The disease (medical) model Vs The positive psychology model – do we need a revolution in mental health? 

For more than a century, psychology has emulated the medical model – maintaining the position that psychological problems are like medical disorders, with specific underlying pathologies that first need to be diagnosed and then treated by specific healing techniques that remedy deficits. Client improvement in treatment, according to this medical model, develops as a result of the application of psychological theories and techniques that help the client to understand his or her problem and its antecedents. This approach often involves the use of specialised skills associated with medical practice such as psychosocial history-taking, mental-status exams, differential diagnosis, and treatment planning.

The popularity of the medical model of healing emotional problems and mental illness is reflected by the fact that the largest-selling professional mental health publication of all time is the Diagnostic and Statistical Manual (DSM), published by the American Psychiatric Association. According to one survey, 70 per cent of workshops and seminars for mental health providers were focused on treatment according to DSM classifications (figure reported at a Duncan and Miller seminar, 2001).

Despite the popularity of this classification system, the DSM approach remains controversial. Here is what some critics have to say about it:

Psychiatric diagnosis represents a flawed extension of the medical model. Diagnosis is empirically bereft of both reliability and validity. It is worthless in terms of treatment planning and engenders harmful attributions by the labelled individual, his or her family, and the helping professionals. Finally, diagnosis changes like the tide, depending on the prevailing currents of politics and the gravitational pull of the marketplace. Diagnosis, however, persists. (Duncan & Miller, 2000, pp. 53–4)

Psychotropic Medications

Reliance on psychotropic medication is central to the medical model. Medication is often the first and only intervention that patients receive. The notion that depression and anxiety are primarily a result of bio chemical imbalances in the brain, is according to an increasing number of critics, an unsubstantiated view enhanced by pharmaceutical advertising. The belief that there are chemical solutions to our psychological and social problems and that taking a pill a day keeps the depression (or anxiety state) away, is according to these critics, misguided and possibly a public disservice.

Further support for the above assertions is found in an investigation in the famous Treatment of Depression Collaborative Research program (McKay, Imel, & Wampold, 2006). Clients who received sugar pills from the top third most-effective psychiatrists achieved better outcomes than clients prescribed antidepressants from the bottom, least effective psychiatrists. How to explain this? In a clever investigation that conducted minute-by-minute analysis of therapist–client interaction, Glassman and Grawe (2006) found that unsuccessful therapists focused on problems and neglected client strengths, while successful therapists focused on their clients’ strengths from the start.

Critics of the medical model are also supported by consistent empirical research findings that the most important factors contributing to effective counselling and psychotherapy are not medication, technique, or therapist, but are rather the client’s contribution and the quality of the client–therapist relationship. These two (common) factors account for 70 per cent of client improvement (e.g., Duncan et al., 2009; Hubble et al., 1999; Wampold, 2001).

If these findings are correct – that the healing force comes primarily from within the client and not from the therapeutic approach or the effects of medication – “then the whole of the medical model of assuming the necessity of different treatments for different disorders falls apart” (Bohart & Tallman, 1999, p. 11).

The Positive Psychology Movement – The study of psychological development using positive perspectives began about a half-century ago. 

Psychologist Donald Clifton was so deeply affected by the horrific effects of negative social engineering on American POWs in the Korean War that he began investigating whether positive reinforcement could be as effective in promoting the reverse – psychological well-being. His views are elegantly addressed in his last book, How Full Is Your Bucket? The book is organised around a simple metaphor of a dipper and a bucket, but is grounded in 50 years of research (Rath & Clifton, 2003). Clifton’s pioneering work on strength-based approaches was recognised in 2002 by the American Psychological Association, which cited him as the “Grandfather of Positive Psychology” and the “Father of Strength Psychology.” In the same year, Clifton was diagnosed with terminal cancer and completed this final book (co-authored with his grandson, Tom Rath) only a week before he died. Dr Martin Seligman, a distinguished psychologist and past president of the American Psychological Association, along with others, formally named this field “positive psychology” in 1998. Dr Seligman argues that psychology’s forgotten mission is to build human strength. He explains this new direction in psychology as follows:

Psychology is not just the study of weakness and damage; it is also the study of strength and virtue. Treatment is not just fixing what is broken, it is nurturing what is best within ourselves. (Seligman, 1998, p. 2)

He goes on to contend that the major psychological theories have changed to herald a new science of strength and resilience (Seligman, 2011). This new science, however, is at odds with the predominant problem-based helping model.

This idea of building buffering strengths as a curative move simply does not fit into a framework that believes each patient has a specific disorder, with a specific underlying pathology that will be relieved by a specific healing technique that remedies deficits. (Seligman, 2002, p. 23)

The development of positive psychology represents one of the most significant challenges to the medical model: it offers an alternative to the predominant emphasis on deficits and pathology (Seligman, 2011). Positive psychology is beginning to have profound impacts on our understanding of human flourishing, including wellness and longevity. Interest in this new field is spreading beyond academia.

The Broaden-and-Build Theory of Positive Emotions

The importance of this “new science of strength and resilience” is illustrated by the research findings of Barbara Fredrickson of the University of Michigan. The American Psychologist published her ground-breaking study, “Positive Affect and the Complex Dynamics of Human Flourishing” (Fredrickson & Losada, 2005). Fredrickson has been studying human emotions for more than a decade. Although we have known for some time that people who are more positive in their outlook live longer and are happier, Fredrickson was interested in determining exactly how positive thinking and the experience of pleasant feelings contribute to happiness and longevity. Fredrickson has developed the “broaden- and-build” theory of positive emotions.

For many years, positive emotions were considered merely fleeting experiences with little evolutionary value for human survival other than temporary distraction. The study of negative emotions (e.g., anger, fear, sadness), by contrast, has attracted most of the research interest over the last half-century due to the apparent link to human survival.

Negative emotions were self-preserving for our ancestors as they prepared the body for specific action, such as fighting or flight. These actions have distinctive physiological autonomic activity associated with them. Studies have consistently found that stress and negative emotion, especially if prolonged and recurrent, can promote or exacerbate cardiovascular illness and other diseases. This helps explain psychology’s focus on negative emotions.

Fredrickson’s broaden-and-build theory asserts that positive emotions (e.g., joy, amusement, serenity, love) are also highly evolved psychological adaptations that increased our human ancestors’ odds of survival and reproduction. The experience of positive emotion widens the array of thoughts and actions called forth (e.g., exploring and playing) and promotes cognitive and behavioural flexibility. A broadened mindset, the result of experiencing positive emotions, carries indirect and long-term adaptive value because broadening builds personal resources, such as social connections, coping strategies, and environmental knowledge. These important assets, in turn, produce well-being and enhance future health. Also of importance is the fact that positive emotions quell the autonomic arousal caused by negative emotions because they broaden attention, thinking, and behavioural repertoire.

Because the broaden-and-build effects of positive affect accumulate and compound over time, indicate that positivity can transform individuals for the better, making them healthier, more socially integrated, knowledgeable, effective, and resilient. (Fredrickson & Losada, 2005, p. 679)

To sum up, the benefits of positive affect (pleasant feelings and sentiments) are as follows:

  • It widens scope of attention.
  • It broadens behavioural repertoires.
  • It increases intuition and creativity.
  • It increases immune system functioning.
  • In general, it promotes health and longevity.

Critical Positivity Ratio for Human Flourishing.

Fredrickson and Losada (2005) argue that evidence from several independent studies shows that flourishing mental health within the general population and within marriages and business groups was associated with positivity ratios of above 2.9:1.

Positivity ratio is defined as the ratio of positive to negative expressions of affect. The authors make the point that a high number of positive sentiments appear to be needed to overcome the “toxicity” of negative affect and to promote flourishing. With a non-clinical population, for example, flourishing mental health was measured by having subjects report the extent to which they felt any of several positive or negative emotions over a period of 28 days. The positive emotions were amusement, awe, compassion, contentment, gratitude, hope, interest, joy, love, pride, and sexual desire.

The negative emotions were anger, contempt, disgust, embarrassment, fear, guilt, sadness, and shame. The subjects who scored the highest on various psychological tests – who had flourishing mental health – had mean positivity ratios above 2.9:1; those with optimal functioning had a ratio above 4:1. Subjects with normal or average functioning had positivity ratios of around 2.5:1. (Subjects with poor mental health had been screened out of this study.)

A study of clinically depressed patients revealed a positivity ratio of 0.5:1 before treatment. After treatment, those who had the most improvement (determined by clinical ratings and self-assessments) had mean positivity ratios of 4.3:1.

Among those who showed average improvement or no improvement, the ratios were 2.3:1 and 0.7:1, respectively.

Regarding positivity ratios in marriage, reports on two decades of research by Gottman and Krokoff (1989) show that flourishing marriages had positivity ratios of at least 5:1, and unions identified as being headed for dissolution, languishing marriages at best-  had mean positivity ratios of less than 1:1. With regards to positivity ratios in groups, Losada (1999) studied 60 management teams as they discussed their annual strategic business plans.

From behind one-way mirrors, the researchers coded each of the speakers’ utterances as being either positive (showing support, encouragement, or appreciation), or negative (showing disapproval, sarcasm, or cynicism). Those teams that had the highest positivity ratios were from organisations that showed uniformly high performance across three indicators: profitability, customer satisfaction, and employee evaluations by superiors, peers, and subordinates. Again the 2.9:1 ratio divided the teams whose performance was the highest – flourishing business teams – from those whose performance was languishing. The authors point out that the 2.9:1 ratio may seem absurdly precise, but that this bifurcation point is a mathematically derived construct that separates flourishing from languishing behaviour with remarkable consistency.

Can we become too positive? 

The evidence that the authors present shows that indeed there is an upper limit of “effective” positivity. When positivity ratios exceed 11:1 there is a disintegration of the complex dynamics of flourishing. It may be suggested that when the number of positive statements is very high, the statements are not reality-based, and thus are seen as insincere and artificial. In summing up their ground- breaking positive psychology research, Fredrickson and Losada (2005) state:

These data suggest that at three levels of analysis – for individuals, marriages, and business teams – flourishing is associated with positivity ratios above 2.9. Likewise, for individuals, marriages, and business teams that do not function so well – those that might be identified as languishing – positivity ratios fall below 2.9. (p. 684)

How the Broaden-and-Build Theory Supports Strength-Based Psychology

It follows from the broaden-and-build theory that enhancing positive emotions promotes well-being. The questions used by strength-based interviewers are directed at helping clients identify their personal strengths and resources. This process results in client empowerment that in turn enhances positive emotions. The evidence is persuasive that increasing positive emotions and experiences in our lives is likely to increase our happiness, well-being, health, and longevity.

psychcorner webinar with Prof Peter Kinderman – Do we need a revolution in mental health?

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