legislation

The last 10 years have seen a number of changes in the delivery of mental health services. The Department of Health has published National Service Frameworks for different specialties (DoH, 1999; see weblinks), which set new standards for services and highlighted examples of good practice. It has also identified 'ten essential shared capabilities' for the whole of the mental health workforce (DoH, 2004). The National Institute for Mental Health has been set up to support new developments in mental health practice.

Mental health services are now organised into multidisciplinary teams, such as community mental health teams, which, in the main, include clinical psychologists. There has also been a much greater awareness of the efficacy of psychological therapies based on recent reviews of treatment studies (DoH, 2001; National Institute for Clinical Excellence, 2002). In its 2000 NHS Plan, the government announced that mental health was one of its three priorities, with a corresponding investment of £300 million in mental health services; to finance, amongst other things, the creation of a new workforce of 1000 graduate mental health workers. It was hoped that the vast majority would be psychology graduates.

Two more recent developments are New Ways of Working, which aims to reshape the practice of psychologists and other professionals, and a joint project to improve access to psychological therapies. However, the recent cuts in NHS budgets may limit the extent to which these policies bring real change.

Finally, government reforms to the 1983 Mental Health Act, currently going through Parliament, are likely to bring changes: possibly broadening the definition of mental disorder; extending compulsory treatment into the community; and allowing some psychologists to have compulsory powers. These proposals have raised a number of concerns within psychology both from professional and service user viewpoints (see News, The Psychologist, January 2007).

Mental health professionals have had to adapt to these and other recent policy initiatives and more recent introductions to clinical psychology (e.g. Cheshire & Pilgrim, 2004) and new psychology of mental health texts (Bentall et al., in press) reflect this.

Useful teaching resources

In terms of general starting points, the Mental Health in Higher Education project (MHHE) aims to facilitate the sharing of ideas and approaches to learning and teaching about mental health across the disciplines in UK Higher Education (Anderson, 2003). The project is a partnership between four subject centres of the Higher Education Academy, including the Psychology Network (see weblinks) which has funded recent research on mental health teaching in undergraduate psychology (Cromby et al., in press). Good practice guidance on user and carer involvement in mental health education and training has been produced in partnership with others (Tew et al., 2004). The project plans regional events for mental health educators, and additions to its collection of case studies of learning and teaching are always welcome (several relating to mental health teaching in undergraduate psychology are available on the website).
Another general resource is Psychosis Revisited (Basset et al., 2003), a teaching pack based on the British Psychological Society report (DCP, 2000). Although primarily designed for mental health workers, it has been successfully used with undergraduates and clinical psychology trainees – the MHHE website includes an example of its use by Mark Hayward at the University of Surrey.
Mental Health Media produce and supply some excellent videos including Myths about Madness (which addresses stereotypes about mental health), Being on a Section (which explores the effect of being treated compulsorily) and the BBC's Horizon documentary about hearing voices. Paradogs (www.pinkpink.demon.co.uk/paradogs.html) has produced Those Who Are Jesus, a video exploring the perspective of those diagnosed with 'delusions'. Mind's online shop (www.mind.org.uk) is an excellent resource for books and videos including an informative video about the Mental Health Bill and Evolving Minds (a video exploring the links between psychosis and spiritual experiences).

Other websites such as www.psychminded.co.uk and www.thepsychologist.org.uk provide good coverage of news and features, and Radio 4's All in the Mind has some interesting programmes, with a listen-again option on its website. Organisations like Mind, the Sainsbury Centre for Mental Health and the Mental Health Foundation all have their own websites listing materials and publications.

Of course, educators should not discount the value of the personal experiences of others. Mind Out for Mental Health's website (www.mindout.net) includes personal accounts of distress as well as links and materials useful in countering negative stereotypes. The US-based MindFreedom website (www.mindfreedom.org) is a useful resource for those wanting to know more about the mental health survivor's perspective on theory and practice as is the UK-based Asylum magazine (www.asylumonline.net). Chipmunka specialises in publishing small books written by service users (www.chipmunkapublishing.com). In addition, the American psychologist Gail Hornstein has assembled a very useful and comprehensive bibliography (tinyurl.com/2lw24f).

A time for change

In this article we have argued for the need to move the undergraduate teaching of 'abnormal psychology' and mental health away from a narrow diagnosis-based approach and, instead, to consider the implications of recent developments in theory and practice. Rather than simply 'jump ship' and adopt a psychiatric mode of explanation, we feel there is now a need to steer a new course and to move towards a consistently psychological account of mental health problems.

- Dave Harper is in the School of Psychology, University of East London. E-mail: [email protected].
- John Cromby is in the Department of Human Sciences, Loughborough University.
- Paula Reavey is in the Department of Psychology, London South Bank University.
- Anne Cooke is at Salomons: Canterbury Christchurch University.
- Jill Anderson is at Mental Health in Higher Education, Department of Applied Social Science, Lancaster University.

Weblinks
Mental Health in Higher Education: www.mhhe.heacademy.ac.uk
Community psychology in higher education: http://mysite.wanadoo-members.co.uk/cphe/
Department of Health mental health section: http://tinyurl.com/aq6jp
Guardian Society special report on mental health: http://tinyurl.com/6yuvb
Higher Education Academy Psychology Network: www.psychology.heacademy.ac.uk
International Centre for the Study of Psychiatry & Psychology: www.icspp.org

Discuss and debate

What are some of the barriers to bringing change in teaching about the psychology of mental health? How might these be overcome?
What might be the elements of a consistently psychological approach to teaching about mental health?
How might users of mental health services and their carers become more fully involved in teaching?
Have your say on these or other issues this article raises. E-mail 'Letters' on [email protected] or contribute to our forum via www.thepsychologist.org.uk.

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