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COMMONWEALTH OF AUSTRALIA Copyright Regulations 1969 WARNING This material has been copied and communicated to you by or on behalf of Flinders University, persuant to Part VB of the Copyright Act 1968 (the Act). The material in this. communication may be subject to copyright under the Act. Any further copying ox communication of this material by you may be the subject of copyright protection under the Act Do not rewiove this notice Introduc | Who are you? How have you come to be who you are? = What influences how you think, feel and act? Are your = personality and behaviour determined by your genetic | make-up and biological events, by your thoughts and _ feelings, by your experiences in the world or by an | interrelationship between some or all of these? Why | are some people seemingly more vulnerable to mental “illness, while others are resilient despite adversity? Most of us, at one time or another, have asked these questions. Through attempting to understand why humans behave as they do, a further question arises: ‘Are personality and human behaviour determined by genetics and biology (nature) or are they shaped by our upbringing, experiences and environmental factors (nurture)? This question has long engaged the "interest and passion of philosophers, healers and health professionals and, in more recent times, scientists. Investigation of these questions has resulted in various | theories being proposed to explain normal and abnormal "behaviour, and mental health and mental illness. This chapter examines these concepts, the theories that tempt to explain them and therapeutic interventions | Alcrived from the theories, It also explores the nature | versus nurture debate, What is mental health? ‘A succinct, universally applicable definition of mental ealth has long been elusive. Even though contemporary lefinitions address the breadth of factors that contribute fo mental health, they are subjective and not easily measured, The critique about the vague nature of lefinitions of mental health is longstanding. In the 980s, Doona suggested that the problem of defining ‘mental health was derived from the fact that the concept _of mental health is not a measurable scientific term, She concluded: ‘health is probably a value judgement ind more amenable to philosophical analysis’ (Doona |. 1982). Her view about the subjective nature of defining “Mental health remains pertinent today. For example, the definition developed by participants at the 2008, international conference of the World Federation for | Mental Health in Melbourne reads: ‘Mental health is a | State of complete physical, mental, spiritual and social _ Wellbeing in which each person is able to realise one's | abilities, can cope with the normal stresses of life, and | Jake a unique contribution to the coramunity’ (World __ federation for Mental Health 2008). It is interesting to __ hote that while the Third Australian Mental Health Plan included a definition of mental health in its glossary ‘Australian Health Ministers 2003, p 5), the fourth plan does not. It does, however, include definitions for ‘mental ‘cath problem, ‘mental health services’ and ‘mental _ illness’ (Commonwealth of Australia 2009, p 84). CBAPTER 8 + BEYOND THEORY: UNDERSTANDING MENTAL HEALTH AND ILLNESS 123 Historical definitions of mental health Barly attempts to understand human behaviour focused more on psychopathology than mental wellness. Demon possession is mentioned in the early writings of the Chinese, the Egyptians, the Hebrews and the Greeks to explain unusual behaviour and it continued to be the predominant explanation for abnormal behaviour until the Middle Ages (Maud & Warelow 2011). However, in Europe, it was not until the léth century that abnormal behaviour was considered to be an illness and asylums were built to house people considered to be insane. From the 19th century in Europe, the USA, the UK and its colonies biomedical explanations dominated and abnormal behaviour was considered to be a disease. Such views led (o humanitarian reform, underpinned by the notion that people living with a mental illness ate as deserving of care as the physically ill (Butcher et al 2011), Contemporary approaches to defining mental health were first proposed in the latter half of the 20th century alongside worldwide mental health reforms, Early definitions focused on the individual's ability to respond to external factors. Kittleson (1989) cited four major components: (1) high self-esteem; (2) effective decision making; (3) values awareness; and (4) expressive communication skills. Kittleson’s depiction of mental health as a positive construct separate from mental illness was welcome but limited. It was welcome because it enabled mental health to be viewed as more than merely the absence of the symptoms of mental illness. However, it was limited because a focus on individual factors implies individual responsibility, which may lead to victim blaming (McMurray 2007; Talbot & Verrinder 2010), Furthermore, definition in terms of the individual failed to acknowledge the contribution of social, political and environmental factors to mental health, In Australia in the 1990s, Raphael (1993) drew attention to contextual and social issues that affect mental health—namely, workplace factors, education macroeconomic forces and other forces. These social forces are acknowledged as contributors to. mental health, as are personal qualities such as resilience, coping, physical health and wellbeing (Raphael 1993). More recent definitions of mental health include social determinants such as social connectedness, acceptance of diversity, freedom from discrimination, and economic participation (VicFfealth 2006), Seligman's research has identified five measurable attributes, which he calls, pillars, that contribute to both physical and mental wellbeing. These are: + positive emotion: to experience love, hope, jay ete + engagement: to be connected to community and society through work, family etc + relationships: to experience close emotional and supportive ties + meaning: to have a purpose in life, and for one’s life to have meaning 124 PARTZ + MENTAL HEALTH AND WELLNESS + accomplishments: to have achieved tangible goals (Seligman 2004, 2011). ‘The emergence of a definition of mental health that encompasses positive constructs, not just the absence of symptoms, is important because it enables mental health and mentalillnessto be viewed as distinct from each other, and not as two points at opposite ends of a continuum. Significantly, it means that the two states are not mutually exclusive—a position advocated by the recovery model ‘A person can enjoy mental health regardless of whether or not they are diagnosed with a mental illness if they have a positive sense of self, personal and social support with which to respond to life's challenges, meaningful relationships with others, access to employment and recteational activities, sufficient financial resources and suitable living arrangements. Recovery: mental health despite mental illness In the latter part of the 20th century mental health services in developed countries underwent major reform (Prince et al 2007). The recovery model emerged at this time and it is now the cornerstone of the reform (Rickwood 2006; Ministry of Health New Zealand 2005; Victorian Government 2009). The recovery model is a person-centred approach to service delivery underpinned by the principles of social justice and equity, which challenges the biomedical approach of focusing mainly on symptom identification and treatment (see Ch 2 for more discussion of the recovery paradigm), Facilitating mental health, minimising the impact of mental illness and managing the symptoms of mental illness are the goals of the recovery-informed approach. New Zealand consumers have identified the following as requisites for recovery: having personal power; maintaining hope and optimism; staying connected with extended family and community; and access to supportive services (Mental Health Commission New Zealand 2004). In the context of mental health reform, the language of recovery is now widely used in mental health policy, services and research—yet the interpretation of the concept varies, particularly between services and service users (Ramon et al 2007). Slade (2009) suggests that this arises from confusion between clinical recovery, which means the relief of symptoms, and personal recovery, which Anthony (1993, p 14) defines as:‘a deeply personal, unique process of changing one’sattitudes, values, feelings, goals, skills, and/or roles. It is a way of living a satisfying, hopeful, and contributing life even within the limitations caused by illness. Recovery involves the development of new meaning and purpose in one’ life as one grows beyond the catastrophic effects of mental illness.” ‘Mental health’ as a euphemism for ‘mental illness’ Health professionals and the health literature have adopted thepracticeof usingtheterms ‘mental health’and “mental illness’ interchangeably over the past 100 years. In 1989 Kittleson drew attention to this phenomenon following an examination of undergraduate mental health texts. He found that ‘personality development and emotional illness make up the bull of mental health, coverage in the texts’ (1989, p 40), A recent search of contemporary mental health literature found that this, practice is still prevalent in texts and journals (Edwards etal 2011; Meadows et al 2007; Muir-Cochrane et al 2010; Pilgram 2009; and journals such as the International Journal of Mental Health Nursing and Issues in Mental Health Nursing). Although these publications include ‘mental health’ in their titles, in the main they contain chapters or articles concerning assessment of, and treatments for, mental illness or mental health problems, ‘The substitution of the term ‘mental health’ when refersing to ‘mentalillness isa 20th-century phenomenon, that has been carried forward into the new millennium, The first references to ‘mental health’ being used as an alternative to ‘psychiatry’ occurred in the UK and the USA from the 1920s. Momentum was gained after World War Il, when proponents such as Caplan (1964) advocated a shift from treatment of mental illness to prevention, In the USA, Szasz (1961) argued that mental illness was a societal ill and not an individual sickness. Amid this debate, legislators worldwide changed the term ‘mental illness’ to ‘mental health’ in the names of legislation. However, this change is nominal because the content of worldwide policy and legislation continues to be concerned with mental illness (Ministry of Health New Zealand 2005; New South Wales Government 2007). The South Australian Mental Health Act 2009, for example, identifies its purpose as ‘to make provision for the treatment, care and rehabilitation of persons with serious mental illness with the goal of bringing about their recovery as far as is possible’ (South Australian ‘Government 2009), Despite the title of the Act, it contains no reference to mental health as a positive concept, nor does it expand on what recovery might mean, Following legislative name changes, organisations that provided treatment and rehabilitation services to individuals with mental illness also changed their names, replacing words like ‘psychiatric and ‘mental illness/disorder’ with ‘mental the emergence of organisations with titles like ‘Southern Area Mental Health Service’, Nevertheless, despite the change of name there has been little shift in the focus of the services provided, as they continue to address the needs of people living with illness, with minimal focus ‘on mental health. This is not to suggest that mental illness treatment services should not be provided; clearly there is a demonstrated need for them and they are not under scrutiny here, Rather, the assertion is that to call ‘them mental health services is a misnomer. A further consequence of using the euphemism ‘mentalhealth’ when referring tomental illness is that this CHAPTER@ © BEYOND THEORY: UNDERSTANDING MENTAL HEALTH AND ILLNESS 125 practice may in fact be contributing to the perpetuation of stigma. Implicit in the avoidance of the term ‘mental illness’ is the notion that mental illness is something to be avoided, hidden or shameful. Ironically, calling mental illness by another name has not reduced stigma; instead, _ithas broadened the application of stigma to now include ‘mental health, CRITICAL THINKING CHALLENGE 8.1 + Whatwords would you use ta describe mental health? + How do you know when you are mentally healthy? Reflect on a time when you consider your mantal health was good. Make alist of the factors that facilitated this good mental health or you. Make alist of negative words used to describe mental illness and consider the impact of these words on people living with a mental illness. Then think ofa more positive wird or term to use for each negative ‘word on your ist + How does mental health differ from mental iiness? _ Theories of personality Personality can be defined as the unique set of cognitive, affective and behavioural characteristics that influence how an individual thinks, feels and acts. Various explanations of personality have been proposed by _ philosophers and psychologists as well as by biomedical _ andsocial scientists. In seekingto understand personality, “theorists have been driven not only by curiosity and “philosophical enquiry, but also to identify factors that "in‘luence both normal and abnormal behaviour. This has _ snabled the development of theories to explain resilience, _ mental health and illness, and also to identify strategies _ f0 prevent or treat mental illness, Explanations of personality can be broadly divided "into three paradigms: _ + biomedical or biological/physical models psychological models, including psychoanalytic, __ behavioural, cognitive and humanistic approaches “4 sociological models. __ Within these paradigms the following are the major Yiewpoints to offer a theory of personality development 0r an explanation of human behaviour: + Biomedical model: proposes that behaviour is influenced by physiology, with normal behaviour ‘occurring when the body is in a state of equilibrium and abnormal behaviour being a consequence of physical pathology. ++ Peychoanalytic theory: asserts that behaviour is riven by unconscious processes and influenced by childhood /developmental conflicts that have either been resolved or remain unresolved, Behavioural psychology: presents the view that behaviour is influenced by factors external to the individual. Bchaviours are learned, depending on whether they are rewarded or not, by association with another event or by imitation, Cognitive psychology: acknowledges the role of perception and thoughts about oneself, one’s individual experience and the environment in influencing behaviour, + Humanistic psychology: focuses on the development of a concept of self and the striving of the individual to achieve personal goals. + Sociological theories: shift the emphasis from the individual to the broader social forces that influence people. This model challenges the notion of individual. pathology. Each of these seemingly disparate perspectives makes a substantial contribution to the understanding of how and ‘hy humans think, feel and act as they do, and thereby identifies opportunities for the prevention and treatment, ofmental illness, Nevertheless, asa comprehensive theary of human behaviour, each also has major shoricomings and no one theory can explain all human behaviour in all circumstances. Let us now look at these theories in more detail. Biomedical model ‘Also known as psychobiology or the neuroscience perspective, the biomedical model asserts that normal behaviourisaconsequence of equilibrium within the body and that abnormal behaviour results from pathological bodily or brain function. This is not a new notion—in the 4th century nc the Greek physician Hippocrates attributed mental disorder to brain pathology. His ideas were overshadowed, however, when throughout the Dark ‘Ages, and later during the Renaissance, thinking and explanations shifted to witchcraft or demonic possession (Butcher etal 2011; Kring etal 2010). In the 19th century, a return to biophysical explanations accompanied the emergence of the public health movernent. In recent times, advances in technology have led to increased understanding of organic determinants of behaviour. Research and treatment have focused on four main areas: + Nervous system disorders, in particular neurotransmitter disturbance at the synaptic gap between neurons. More than 50 neurotransmitter have been identified, four of which are implicated in mental illness. These are acetylcholine (Alzheimer's disease), dopamine (schizophrenia), noradrenaline (mood disorder) and serotonin (mood disorder). + Structural changes to the brain, for example following trauma or in degenerative disorders such as Huntington's disease.

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