A strategy for mental health policy and the process theory of psychology

By Dr Graham R. Little PhD AFNZIM

November 2002

© 2002 Graham Little: This paper as with all others at this site is copyright, but parts may be copied and reproduced consistent with review and discussion provided recognition given the author of the ideas.

Note: this paper is not intended as a stand alone paper and must be read in conjunction with the other papers at this site, in particular Psychological theory and its impact on mental health policy, and Definitions of insanity and mental illness and the impossibility of temporary insanity.

Contents

Background *
The issues *
First two type of malfunction as arising from theory *
The third type of malfunction arising from the theory *
The process theory of psychology *
Definition of mental health *
Skills and understanding *
Emergent strategy for mental health policy *
Managing mental ill health *
The management model *
Developing greater mental health *
Issues in developing community mental health as emergent from process theory *

Background

In the earlier paper Psychological theory and its impact on mental health policy I began discussion of several issues in the conceptual landscape surrounding mental health, insanity and social policy, for example:

Can someone insane be mentally healthy? What precisely is the relationship between mental health and general personality disorders including insanity?
How can we build a prescription for mental health not depending on the absence of mental ill health as the base of the definition?
Does the paradox of composition have a place in determining social strategy for mental health? Is sympathy and understanding adequate at the policy and social strategy level? Or do we need tougher, clearer models of social effectiveness at the social strategy and policy level?
If we build a definition of mental health, how does it relate and fit within the model of psychology that has been developed? (Why we do what we do: the outline of a general theory of psychology.)

I will not aim to respond to all these issues in this paper, and will only focus on three.

The issues

The three issues the focus of this paper are summarized as follows.

What is mental health, and when we use the term to what do we refer, or to what should we refer?
How does the definition relate to the theory developed and so relate to definitions of insanity, personality disorder and mental illness?
From the backdrop of the definitions and understanding, and from within the theory, what should a Government be aiming to do to build the best possible mental health within its society?

There are many subsidiary issues within each of these broader questions. For example, if the definition of mental health we develop does not fit popular usage and understanding, what should be done about that? If we develop a focused mental health policy that does not include dealing with mental ill health, which should get priority for funding and how do we decide? Where do we draw the line, or where should Government draw the line between funding mental health and encouraging certain norms and values as a way of life? Can we in fact build mental health understanding and social policies and strategies that are non-partisan, non-political and non-cultural?

First two types of malfunction as arising from theory

Mental illness is the most direct and most simple definition that arises from the theory; mental illness is precisely failure of the mechanisms that underlie our psychology, so mental illness is solely neurological and damage to neurological systems; and with inclusion of damage, a person mentally impaired as result of an accident falls within the broader definition of mentally ill, in exactly the same way someone with a broken leg from an accident is ‘ill and needing hospitalized’.

Mental illness relates to the failure in the ‘normal’ functioning of the mechanism, with the other type of functioning relating to the values taken by the variables in the theory, so that insanity then becomes the exhibition of values of the variables that fall outside the range of ‘acceptable’ by the society. Someone defined as insane is typically a danger to themselves or to others in the society. I do not intend to explore further here issues surrounding insanity, personality disorders and counseling, and will leave that to a forthcoming paper, but I must point out that the definition based simply on the values of variables is not quite sufficient for insanity and for personality disorders, since there is another important aspect to the living reality of the theory, and it is to that I now turn.

The third type of malfunction arising from the theory

In preparing earlier papers, and in earlier thinking about mental illness, and other forms of mental disorder and maladaptive conduct, the first two ways the system could malfunction were immediately evident, that is the mechanism could fail, or the values of the variables could fall outside the range of that acceptable to the society, so mental illness and insanity/disorders would seem to be defined directly from the theory and in part they are.

The third way in which the theory could malfunction is somewhat subtler, less immediately obvious, and is best understood by example. Imagine a person with a quality to their mental sets that tended to make the sets inflexible. Now imagine the person in a situation that changes requiring them to adapt different roles and actions, they are slow to make the transition to the new mental sets and new habits and reactions arising from the role necessary in the situation, as a result their behavior is not ‘at ease’ not quite appropriate, in sufficiently severe cases the person would be described as having a ‘personality disorder’, but not one arising from mechanisms or values to the variables which could both be within the range ‘normal’. Imagine another person who rather than make slow transitions, made the transition in rapid jumps, so they exhibit one role and reaction at one point, then suddenly are in some other quite different state. Both of these examples could arise by a lack of skill and understanding at the nature of roles and nature of self so that the person allowed or did not allow new and more relevant mental sets to emerge as appropriate.

In yet another example the person does not understand the fallibility of their own attitudes, that is they think that because it arises in them and feels right it is right, with the level of this potential problem being only at one extreme end of the normal, then combine this with weak self management skills, so that when inappropriate attitudes arise the person is not certain that they are wrong and is poorly equipped to deal with them even if they do think they are wrong.

Elsewhere I have discussed these self-management skills (Nouskills: skills of the mind), referring to them as nouskills. In effect nouskills are the means of managing the processes of the model, they describe managing knowledge, emotions, reactions, habits, and relating all these to outside situations. They also describe how we do or do not deal with inner tensions, stress, and our ability to calm ourselves as needed by social and relationship circumstances.

The first two ways in which the system could malfunction describe static malfunction, mechanisms and values of the variables, the third manner of malfunctions describes how the theory in action, the very movement among parts of the structure that describe a person can itself malfunction, and the theory also proposes that the skills of translation of one state – one set of mental sets in operation – to another state with a second set of mental sets in operation is significantly learned and can be improved by developing in the person better nouskills appropriate to their circumstances. At the point where nouskills are not learned, where they are genetic, effectively begins to describe the ‘hard wiring’ of the brain and nervous system. But sufficient is now understood of the immense plasticity of the brain and nervous system, that where in fact a person has inadequate natural development of ‘smooth flow and function’ then they can be taught nouskills that will and can impress upon the plasticity of the system to good effect to improve the ‘flow and functioning’.

Consider a third example, one combining both inadequate skills at self management with mental sets that are extreme, for much of the life the person got by, merely showing occasional slight signs of instability and extreme behavior, then in some circumstance, the two factors collided into causal thrust that resulted in the person exhibiting behavior not previously exhibited, say extreme violence. The extreme mental set can be said to be ‘insane’, but the person is not, for they know better, and have generally been able to restrain themselves, except for the one occasion when extreme emotions combined with extreme response from the extreme mental set combined with poor self management skills, and perhaps only moderate desire to moderate themselves resulting in the unleashing of extreme behavior..

There is an important proviso to the above comments that is the person must understand what a nouskill is and how it can and will help them, and must be to some degree committed to helping themselves. Without the backdrop of self-help, merely offering nouskills as ‘knowledge’ to be learned as one might learn history will not help the person. Nouskills are to be lived, and need to be part of and seen to be part of the tools of effect living.

The process theory of psychology

It is from these considerations that the name emerges for the theory of psychology I have developed, I call it the ‘process theory of psychology’, because the living dynamic of it is ‘process’, flow, movement and transitions from one inner state to another. The management of the transitions, the management of the inner processes whereby our very existence comes to be and is exhibited to the world outside of us is likely something important to us, and is the very essence of what is intended to be conveyed by the term nouskills which are the conceptualized techniques for better managing our inner transitions, states and processes.

Definition of mental health

A prescriptive definition of mental health implies a manner of functioning of the psychological processes within the person, so that the following applies in a mentally healthy person.

Integration: There is an integrated quality to their thoughts and attitudes giving rise to a consistency in their reactions across various situations.

The person has no extreme mental sets, with the overall pattern of their psychic structure exhibiting an integrated quality, with a balanced relationship between attitudes and reactions in one mental set as compared to another.

Nouskills will enable the identification of extremes and the developing of self-statements, self-arguments and attitudes that moderate the extremes and provide the balance.

Poise: Within the functioning of a person’s life there are no great swings of mood, emotion or attitude that are not related to events of significance to them.

Follows in part from effective integration, and further supported by nouskills that enable self-management of states and development of a calmer demeanor when under stress and pressure of circumstance. Also indicative of integration, with no extreme mental sets.

Transitions: There is an ease of transition from one role to the next.

They have the skills to shift from one role to another, to allow transitions between mental sets that do not exhibit marked breaks of conduct.

The first, and most important issue is that these factors traverse a fine line between values of the variables, and value independent aspects of the system. For example, a complete lack of integration and poise is an appropriate state, but not one likely to result in harmonious social circumstances. Normative decisions are an integral aspect of social policy on mental health, insanity is normative, hence the degree of normative determination here is slight when compared to other normative aspects, but it is there, for example, the choice of balance and poise are choices of one set of values of the variables, when others could have been chosen, and this set of choices does represent a set of human values. (Note that in adopting such a set of choices challenge and protest are not excluded, nor is conformity encouraged, the factors of conformity and protest involve more of the selection of values of variables, not transitions between states a consequence of those values.).

If ‘person in their environment’ describes a complete system then ‘mental sets’ describes sub systems of that system, with the three factors of integration, poise and transitions describing how one subsystem relates and translates to others. It is this focus on ‘movement and relationships’ that encouraged adoption of the term ‘process theory of psychology’.Essentially, such a view of mental health states ‘if you use nouskills to seek greater integration of your thoughts and attitudes, develop greater poise as a result, use the skills to enable smoother and easier transitions between roles and mental sets, and if you finally seek to be at peace with yourself and how you conduct yourself, then you will live a more satisfying life for you, and this regardless of the goals/values you might set for yourself’ (so the drug czar killer can be as content and mentally healthy as the vigorous, really normal and nice neighbor next door).

The full theory does not distinguish between integration and poise and total lack of integration and absolutely no poise they are both legitimate when we choose one over the other, then we insert norms and values into the situation, but from within the chosen set of parameters, then a Government can offer tools to enhance the mental health of normal people and those who are insane (in that an insane person can be mentally healthy and can improve upon their mental health in the sense of living more effectively according to the goals and values important to them, this despite those values being outside the society in which they live). A Government is then adopting the broadest based philosophy and strategy available.¹

Skills and understanding

Seldom do skills exist without necessary understanding and judgment. Developing nouskills in the areas as outlined above will involve necessary understanding of the theory behind the application of the skills. The knowledge to support the nouskills must answer questions like: why do I have different sorts of thoughts? Where do my thoughts come from? Why is it I act this way one day and a different way another day in same sort of situation? How do I manage my thoughts, why should I? How I feel is how I feel, it is me? At another level, the theory must also settle the issue of ‘who?’ Who is running me? Who is in charge? Can I help myself? What is I and what is my spirit?

The theory does point to the Thought as core determinant of human behavior, and Thought in a person arises from at least in part the society and culture of the person. But equally, the theory stresses multiplicity and choice of mental sets allowed, mental sets are not causal and not necessarily emergent, they are allowed, or colluded with in their emergence. Causality of our conduct rests with us as individuals, society laid in us the core framework of Thought, but the very multitude of mental sets within any adult precludes the essential causal nature of any one, without active involvement of the deciding ‘I’.
Without strong theoretical and explanatory backdrop these questions will overpower application not so rooted in theory and explanation resulting in no improvements.
Emergent strategy for mental health policy

From within the theory there are immediately two crucial aspects to any mental health policy.

Management and reduction of mental ill health in the community.

Development of greater mental health in the community.

There are enormous differences between these two elements.

One is seeking to reduce a problem; the other is seeking to enhance better quality of life.

For one the targets are known to authorities and can be identified as people, for the other, the target is not so identifiable and likely applies to everyone.

For one, with identifiable targets for funding, and for particular management of people, ethics of care, compassion and concern backed by objectivity are valid, doing much for a small number of people. For the other, it is a mass campaign, no particular individual targets identified, the aim is to improve everyone a little bit.

It should be apparent that in any circumstances which fails to differentiate between these two elements, then funding will be wasted, and effort, no matter how well intentioned will be less effective than it otherwise could be.The two elements do interact, in that if the second is done well, it could have a positive impact on reducing the first. But likely efforts to develop greater social mental health will be slow, and will need to be truly strategic and long term since social attitudes and philosophies of psychology and self and self control form such a potent aspect of the issue.

Managing mental ill health

Management of mental illness, insanity and serious personality disorders has been and is the current main focus of ‘mental health policy’. No attempt is made here to review or provide a comprehensive assessment of these services as they currently exist, sufficient to note that it is an area of general health that is currently a struggle for many nations their being much debate in New Zealand, and evidence of uncertainty and debate in the United States with the establishment and brief for the Presidents New Freedom Commission on Mental Health (www.MentalHealthCommission.gov). I suggest that part of the problem, if not a significant part is due the divisive and fractious nature of understanding in psychology, cause and the etiology of human activity.

The following are notes and observations of the situation from within the framework of the process theory of psychology.

Technological issues: There are three technical issues of considerable significance.

Causal identification: The theory distinguishes between malfunction due mechanisms and those due values of variables and processes. The problem is that all underlying causal circumstances could generate the same or very similar symptoms. At stake is clear identification of cause and intervention, and as yet there is no non-invasive system or technology to enable differentiation between different etiologies.

Prediction: There have been in New Zealand a number of very high profile cases where people have been discharged from care and committed serious criminal offences including murder days after being released. In one case, the father of one person who killed his mother pleaded with authorities not to release the young man. I suspect that the issue of adequate prediction of likely future conduct remains weak in many if not most countries. The theory states that full and total prediction of future conduct is in principle not possible, generally because of the dynamic, interactive and plastic nature of the system (a person in their environment), as science this is a direct social parallel to the Heisenberg uncertainty principle. It follows there is no technical solution to this problem, only management solutions that entail checklists, and guidelines to set standards of judgment clearly not exercised in the New Zealand cases noted above.

Treatment efficacy: Given the intellectual confusion surrounding core issues of understanding it is little wonder that the treatment regimes are equally fractious, divisive and typically under serious debate. The two issues above would on their own be sufficient to throw significant confusion into treatments and their application. The theory provides an integrating framework enabling better dealing with the issues of treatment and the longitudinal study of tactics and strategies for specified conditions. One thing the theory makes clear, there is and can be no ‘overall’ solution, for example, it is predicted that for personality disorders there will be a burgeoning range of disorders identified, this because the category is dealing with values of the variables, and this will exhibit immense range across a modern population, and what is more will exhibit constant extension since the ideas and issues emerging in the society will be in a process of constant flux and change. The range of values of variables will be constantly expanding with an equivalent expansion in the range and potential for the values of variables to be outside those normative of society, and unless the general range of ‘what is defined as normal’ expands at the same rate as the expansion in the range of values of variables, which it is not, and never will due issues of ‘social drag’, the problem of normatively abnormal conduct will grow rapidly. In practice this suggests we will have more ‘mental ill health’ now than we did one hundred years ago, which was more than one hundred years before that… and that the problem is likely growing exponentially. The issue of the exponential expansion of mental ill health will also be compounded by inadequate conceptualized approaches to mental health policy and promotion of that policy, in particular failure to account adequately for the self-fulfilling aspects of the causality of human conduct, and the issues involved in the fallacy of composition. For each of the identified ‘psychosis’ there will be needed a unique remedy, and while this may be similar to other remedies, it is likely not exactly the same, and training of clinical practitioners will need to reflect this diversity with no one practitioner able to encompass and be proficient with the full range of psychoses exhibited or likely to occur. The categorization of tactics, strategies and their likely application to exhibited symptoms and estimated etiologies is a immense topic requiring much greater systematization and development than yet undertaken, and it is from such work that orderly progress will and can be made on training and effectiveness of the clinical practitioners; and this work conducted alongside detailed longitudinal studies of treatment effectiveness.

The management model

People with serious mental illness are different, not easy to communicate with, and typically not people the general population will gravitate to and make friends with; and frequently the family does not have the skills to cope and care for them. There is a body of thought that sees the ‘stigma’ of mental illness as handicapping such people in society, the issue is whether or not the opening statement has any validity, if so then seeking to ‘overcome’ the stigma is likely to be of limited impact with people correctly perceiving the reality (as in opening sentence). Mental illness as a break down or damage to the underlying neural mechanism is precisely parallel to a broken leg or common cold, circumstances beyond the control of the individual, sad, often tragic, and requiring professional care and support. Simply placing such people back in the general community will leave them lonely and distressed. They certainly often need community, which might suggest something akin to the retirement village rather than a hospital, but a community of kindred folk with professional support close by.

Issues of insanity and personality disorder raise different questions, since from within the model these are issues that while difficult, are not beyond the management and control of the person. The model suggests that to some degree the person is able to choose, and can make progress although it may easily be a difficult fight within themselves. Depression, for example, is a common social disorder; it seems to me unlikely that a person will reach forty-five without experiencing depression to some level. Elsewhere I have referred to depression as an ‘affliction of the spirit’ (Definitions of insanity, mental illness and the impossibility of temporary insanity ).

An important issue is the self-fulfilling potential of humanity, the model makes this very clear, therefore if ideas are promoted that suggest ‘depression is normal and an illness’ will this in and of itself promote depression, causing people themselves to fight less? What if Government adopted a different philosophy, namely that depression is common, not a big deal, and can be managed by applying these effective nouskills, going to these seminars where one can share with people wrestling with their own spiritual hope and security, or going to these counselors recognized and trained in dealing with depression.

From this analysis emerges a strategy offering a graded response to mental disorders in the community. First, forensic retention centers, then hospitals for the most acute and those necessarily requiring full professional care, then communities of care, and finally the offering of support, encouragement and coaching for those able to take care of themselves, this bringing us to the next significant topic of developing greater mental health in the community.

Developing greater mental health

At one level, the distinction being drawn between managing mental ill health and developing mental health is the same as managing physical ill health, and building physical health. As policy there is emerging distinctions in normal health, the smoking campaign for example, and constant promotion of healthy eating and exercise are all promoting positive health. In normal health it is better understood and accepted that some illness can be prevented, and that good physical self-management practice will help, even if the advice is often ignored. For mental health, without a strong orienting theory the issues are much more blurred and less clear in the minds of people. First there remains the strong view that causality is linear, derived from deep issues like ego, id, and unconscious, cemented by external parameters like the ‘system’ and society, with little justification or serious scientific support for such views. The fragmentation of psychological schools and the burgeoning treatment styles and regimes, each with its adherents, all adds to the confusion in the popular mind. This, right down to fundamentals such as ‘what does cause my conduct?’, and ‘how can I understand me?’. Little wonder the policy area of ‘mental health’ is dominated by concerns over managing mental ill health. With the fragmentation and divisions of psychology, for any Government, for example, to promote any system of thought would be seen as ‘favoritism’ for one group over another, and any promotion of any set of ideas as regards mental good health likely to become a political minefield.

The only solution to the issues is for the development of a comprehensive and clear orientating theory that prescribes and enables adoption of one system over others. With the emergence of an orientating theory, a paradigm for psychology then what to do to best effect will emerge and be clear and specified. Achieving a paradigm for psychology requires the theory measure up to the issues and factors relating to judgment in science as spelled out at this site. The factors relating to judgment of theory and science extend far beyond the naive issues of empiricism, positivism or falsification, demanding a balanced and comprehensive view of the elements that might bear to the validity of a theory, and to the detailed understanding of what a theory can and cannot tell us, and to the careful distinction between a variable and the range of values available to that variable.

Very few if any theories of psychology yet developed have sought to match themselves to the range of detailed issues and elements of judgment here outlined. The only one to date being process theory outlined at this site: whether right or wrong, and the jury is still out, it points the only way forward, it is the only system of thinking that even begins to deal with the range and complexity of issues that underlie and are intertwined with the a theory of psychology (it is a mission just unraveling the issues and how they relate to the theory). See Psychological theory and its impact on mental health for a brief description of the elements of the process theory, and see previous papers at the site for detailed elaboration of the items and issues.

Issues in developing community mental health as emergent from process theory

The following issues and analysis is derived solely from the process theory, and no attempt made in this paper to relate the discussion to prior literature in any detailed way. Previously, above was stated the following

.…‘if you use nouskills to seek greater integration of your thoughts and attitudes, develop greater poise as a result, use the skills to enable smoother and easier transitions between roles an mental sets, and if you finally seek to be at peace with yourself and how you conduct yourself, then you will live a more satisfying life for you, and this regardless of the goals/values you might set for yourself’

As discussed, the theory is value neutral, it does not offer choices nor solutions; actual living demands we adopt some set of values in the range available, and then those describe our states, but in so choosing we deselect other values in the range, which is to deselect other ways of being in the world.

The emphasis here is on the processes of living, and it is argued represent the least value laden group of choices available, and represents the group of choices most likely to applicable to the widest possible group of people. It follows that a form of greater good is implicated when these choices, that of developing effect nouskills are adopted.

Developing greater mental health then involves the following.

Promotion of the process theory of psychology as currently the most complete analysis of the issues of causality of human conduct (see Psychological theory and its impact on mental health for a summary of the theory and its chief implications and attributes).

Promotion of the core elements of the theory as they are seen to emerge, that is the multiplicity of the causal structure, the non-linear nature of the causality, the emergence of "I", and with our conduct not predetermined, our ability to choose, albeit in the face of habit and in conflict with much we might hold dear and right.

Development and promotion, both via school curricula and to the general population of the ability of manage ourselves to our benefit and betterment, exactly parallel to normal physical health; and that nouskills are the manner and technique of effective self-management for better mental health.

Offering of financial support and encouragement to those seeking more detailed support and advice, beyond the permission giving of public seminars and school curricula, with those offering the counseling being recognized by appropriate bodies as having the skills and having developed the necessary competence (bearing in mind the specific and detailed nature of training as it emerges under process theory, with there being limited scope for an ‘all embracing’ training system that will enable a practitioner to cover the full range of maladaptive circumstances, that is able to deal with the full range of values to the variables of the theory).

The strategy is focused on developing the mental coping resources of the society, and suggests that if this done, more people will have less mental disorder, and enjoy life more and more fully. The facilitation of the option for greater peace and contentment by more people is surely one of the prime directives of all democratic government, and a directive that hopefully, form within accepted and orientating theory as here offered, is a directive able to be implemented and applied without fractious debate, and by parties from all sides of the political divides.

¹ The term ‘values’ has two connotations, as the ‘value’ of a variable, and as a human value. Interestingly, what emerges from the theory is that the two are parallel. When we make any choice, and our very fundamental makeup, all entail the selection and adoption of one set of values (in the sense of options of the variables), with our very being circumscribed and described by this set of variable values. But such a selection, whether by upbringing or choice or genetics describes one set of options among many, with that set of options describing us. Within the set of options describing us, an aspect of the (variable) values, then lays our human values. We can now say within the values resides our values.