Making sense of mental health: a qualitative study of student counsellors

ABSTRACT

More and more people in the UK have poor mental health. Consequently, there is a growing demand for mental health professionals such as counsellors and psychotherapists. The aim of this study was to explore how trainee counsellors make sense of mental health in general and concepts like disorder, diagnosis and treatment in particular. We employ semi-structured interviews to explore what seven UK-based trainee counsellors thought and felt about mental health and disorders and how this affects their motives and intentions in relation to practice. A four-dimensional “Folk Psychology Model” (pathologising, moralising, medicalising and psychologising) provides a useful framework to illustrate and explain tension, complexity, diversity, contradiction and confusion among trainee counsellors' views. These views reflect more general contested epistemological, and perhaps even ontological beliefs, operating within and between relevant parent disciplines and professions about the mind and mental health.

KEYWORDS:

• Student counsellors
• mental health
• mental illness
• mind
• disorder

Introduction

According to the Health and Safety Executive, 15.4 million working days are lost in the UK because of stress, depression, or anxiety (Health and Safety Executive, n.d.). The British Association for Counselling and Psychotherapy (BACP) works, inter alia, to “promote the role and relevance of the counselling professions in improving psychological wellbeing and mental health”. It also plays a key role in promoting and accrediting competent and ethical professionals. The BACP is a broad church embracing an eclectic range of methods and approaches as evidenced by the types of therapy and speciality divisions listed on its website (BACP, n.d.). Underlying the BACP’s core philosophy is a complex admixture of ontological, epistemological and methodological beliefs about persons, minds and mental health. To some extent, this eclecticism is reflective of the contested nature of concepts like “mind”, “mental health”, “disorder” and “mental illness”. The complexity is exemplified by the difference, say between Szasz’s (1974) thesis that mental illness is a myth, and Churchland’s (1981) eliminative materialism, which suggests that advances in neuroscience will render psychology, and thereby it’s explanatory, diagnostic and therapeutic value, meaningless – the very concepts of “mental” and “mind” will become obsolete. Conceptual difference and variation in thinking about the mind in the counselling field is perhaps more familiar in terms of the four core approaches – humanistic, psychodynamic, behavioural and cognitive – which form the basis of much training (Short & Thomas, 2014). Each approach differs in terms of how they identify, explain, and “treat” individuals and their minds.

Understanding how trainee counsellors conceive of mental health and central concepts like disorder and diagnosis is important because their beliefs influence how they think and behave in relation to their own and others’ “disordered” or “distressed” minds. Beliefs guide decisions to pursue counselling as a career, attitudes towards clients and crucially, therapeutic decisions and judgments (Larkings, Brown, & Scholz, 2019). Moreover, once qualified, counsellors will have the power to influence the mental health narrative that comes with being a member of a professional class (Morgan, Felton, Fulford, Kalathil, & Stacey, 2015). Their beliefs can confirm or challenge stereotypes and stigma (Byrne, 2001).

There is some research on various aspects of trainee counsellors’ experiences, for example how their religion impacts their training (Hunt, 2018), the stress of counselling training (Kumary & Baker, 2008; Truell, 2001), aspects of the process of training (Folkes-Skinner, Elliott, & Wheeler, 2010; Mehr, Ladany, & Caskie, 2010), and issues of competency (Brown-Rice & Furr, 2013). However, few studies have focused on key aspects of their “philosophy” with respect to the subject (counsellor identity), or object of their work vis à vis the client, or the relationship between the two. Bondi (2003) and Fitzpatrick, Kovalak, and Weaver (2010) offered some qualitative insights into identity creation (the former) and developing a theory of practice (the latter), but these do not seek to access and analyse core ontological or epistemological commitments. In this research we explore trainee counsellors’ philosophical commitments in relation to mental health and disorder, and how these affect their motives and intentions in relation to practice.

The folk psychology model

To frame our investigation, we adopt Haslam’s “folk psychology” model. Haslam (2003) argued that laypeople understand psychiatric phenomena like mental health, mental illness and disorder along four key dimensions. Each dimension represents a different modality or way of constructing a particular phenomenon. The first dimension in Haslam’s (2003) model is “pathologising”. Pathologising is a precursor to the other dimensions and involves a “judgment” or “making a call” that this or that person’s mind is different – they are behaving differently or experiencing difficulties (depressed, anxious, hyperactive, schizophrenic, addicted or some such). Trying to explain (rather than describe) difference is akin to solving a puzzle – what is it about this person that explains or causes their behaviour? Haslam (2003) argued that there are four components to the attribution process. First, the rarity or infrequency of behaviour makes it a candidate for pathologising (e.g. according to Morse, 2011, only 15–17% of people who try addictive substances become addicts, therefore “addiction” might be pathologised to the extent that its rare). Second, if the rare behaviour is difficult to comprehend or explain (why do only 15–17% become addicted to alcohol although many more consume it [often to excess]?) then it is more likely to be pathologised. Third, the behaviour is attributable to some internal feature of the person such as their personality (low self-esteem) or biological constitution (damaged neural pathway). Finally, a behaviour is pathologised in relation to collective beliefs or judgments about the desirability or otherwise of the behaviour (Haslam, 2003). Behaviour like obsessive drug use is more likely to be pathologised than obsessive working practices (Maté, 2018). The three other dimensions in Haslam’s model – “moralising”, “medicalising” and “psychologising” – are systematic approaches to solving the pathologising puzzle.

Moralising

According to Haslam (2003), moralising explains deviant behaviour in terms of traditional person or mind language such as intentional action subject to or issuing from beliefs, reasons and desires. When moralising one assumes that human action is largely under an agent’s conscious or deliberative control and deviance is a conscious choice. To moralise mental abnormality is to treat it in the same way as other actions for which the individual may be praised or blamed.

Medicalising

To medicalise psychological abnormality is to provide a causal explanation in terms of a somatic aberration or a disease (Haslam, 2003). To medicalise is not just to embrace biomedical ideas. The process involves an excessively essentialist commitment. Laypeople (and some psychiatrists, and perhaps trainee counsellors) are prone to essentialise when thinking about diseases (Adriaens & De Block, 2013) and about other aspects of human variation. Haslam and Ernst (2002) found that essentialist thinking about mental disorders is characterised in terms of beliefs in “natural-kinds” or “natural-categories” that are culturally universal and historically invariant. Membership of the discrete category (e.g. Schizophrenic) is fixed and immutable. Members of the category are homogenous and different in kind to non-members. The category is thought to be informative and allows us to make inferences about all members (Haslam & Ernst, 2002).

Psychologising

Haslam’s (2003) fourth dimension offers an explanation in terms of mental (rather than somatic) categories but retains a non-intentional (non-conscious) explanation for some behaviours (disorders). To psychologise is to invoke functional and/or mechanistic explanations at the psychology level (obsession, compulsion, cognitive distortion, or some such). Furthermore, the idea that all actions are rooted in rational awareness is rejected and explanations such as “I couldn’t help it” or “I didn’t want to do it” are permitted.

Another aspect of psychologising is seeking to explain the reasons one currently has for acting in terms of a causal history. Van der Kolk (2014) provided a systematic and detailed account of how trauma such as sexual abuse or violence explains current dysfunction like self-harm or depression and anxiety [Maté (2018] offers a similar account for addiction). Current (dysfunctional) behaviour has an identifiable and verifiable antecedent cause, namely the mind and brain’s reaction to historic/ongoing abuse. Long and Jenkins (2010) found counsellors often “psychologised” self-harm as a response to past difficulties with some drawing specifically on Freudian concepts in the process.

Theoretical utility

How does the model help us interpret how trainee counsellors think about mental health? First, the model provides a useful framework to examine an individual’s conception of mental health and disorder and helps explore the coherence of, and any tensions within, an individual’s view. Second, the model allows us to see how an individual’s beliefs and attitudes might vary across different aspects of mental health and/or between different contexts (e.g. one might think very differently about Schizophrenia and body integrity identity disorder [BIID]). Alves and Gazzola (2011) found that counsellor’s professional identity was context bound. Counsellors working in a “medical” setting might be more likely to medicalise a particular condition than if they were working in a community setting or perhaps in private practice. Third, there is empirical support for the explanatory utility of the model (Haslam & Giosan, 2002; Levi & Haslam, 2005). Research shows that laypeople pathologise in the way the model suggests (rare, puzzling, attributable to an internal feature and undesirable). Ogden and Simmonds (2013) explored the tension counsellors and psychologists felt when considering the status of “prolonged grief disorder” and its inclusion in DSM-V. There is a clear sense in which participants were reluctant to “pathologise” grief in terms of a formal disorder. Fourth, the model has potential to illuminate cultural differences and the sources of stigma. Rivas and Hill (2018) found that counsellors were aware that medicalising disability (particularly physical disability) tended to create stigma. Finally, the model has the capacity to illustrate historical change and paradigm conflicts. Homosexuality has been de-pathologised and other conditions such as substance abuse and personality disorders are now psychologised where they used to be moralised (Haslam, 2003). With the expansion of neuroscience there is a growing tendency to medicalise (or perhaps biologise) mental categories in terms of brain circuitry or some such. Although the model has not been employed to explore mental health professionals’ views, this research proposes (and to some extent evaluates) two assumptions. First, from a conceptual perspective the model seems to have significant breadth for exploring trainee counsellors’ views. What they discuss in terms of “counselling”, broadly conceived, can reasonably be expected to fall under one or more of the model’s dimensions. Secondly, at the trainee stage of their careers, one would not expect participants to have radically different frameworks to “lay–people” although they may differ significantly in the emphasis or importance they attach to certain dimensions.

Methods

We adopt Flyvbjerg’s (2006) injunction that good social science is problem or question driven and adopt methods best suited to answer the question. McLeod (2011) argues that qualitative research and qualitative methods seek to develop insight into how people make sense of their world. Qualitative research is employed to gather and analyse expressions of experience through words or in the form of stories (Levitt et al., 2018) often disclosed in conversations. To address the research question, (qualitative) data often characterised as “rich” or “thick” (Flyvbjerg, 2006) in the form of the knowledge, values, attitudes, conceptual and interpretive frameworks, beliefs, and motives of the trainee counsellors were sought. Ideally, data collection would involve a longitudinal process drawing on observations and conversations in different contexts and settings where participants are discussing and embodying their ideas and knowledge (such as classroom discussions, personal and professional development work, sessions with clients or supervisors). Such a design would be practically and methodologically unachievable, and ethically undesirable on several grounds (including client/therapist confidentiality). This study is exploratory and more modest in scope. We sought, therefore, to gather data using a practical, methodologically reasonable, ethically justifiable and widely used alternative, namely interviews (Folkes-Skinner et al., 2010; Gibson & Cartwright, 2014; Johal, 2017; Nicholl, Loewenthal, & Gaitanidis, 2016).

Data collection

Semi-structured interviews are a flexible and powerful means of accessing the way people think and make sense of their experiences (Rabionet, 2011). According to Hammersley (2008) what people say – in interviews and elsewhere – can help us to understand their views, beliefs and dispositions more broadly. According to Knight (2002) semi-structured or lightly structured interviews exemplify the following characteristics: they are flexible and open ended, they allow the researcher to probe and test the participant’s views, participants can be encouraged to share their stories or views openly around certain topics, so complexity and ambiguity are more likely to be captured. Semi-structured interviews were conducted in a quiet social learning space at the university lasting between 35 and 63 minutes. The interview schedule was designed to maximise opportunity to “talk freely” about their ideas and views on mental health. The wording and order of the questions below are indicative of the main questions asked, but the interviews are better characterised as conversations that allowed participants to share their ideas at length. The quality of data from interviews often depends on the skill of the researcher in developing rapport and encouraging the participants to speak freely (Gratton & Jones, 2010). The interviews were structured around the following key questions: tell me about why you decided to enrol on a counselling course? how do you see/think about mental health or mental illness? What do you think are the main factors that contribute to poor mental health or to good mental health? How do you see yourself helping people with mental health difficulties – what is it that counsellors do – what changes (if any) do they elicit? What do you understand by terms like disorder and diagnosis? Do you think attitudes towards mental health have improved?

Participants

Five female and two male trainee counsellors studying for an MSc in Counselling at a British University were opportunistically recruited through e-mail and invited to participate in the study (Gobo, 2007; Knight, 2002). A sample size of between 8 and 10 was sought, but seven was achieved (the trainees have a significant time commitment, many also work part-time and there are numerous other opportunities to participate in research at the department). Nevertheless, given this research question, seven participants are a reasonable sample for research of this kind (Flyvbjerg, 2006; Sim, Saunders, Waterfield, & Kingstone, 2018) and is in line with similar research in the counselling field (e.g. Hunt, 2018; Nicholl et al., 2016; Randall & Bewick, 2016; Truell, 2001; Waters, Spong, Morgan, & Kemp-Philp, 2018). The diversity within the sample reflected the diversity of the cohort – in terms of age (23–54), gender (3:1 male to female ratio), experience and background (mature students returning to academia and recent graduates), although this was not purposively sought (Silverman, 2000). Ethical approval was obtained through the participating university’s rigorous process. The lead researcher continued to engage in reflective discussion (with co-author and colleagues) on ethical issues throughout the research process. The topic under investigation is not particularly challenging, but there were potential risks (detailed in the ethics application) that were managed carefully. These included the preservation of anonymity and, if necessary, identifiers (such as nationality) have been redacted; management and storage of data (password protected laptop); discussion of traumatic or painful issues (most participants did talk about personal or family difficulties, including recollection of extremely traumatic events, but there was no need to stop any interview or take any actions to manage risks).

Data analysis

The data were analysed using deductive and inductive thematic analysis. According to Braun and Clarke (2006), thematic analysis is an accessible and theoretically flexible approach well suited to research in psychology and other social sciences. The method can provide a rich, detailed, and complex account of the data collected (Nowell, Norris, White, & Moules, 2017). The method is used to identify, organise, describe and report themes found within a data set (Braun & Clarke, 2006). The analysis was guided by a clear, well informed, and sophisticated understanding of the dimensions of Haslam’s (2003) model. Following Braun and Clarke (2006), decisions about the importance of data were flexible and reflective, and not driven by quantifiable measures but rather by relevance and importance relative to the research question.

The following steps were followed in order to improve the trustworthy nature of the analysis (adapted from Nowell et al., 2017).

Phase 1 – familiarisation: listening to recordings, reading transcripts.

Phase 2 – Generating initial or tentative codes based on the framework (i.e. “this type of response is indicative of control, or stigma”).

Phase 3 – Reading, coding (using colour codes) of original transcripts. According to Creswell (2014) this is a systematic process where specific statements are analysed and categorised to the extent they represent the phenomenon of interest (for example if participants discussed disorders in terms of neurochemical antecedents, this particular aspect of the data was coded as an example of “medicalising”).

Phase 4 – Generating new document with data (quotes) from different participants under thematic headings.

Phase 5 – Analysing and interpreting the data including distilling relevant or indicative quotes.

Phase 6 – Writing it up.

Trustworthiness

Judging the value of qualitative research is a contested (and perhaps essentially so) task (Hammersley, 2008). Concepts such as validity and reliability are eschewed in favour of notions such as trustworthiness and rigour. A key strategy for us was to develop rapport with participants. A concerted effort was made to establish conditions conducive to open dialogue (Rapley, 2007) by drawing upon personal experience, employing listening/counselling skills and maintaining a reflective approach.

When conducting interviews there is likely to be a certain amount of reactivity to the procedure (being interviewed) and to the researcher (Hammersley, 2008). Participants were frequently self-conscious about their answers. Sometimes they were concerned about giving right answers (i.e. demonstrating knowledge or fear of demonstrating ignorance with respect to purported “facts of the matter”) – “I know I don’t know enough about things like this” (p. 1) and “I don’t really know how to answer your question. Please guide me here” (p. 3). At other times they were more concerned about making, or appearing to make, value judgments – “I'm always so careful with my terminology, kind of what the course has done to me is make me really careful of offending anyone” (p. 1) and “I'm still learning in a training process and I think there might be the possibility that I might change, even the things I've said today” (p. 2).

Clearly, participants were often wrestling with a bunch of competing ideas and demands. Given the complexity of the counselling process, honest doubt and self-awareness is a strength, but it is not possible to discern whether certain lectures, principles, the BACP ethical framework and so forth were operating like an implicit filter for the participants. In other words, were they presenting their front stage (counselling) persona – the one they wanted to show (Goffman, 1971)? It is not possible, and perhaps not desirable, to try and unpick the layers of complexity embodied in the responses nor to seek to explain certain “views” in terms of certain “characteristics” or “persona”. We, therefore, present their views in their own words as far as practicably possible and interpret and analyse these in light of our research question and Haslam’s (2003) model.

Results and discussion

Trainee counsellors are different to lay-people in at least one significant way, namely that they have made a conscious choice to pursue a “helping” profession. It is not surprising therefore, that responses reflected this shared commitment. To some extent, all participants were self-consciously aware of the nature of the challenge they were undertaking and to differing degrees and in different ways were nervous, anxious, apprehensive, but also confident, excited and motivated about their chosen career. Some participants appeared more assured and confident in their knowledge and experience than others, which might be attributable to factors such as age and life experience.

It was clear from the data that Haslam’s (2003) model does indeed offer a useful means of capturing or expressing individual differences in beliefs about mental health conditions. Moreover, in line with Haslam’s findings (2003) the many differences between participants as well as differences/tensions within an individual can usefully be explained in terms of a commitment to, or the level of endorsement of, a dimension. The findings will be presented and analysed under the four dimensions from the “folk psychology” model.

Pathologising

It was a challenge to identify any systematic approach to pathologising among participants. Participants seemed to have their own examples (of conditions, clients, or persons) in mind – already pathologised so-to-speak. Participants tended to attribute “problems” to internal characteristics (Haslam, 2003) like being sensitive, overthinking, having poor coping skills, lack of resilience, poor self-confidence and anxiety. The role of certain environmental factors was also stressed (family breakdown, abuse, exam pressure). In combination these could lead to “unusual” or “extreme” distress, poor functioning, or dysfunctional coping (e.g. use of alcohol).

… suffers a level of distress which is affecting their ability to function in a family situation, in a social situation, in a work situation, for example and their level of mental health, or lack of it, is getting in the way of their functioning in those aspects of their lives which are important (p. 7).

Certain rare and undesirable behaviours were also considered to be indicative of poor mental health including self-harm, substance abuse, attention seeking and avoidance. At times participants tended to employ either a “subjective” or “client knows best” approach (i.e. the client decides if they have a problem). Bolton (2013) argues that clients/patients look-up symptoms on the internet or are influenced by public discourse and increasingly self-diagnose (pathologise) before consulting with professionals. At other times participants accept that some other professional or organisation have already done the “pathologising” or diagnosing (e.g. doctor, psychiatrist, mental health nurse).

Interestingly some participants sought to “normalise” or “de-pathologise” conditions such as anxiety or depression.

Because I know depression is linked – it is classed as a mental illness, but I don’t think people who are depressed are mentally – I don’t know – unstable. I know that in a way they are, but it just doesn’t exclude them from society and it’s the same with anxiety and stress, we’re put under so much stress and pressure at work, at school, at … we’re only human we’re bound to crack! (p.4).

Perhaps personal experience (all participants had experienced personal and/or family mental health issues) and “counselling knowledge” reduces the perception of rarity in ways suggested by Haslam (2003). He argues that the extent to which one can give a plausible explanation for something, say a depressive episode, the less likely one is to pathologise it. Moreover, it is possible that some participants are concerned about the tendency to pathologise normal fluctuations in mood (e.g. sadness, worry and fear) – a process Haslam (2016) calls concept creep – which leads to more people classified with more mental health problems/disorders.

Moralising

Control

This dimension reveals several tensions, uncertainties and contradictions. On the one hand, some participants sought to draw clear lines between mental health and moral character in general and between an individual’s condition – say depression – and their moral behaviour in particular – “I am in control of myself. I may not be in control of what’s happening in my life, but I'm in control of how I respond to what happens to me” (p. 4). People, including themselves, who may have certain mental health difficulties or disorders should not be exempt from ordinary language moral considerations like responsibility – “ … if we do something wrong we should take responsibility and ownership of it” (p. 2).

On the other hand, some participants did acknowledge that certain conditions or experiences were part of the explanation for problematic behaviour, but these were not sufficient excuses for it. All participants found themselves trying to reconcile the tension by steering a non-judgmental path. Sadler (2013) identifies similar challenges within the DSM in reconciling wrongful conduct and mental disorder. Some deviant behaviours are classified as disorders (medicalised or psychologised) where others are not without a clear consistent clinical rationale.

A common approach to try and reconcile the tension was to separate the person from the symptoms or behaviour – a kind of phenomenological gerrymandering with little or no clear justification or consistent application (Sadler, 2013). For example, some implied that one might not be responsible for having a particular disorder (they medicalise or psychologise the pathology) but are responsible for behavioural symptoms, particularly if they (symptoms) are anti-social like lying and attention seeking (moralise the symptomatic behaviour). In relation to a person with mental health difficulties, one participant said “ … the trouble with her is attention-seeking – I don’t really like that term, because she needs attention, but she says things to get reactions, and often lies” (p. 1) (lying might be symptomatic of disorder such as a “narcissistic personality disorder” (Kernberg, 2010)). Another participant was more forthright – “Sometimes it’s an excuse, people saying “Oh, I was depressed or deeply depressed” – that’s bollocks. People should be responsible for their own actions” (p. 3).

It is not clear on what grounds participants separate some antecedent condition (e.g. addiction) from the behaviour (symptoms) of the addict such that they are responsible for one, and not the other. The epistemic problem (what is the precise relationship between symptoms and antecedent causal mechanisms, and which are under an individual’s control?) is an important one, but perhaps not for counsellors. Their primary goal is to help clients and there are therapeutic reasons for withholding moral judgments and not blaming individuals (Pickard, 2011). Non-judgmental and unconditional positive regard are core conditions which most counsellors are introduced to early on in their training (Rogers, 1957). Pickard (2011) argues that “blame” is counter-productive in terms of therapeutic approaches, however. Holding “service users” accountable for their behaviour is crucial (Pickard, 2011). The literature on addiction and responsibility suggests that although it might be very difficult for individuals with certain problems to exercise control, they are able to do so – and of course therapy is, among other things, a process of helping to get “more” control (Levy, 2011).

There was a clear sense in which “help –seeking” or more specifically “genuine” help-seeking was considered praiseworthy among those with problems.

If you know you’re acting in a certain way towards your partner because you’re struggling with your own emotions - you know that hitting them is wrong because you saw it in your own household when you were a child and you found that hard to deal with. You know what you're doing is wrong. Go and seek help (p. 3).

I can’t really help but prioritise help-seeking, … , you can go to therapy just to tick a box and say that you're doing it and continue to engage in behaviour that you recognise is damaging to yourself or others, (p. 5).

It is not clear when and to what extent participants considered the ability, willingness, or power to seek help within an individual’s control. Nor is it clear whether participants think that one can distinguish between clients’ genuine and non-genuine engagement – the former counts as mitigation for “bad” behaviour. This is further evidence of uncertainty and contradiction about which aspects of a person’s (client/patient/service-user) behaviour was “caused” by the condition and which was a choice (e.g. to lie and manipulate) and therefore straightforwardly blameworthy.

Stigma

According to Haslam (2003) the way people operate within and across the dimensions illuminate aspects of stigma. One would suspect that trainee counsellors are committed to reducing stigma and its negative impact, and there was explicit evidence of this.

… I think that’s what stops people from reaching out to counsellors to access stuff, and actually they need to speak up for themselves because they fear that their family will find out; or their employer will find out and they’ll class them as mentally ill (p. 4).

I've had that with friends as well “I don’t want to be called crazy. I don’t want to be crazy.” But then what is crazy and what is normal? (p. 2).

It was evident that some participants felt that stigma attached differently to certain disorders or conditions. A diagnostic label might contribute to stigmatisation. One participant felt that some disorders were more likely to elicit less understanding or sympathy. When discussing schizophrenia for example –

“Oh, they could be potentially dangerous!” or “They must just … ” “They're the crazy ones!” Again maybe there’s a lack of awareness and a lack of understanding of what that means, or maybe it’s portrayed in the media and I think that is something that is still probably done to an extent, where they over-exaggerate it potentially, just to get that sensationalism in the media, in film or whatever and that could contribute to a lack of understanding (p. 2).

Another participant, perhaps trying to challenge stigma associated with the condition –

But actually with schizophrenia, people are beginning to see more that actually schizophrenics are more likely to hurt themselves than other members of society (p. 7).

Although it was evident that all participants were keen to challenge generalisations and stigmatisation, they often fell into the “generalising” or “essentialising” trap discussed by Adriaens (2007). According to Haslam (2003) one strategy considered to reduce stigma was to seek to explain “deviance” in terms of an antecedent biological cause, in other words to medicalise a condition. It is a strategy associated with Alcoholics Anonymous (AA). They (AA) sought to medicalise alcoholism and slogans such as “it’s a disease not a disgrace” or “sickness not sin” capture the ideology (Flanagan, 2013). The idea is that attributing a condition to a pathology (rather than choice) will elicit sympathy and compassion rather than condemnation. Although medicalising may reduce blame, people who have a “biogenetic” understanding of mental illness are more likely to hold negative views about it because it implies essential difference, abnormality, fixed nature and unpredictability (Haslam & Kvaale, 2015). In other words, such an approach increases stigma, harsh treatment and suspicion. Walker and Read (2002, p. 313) argue that de-stigmatisation should not focus on persuading the public that mental health problems are biogenetic illnesses.

Medicalising

Hierarchy

A significant amount of “medicalising” language was used by all participants in relation to conditions that might be considered more serious. A parallel belief in a kind of hierarchy of expertise could also be inferred from the data where serious psychiatric disorders were thought to be the purview of doctors, psychiatrists and clinicians.

So I feel that there are GPs and psychiatrists and things who are a bit more qualified for diagnoses and obviously some kind of medication and things like that (p. 6).

And also we have to rely on clinical assessments by people like doctors, community psychiatric nurses, and other mental health people who are in a position to make an assessment (p. 7).

Management of the disorder was deemed to be a medical concern, whereas supporting clients with the impact of the disorder on their lives was considered to be within the remit of counsellors – “I don’t think it’s so much a counsellor’s job for diagnoses, I think counsellors very much offer support after that” (p. 6).

Disorders

According to Haslam (2003, p. 628) medicalising involves applying a “coherent natural kind ontology” and this is evident in the data. Participants demonstrated a general and somewhat uncritical acceptance of disorders – they are to be discovered or diagnosed by medical experts. Some were also confident in the Diagnostic and Statistical Manual of Mental Disorders (DSM).

[DSM] … is based on what I would suggest is quite a robust analysis of those conditions and indicators and symptoms, based on thousands and thousands of people, and underpinning that, genetic analysis and empirical studies etc. And I don’t think we’re completely there yet, in terms of fully defining what conditions are in distinct, neat kind of packages. I think there are masses of overlaps and I think there are degrees of different manifestations of those categories (p. 7).

Such confidence in the DSM is not universal. There is widespread scepticism about the disease model of psychiatry (Davies, 2013; Foddy, 2011; Heyman, 2009; Szasz, 1974). Adriaens (2007, p. 513) offers a specific critique of an essentialist “natural kind” understanding of schizophrenia arguing that far from being a homogenous disease, it (schizophrenia) is “a reified umbrella concept” for a heterogeneous group of conditions and symptoms.

When attributing certain conditions to factors outside of an individual’s control, genetic or heritability factors were common. Hereditability was discussed in terms of genetic hereditability, non-specific or vague predispositions, and “runs in the family” – although awareness of the difference was not always clear. None of these “inherited” factors were considered straightforwardly deterministic (Condit et al., 2001).

I think I’d be more prone to it, I guess, from a genetic point of view. There are multiple factors that influence depression and for me there was my grandma had, my grandpa had it. My aunts had it, on my Mom’s side and my grandparents, their parents had it. But it doesn’t mean that we are all going to have it (p. 2).

Again, it depends because with a depression, I think they actually found a gene in DNA that is responsible for depression and some people have it and its just active, and some people it’s not activated (p. 4).

Medication

Another interesting feature of the data was the attitude towards medication. Many subscribed to the idea that depression was a result of or caused by, some brain level deficiency or pathology. Depression is not a choice, the data suggests, but the result of underlying neuro mechanisms. That depression is caused by a deficiency in monoamines or some such suggests that the deficiency can be corrected by chemicals (anti-depressant drugs). There is significant scepticism (e.g. Davies, 2013; Moncrieff, 2008) about the pharmaceutical industry’s role in medicalising “mental” conditions. Moncrieff (2008) claims that the belief that anti-depressants work by correcting an abnormal brain state is a powerful, but largely unsubstantiated, medical “fact” that pervades lay-thinking and, more importantly, influences medical practice ([over]prescribing anti-depressants). Although the participants medicalised depression and endorsed the use of medication, overall they did not see anti-depressants as a fix but as a means to facilitate other therapies.

No, I don’t think it cures anything (…) I think it is beneficial for the client to stabilise and to get to a point where they are actually capable of engaging in a therapeutic session (p. 2).

… where somebody is suicidal and clearly has a chemical imbalance or it’s become obvious, that can help somebody to get to a stabilised point (p. 3).

A person with personal experience thought that the numbing effects of medication were counter-productive because they can also inhibit “normal” emotional experiences and contribute to a sense of frustration and alienation. It seemed that certain intuitions were at odds with dominant medical practice, but there was an unwillingness to embrace a strong critique of medication even though most didn’t think it really solved the underlying issues and some believed they were a pernicious part of the problem.

The brain

The less comprehensible the behaviour becomes, the more resistant it is to treatment, and the more “somatic” the symptoms seem, the more likely participants were to look for a medical explanation. Neuroscientific explanations were common.

… it’s partly how you're wired, literally how you're wired and how your neural processing goes on if you're going to be vulnerable … . (p. 3).

… biologically it has been proved that some people are just born stronger, the way the brain is structured deals better with certain situations than other people (p. 4).

… there are definitely neurotransmitters that are misfiring, neurotransmitters that are kind of not present, that are having a direct effect on those areas of the brain associated with particular moods (p. 7).

The effect of powerful institutions in shaping conceptions of mental health has significant ontological and ethical implications across all four of the dimensions (Morgan et al., 2015). Neuroscientific developments are potentially muddying (or perhaps clarifying) the waters. According to Levy (2007), advances in neuroscience might help shed light on complex and controversial psychiatric conditions such as body integrity identity disorder (BIID). This condition is characterised by a persisting desire to have a limb removed – there is a mismatch between the agent’s body and how they subjectively experience their body (Levy, 2007). It is analogous in important ways to gender dysphoria (previously gender identity disorder). Currently, surgery (removing the limb) is not a common nor ethically permissible strategy to “treat” the former condition (Müller, 2009), but gender reassignment surgery is open to individuals with gender dysphoria. Levy (2007) argues that if the cause of BIID is a mismatch between how the brain (cortex) represents the body and the objective body, then psychological treatments might not be effective, and surgery could be the answer.

Despite commitments to neuroscience explanations, there was disagreement between and confusion among some participants about whether medical explanations were exhaustive. One participant explicitly rejected the idea that a person’s anti-Semitism might be explained in terms of a medicalising and psychologising perspective – “I don’t know of any psychological or genetic or biological evidence that would say that somebody is predisposed to being anti-Semitic” (p. 7). This raises the deterministic question once more and to what extent it is dealt with consistently. It seems that we are much more willing to accept a deterministic explanation for actions if these actions do not grossly offend our moral sensibilities. Notwithstanding the philosophical debates around free-will and determinism that arise in light of increasing knowledge about the brain (that determinism purportedly dissolves the idea of freedom and responsibility entirely), there is evidence that certain extremes of behaviour might be symptoms of a disorder. Poussaint (2002) argues that extreme racism can be a delusional symptom of psychotic disorder. The way in which a particular disorder manifests itself, the content of a delusional belief, is very much tied to a particular cultural context. Davies (2013) describes how different cultures have “symptom” pools which can be used to express their distress. Anorexia, self-harm, and perhaps racism or homophobia might be ways in which certain individuals socialised in certain ways express their “distress” or “disorder”. Although it may be true that there is no predisposition for any of these specific “manifestations”, there could be a predisposition for the antecedent or underlying condition. Maté (2018) argues that it is largely a matter of luck (personal circumstances) that he become addicted to work and spending as means to medicate trauma, rather than heroin.

Psychologising

All the participants were comfortable in employing “psychologising” language and vocabulary, and to some extent dipped in and out of the four core approaches – humanistic, psychodynamic, cognitive and behavioural. For example, when trying to explain complex prior causes that lead to certain conditions/personality types, participants gave “approach” specific illustrations.

I think it is necessary to understand the psychological concepts behind it and again it depends on the kind of approach and I'm still under training, so I will see what kind of approach I would take or what kinds of approaches I would integrate (p. 2).

There were some specific psychodynamic explanations for example –

… being defensive or in denial, but I don’t think I was that bad (p. 1).

It was just the environmental factors that contributed, I guess, to me getting it [depression]. The lack of support at school, the lack of support at home, the lack of support from friends, probably my unhealthy way of dealing with emotional stress that I was having … (p. 2).

Some participants also talked about personality in a cognitive way, for example –

I have an extrovert side but also quite an introverted part of me which often needs to be re-energising without people around and needing space to myself (p. 2).

… and learning and relearning and kind of restructuring your personality, essentially. I don’t know how much I believe in an inner core that just is you forever (p. 5).

One clear example of psychologising was the attribution of current aspects of personality to previous experience in terms of interaction with environmental or “structural” factors (Van der Kolk, 2014). Specific events were mentioned such as bereavement, trauma, exam stress, lack of nurturing at home, hostility, parental break–up, and poor mental health (including addiction) in the family. One participant discussed Adverse Childhood Experiences (ACEs) as “predictive” of a range of potential problems in adulthood, including poor mental health and specific disorders (e.g. addiction).

… it does seem to be that if you’ve had a certain number of these adverse childhood experiences, whether its parents’ substance abuse, the loss of a parent or abandonment, witness domestic violence in the household, being sexually abused – things like that. If you have one you might get through it. If you have more than four statistically you're more likely to have some of these more negative things as you get older (p. 3).

It’s not surprising that psychologising language dominated participant’s accounts of the qualities of a counsellor. Responses were shot through with the humanistic or person – centred qualities such as trust, kindness, active listening, compassion, respect, self-awareness, being objective, detached or un-biased. Regardless of participants’ views across the other dimensions, there was a consistent psychologised commitment to counselling. Participant 3 captured the essence of a good counsellor quite poetically –

I think kindness is missing in a lot of people’s lives and I think kindness has the ability to change somebody’s whole experience of the world and themselves. And treating somebody with kindness and giving them the respect they deserve, can change everything for that person; and if you remove that kindness you can crush them (p. 3).

And in perhaps more familiar person-centred language (Short & Thomas, 2014) – “But compassion. Respect and maybe that general genuine love towards people and life and that unconditional positive regard” (p. 4).

Again, in terms of the counselling process, or what a counsellor does, responses were dominated by person-centred ideas or a commitment to certain important values (Morgan et al., 2015). Participants focused on “listening”, “providing space”, “supporting”, “helping”, “guiding” in a cooperative process focused on certain “difficulties”, “feelings”, “issues”, “emotions” and “behaviours”.

… trying to enable people to reach their full potential and overcome difficulties; working with people to identify set goals, in terms of therapeutic goals, what they want to achieve themselves, what they want to get out of therapy, and then working alongside them and at times steering them, maybe, and suggesting to them, to a process of therapeutic change (p. 7).

Despite the sometimes tentative, confused, reticent, contradictory, inconsistent and incongruous ways the complexity of the explanatory and pathologising dimensions were manifested in the data, there emerged a strong commitment to counselling at its most basic level – a relationship between two people committed to facilitate change.

The confusion and contradiction in the embodied views of the participants about knowledge and explanation in the realm of the “mental” is reflective of higher level ontological, epistemological and methodological tensions (Bolton, 2013; Sadler, 2013). For example, Heyman (2009) and Foddy (2011) dispute the scientific (medicalised) explanation of addiction as a “chronic, relapsing illness” characterised by compelled “using” (Leshner, 1997). They argue that addiction is not a disease. Addicts are able to choose, and many give up the habit with no formal intervention. Moreover, most successful treatments for addiction involve helping the person not their brain (Flanagan, 2011). Counsellors are therefore well equipped to help.

Conclusion

The aim of the study was to explore trainee counsellor’s views about the complex and multi-layered nature of the mental in general, and mental health in particular. Haslam (2003) offered a framework that described four ways in which people understand disordered minds. This research showed that trainee counsellors do seek to make sense of minds or aspects of “the mental” in ways suggested by the framework. We also found that the participants shifted between frameworks or theories in ways that are potentially contradictory (e.g. granting agential choice and freedom in one case, but not another) but this was not unexpected given the inherent tensions between frameworks/theories that seek to explain the mental at the theoretical level. There is a tendency among participants to privilege the medical or science perspective, particularly in relation to “complex” or “serious” conditions with a parallel deference to “medical” professions when it comes to treating certain conditions. In other words, scientific (medical, biological, neuroscientific) evidence was given more weight than other forms of evidence. This might be because the course is located at a department specialising in neuropsychology and trainees get a lot of “neuro/medical” input. Moreover, all participant’s placements were within the NHS which might further “elevate” the medical dimension. Research drawing on participants from other courses and on different placements might reveal different perspectives (Alves & Gazzola, 2011). One participant expressed concerns about a potential hierarchy and its implication for the status of counsellors:

Oh yes, society I think is stratified in that way, so that psychiatrists are the most educated, intelligent, deal with the most complex and difficult and they can prescribe medication. Then below that pinnacle come the psychologists, and then I think counsellors and jobbing everyday counsellors and psychotherapists are kind of – probably at the bottom of the pile really. Probably on a par with psychiatric community nurses or even below (p. 7).

Yet participants were committed to the benefits of counselling across a range of mental health conditions. Moreover, participants demonstrated an emerging commitment to certain central therapeutic values and the important role these played in the client-therapist relationship.

Future research might examine experienced counsellors in different contexts to see if they think differently about these dimensions. With more experience comes more confidence in one’s own “philosophy” and methods. It would also be interesting to compare perspectives across different institutional or course types (e.g. integrative versus exclusively cognitive bases) and across placement locations (different universities and colleges) to see what role the context has. Such comparisons would require a different methodological approach. Future research could also focus more narrowly on one or more of the dimensions identified above and its impact on the therapeutic choices of individuals. It might also be interesting to explore how the recent BACP SCoPED exercise manifests aspects of the framework explored above. It is difficult to offer any specific implications for training and practice because our own preference for, or belief in the therapeutic benefit, of one dimension over another will not be shared by all other trainers/educators and practitioners. We do believe, however, that understanding some of the important epistemological tensions and contradictions between these dimensions is vital. Confusion at the epistemological level may lead to confusing messages and contradictory practice at the therapeutic level. A more nuanced understanding of the different dimensions and the relationship between them may also help trainees understand issues around stigmatisation and hierarchy.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Due to the nature of this research, in which participants disclosed sensitive information about their personal experience, data containing identifiers cannot be shared publicly. However, anonymised data can be made available upon reasonable request to the authors.

Additional information

Notes on contributors

Carwyn Jones

Carwyn Jones is a Professor of Sports Ethics at the School of Sport and Health Sciences – Cardiff Metropolitan University in the UK. His current research interest is in sport, moral development, mental health, and addiction. He is a qualified counsellor and works privately and in third sector addiction services.

Sian Edwards

Sian Edwards in a PhD student at Cardiff Metropolitan University. Her PhD research is an exploration of the role of sport in the manifestation and treatment of addictive behaviour. She has a MSc in Clinical Psychology and a MSc in Sport Psychology, and has a background working in mental health services.