Review article
A review of the role of illness models in severe mental illness

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Abstract

The ways in which people think about illness experiences have been associated with a variety of important behaviours and emotional responses in patients, carers, and professionals. Some of these responses have been shown to be related to outcome. Explicit models such as the self-regulation model (SRM) [Leventhal, H., Nerenz, D. R., & Steele, D. F. (1984). Illness representations and coping with health threats. In A. Baum & J. Singer (Eds.), A handbook of psychology and health. Hillsdale, NJ: Erlbaum, 219–252.] have been shown to be useful in highlighting key beliefs across a wide range of different physical illnesses. The specific beliefs about mental illness that have been assessed have been varied and largely without a common theoretical framework. This has resulted in a literature from which it is difficult to draw firm conclusions. The central aim of this paper is to assess the applicability of the SRM to mental illness. To this end, we review studies to date that have examined the beliefs that people with a mental illness have about their experiences. In addition, we review studies that have examined the beliefs of relatives of people with a mental illness and professionals who work with this population. We assess to what extent these studies are consistent with the SRM before suggesting ways in which the model could be further developed and tested. The SRM is presented as a useful framework for more advanced investigations into the function of beliefs about mental illness and how these can be modified in order to effect outcome. Developing psychological theories common to both physical and mental health may eventually result in an integrated approach in which mental illness becomes less stigmatised within the treatment setting.

Introduction

There is nothing either good or bad, but thinking makes it so. (Shakespeare, Hamlet, Act 2 Scene 2)

The way in which people think about events is important in determining their emotional and behavioural responses. This is true for a wide range of events, including health problems. The relationships between beliefs about illness and emotional and behavioural responses have been extensively explored in both physical and mental illness, but largely from different perspectives.

In trying to understand variation in physical health- and illness-related behaviours, psychologists have focused primarily on social cognition models. These models attempt to identify the key cognitions that mediate between extrinsic factors that have been associated with health behaviours, such as demographics and social factors, and individual behaviours. The models that have been most widely applied include the health belief model Becker, 1974, Becker & Maimon, 1983, Janz & Becker, 1984, health locus of control Seeman & Seeman, 1983, Wallston et al., 1978, protection motivation theory Maddux & Rogers, 1983, van der Velde & van der Pligt, 1991, theory of reasoned action/planned behaviour Ajzen, 1988, Ajzen, 1991, Ajzen & Fishbein, 1980, self-efficacy theory Bandura, 1982, Bandura, 1991, Schwarzer, 1992, the transtheoretical model of change Prochaska & DiClemente, 1984, Prochaska et al., 1992, and self-regulation theory (Leventhal, Nerenz, & Steele, 1984). All of these models assume that individuals are rational beings whose health-related behaviour depends upon their understanding of relevant information. They have all been widely applied to a range of physical illnesses and overall have been able to account for a significant amount of variance in illness-related behaviours, making the key cognitions in each model an important target for intervention (Connor & Norman, 1995).

In trying to understand variation in health- and illness-related behaviours in severe mental illness, there have been very few attempts to draw on any of the developments made by the physical illness models. In mental illness, the study of beliefs has generally been focussed on people's interpretations of internal and external experiences and how these interpretations contribute to the development and maintenance of psychotic symptoms. Examples of this area include studies of: (1) beliefs about intrusive thoughts, which may predispose them to be experienced as auditory hallucinations (Morrison, 1998); (2) information processing bias such as jumping to conclusions that result in persecutory interpretations of innocuous events (Garety & Hemsley, 1994); and (3) tendency to make external and personal attributions for negative events (Kinderman & Bentall, 1997). There has been less exploration of other potentially important beliefs, highlighted in the physical health literature, such as the possible causes of the experience, beliefs about control or treatment, perceived consequences, and how long the experience is likely to last for (though important exceptions to this are reviewed below).

Garety, Kuipers, Fowler, Freeman, and Bebbington (2001) have used the term “secondary appraisals” to refer to evaluations of the experience of psychosis itself (such as what caused it, and how an individual can control it, what are the consequences to the person's life), as opposed to primary appraisals of the meaning of anomalous experiences that may drive the core symptoms (such as “people who are looking at me intend to do me harm”). Some distinction between different types of appraisal is potentially very useful, especially when the individual is able to recognise that their primary appraisals are part of a mental illness. For example, their secondary appraisal may include beliefs such as “these thoughts about people wanting to hurt me are caused by stress” or “I can control these experiences by taking some medication or reducing my stress.” However, the distinction between primary and secondary appraisal becomes less clear when the individual does not recognise their experiences as being part of a mental illness. Their causal explanation may be that their thoughts about people wanting to harm them are due to the fact that people really are trying to harm them. The primary and secondary appraisals are not easy to distinguish in this scenario and therefore the model becomes less useful. In addition, the terms primary and secondary may be confusing as they are already used in the related literature on coping and have specific and somewhat different meanings in that context (Lazarus & Folkman, 1984).

It is our suggestion that attempts to develop an understanding of the role of beliefs in mental illness would benefit from drawing on the extensive work that has been already done in understanding the role of beliefs in physical illness and, in particular, the self-regulation model (SRM) (Leventhal et al., 1984). This model is particularly useful for understanding severe mental illness for the following reasons.

  • (1)

    The SRM emphasises the importance of emotional representations as well as cognitive representations. This may be particularly important in mental illness where dysregulation of emotion may be integral (Garety et al., 2001).

  • (2)

    The SRM is currently the most widely used model because of its reliability and validity in exploring important patient beliefs across a range of physical illnesses, and the advances this has made in understanding self-management Hampson et al., 1995, Hampson et al., 1990, and recovery Horne et al., 2000, Petrie et al., 1996. The wide applicability of the model suggests it may also be appropriate for mental as well as physical illness.

  • (3)

    Much of the work that has been done in mental illness is consistent with this model. This literature is reviewed below.

  • (4)

    Preliminary studies in mental illness indicate that the SRM explains considerable variance in important outcome measures for both patients (Clifford, 1998) and relatives (Barrowclough, Lobban, Hatton, & Quinn, 2001).

  • (5)

    Finally, the SRM would have the added advantage of encouraging a wider exploration of beliefs about mental illness within clinical practice and research.

Section snippets

The SRM (Leventhal et al., 1984)

The SRM is based on the premise that patients are active problem solvers whose health-related behaviours are attempts to close the perceived gap between their current health and a future goal state. The coping strategies they select (for example, whether or not to take medication) are guided by their interpretation and evaluation of their illness. The outcome of these behaviours is then evaluated and fed back into their model of the illness, and/or used to shape future coping responses. This

Assessing beliefs about illness/health

Since Leventhal originally proposed the SRM, there has been considerable support for both the specific beliefs that constitute the way in which people think about physical illness, and their utility in accounting for variation in outcome in a number of areas. A questionnaire that assesses these dimensions; the Illness Perception Questionnaire (IPQ) (Weinman, Petrie, Moss-Morris, & Horne, 1996) has been used with people with a wide range of health problems. Using this and similar measures, and

Validity of the SRM in understanding mental illness

The central aim of this paper is to assess the applicability of the SRM to mental illness. Studies are reviewed that have examined the beliefs that people with a mental illness hold about their experiences. We will assess to what extent these studies are consistent with the SRM before suggesting ways in which the model could be further developed and tested.

This review includes all studies in which a clear attempt has been made to explore a link between beliefs about mental illness, and

Limitations of illness models

It is hypothesised that models of illness that have been found to be helpful in physical illness may be usefully applied to mental illness to further our understanding of people's responses to illness. It is likely that modifications will be necessary and that different dimensions of understanding to those identified in physical illness may be critical. However, the work on illness perception in physical illness provides us with a methodology to develop and test a framework that is needed to

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