The Illness Ideology and Clinical Psychology

Words can exert a powerful influence over thought. Long after the ancient roots of the term clinical psychology have been forgotten, they continue to influence our thinking about the discipline. Clinical derives from the Greek klinike or “medical practice at the sickbed,” and psychology derives from psyche, meaning “soul” or “mind.” Although few clinical psychologists today literally practice at people's bedsides, many practitioners and most of the public still view clinical psychology as a kind of medical practice for people with “sick souls” or “sick minds.” The discipline is still steeped not only in an illness metaphor but also an illness ideology—as evidenced by the fact that the language of clinical psychology remains the language of medicine and pathology. Terms such as symptom, disorder, pathology, illness, diagnosis, treatment, doctor, patient, clinic, clinical, and clinician are all consistent with the ancient assumptions captured in the term clinical psychology and with both a metaphor and an ideology of illness and disease (Maddux, 2002, 2008). Although the illness metaphor (also referred to as the medical model) prescribes a certain way of thinking about psychological problems (e.g., a psychological problem is like a biological disease), the illness ideology goes beyond this and tells us to what aspects of human behavior we should pay attention. Specifically, it dictates that the focus of our attention should be disorder, dysfunction, and disease rather than health. Thus, it narrows our focus on what is weak and defective about people to the exclusion of what is strong and healthy.

This illness ideology emphasizes abnormality over normality, poor adjustment over healthy adjustment, and sickness over health. It promotes dichotomies between normal and abnormal behaviors, between clinical and nonclinical problems, and between clinical and nonclinical populations. It locates human adjustment and maladjustment inside the person rather than in the person's interactions with the environment and encounters with sociocultural values and societal institutions. Finally, this ideology and its language portray people who seek help for problems in living as passive victims of intrapsychic and biological forces beyond their direct control. As a result, they are relegated to the role of passive recipient of an expert's care as opposed to an active participant in solving their own problems and taking control over their own lives.

Clinical psychology's deeply entrenched association with the illness ideology has gone on far too long. We believe that it is time for a change in the way that clinical psychology views itself and the way it is viewed by the public. We believe that the illness ideology has outlived its usefulness for clinical psychology. Decades ago, the field of medicine began to shift its emphasis from the treatment of illness to the prevention of illness and then moved from the prevention of illness to the enhancement of health (Snyder, Feldman, Taylor, Schroeder, & Adams, 2000). Furthermore, more than three decades ago, the field of health psychology acknowledged the need to emphasize illness prevention and health promotion. Unless clinical psychology embraces a similar change in emphasis, it will struggle for identity and purpose in much the same manner as psychiatry has for the last several decades (Frances, 2013; Wilson, 1993). For example, over half a century ago, clinical psychologists overtook psychiatrists as the major providers of psychotherapy. Now, social workers are overtaking clinical psychologists in the provision of these same services. Clinical psychology needs to redefine itself as a science and a profession and expand its roles and opportunities in order to survive and thrive in the rapidly changing market of mental health services. The best way to do this is to abandon the illness ideology and replace it with a positive clinical psychology grounded in positive psychology's ideologies of health, happiness, and human strengths.

Historical Roots of the Illness Ideology in Clinical Psychology

Despite the illness ideology's current hold on clinical psychology, the discipline was not steeped in the illness ideology at its start. Some historians of psychology trace the beginning of the profession of clinical psychology in the United States back to the 1886 founding of the first “psychological clinic” in the United States by Lightner Witmer at the University of Pennsylvania (Reisman, 1991). Witmer and the other early clinical psychologists worked primarily with children who had learning or school problems, not with “patients” with “mental disorders” (Reisman, 1991; Routh, 2000). Thus, they were more influenced by psychometric theory and its emphasis on careful measurement than by psychoanalytic theory and its emphasis on psychopathology and illness. Following Freud's 1909 visit to Clark University, however, psychoanalysis and its derivatives dominated both psychiatry and clinical psychology (Barone, Maddux, & Snyder, 1997; Korchin, 1976). Psychoanalytic theory, with its emphasis on hidden intrapsychic processes and sexual and aggressive urges, provided a fertile soil into which the illness ideology deeply sank its roots.

Several other factors encouraged clinical psychologists to devote their attention to psychopathology and thereby strengthened the hold of the illness ideology on the field. First, although clinical psychologists were trained academically in universities, their practitioner training occurred primarily in psychiatric hospitals and clinics (Morrow, 1946). In these settings, clinical psychologists worked primarily as psychodiagnosticians under the direction of psychiatrists trained in medicine and psychoanalysis. Second, after World War II, the United States Veterans Administration was founded and soon joined the American Psychological Association in developing training centers and standards for clinical psychologists. Because these early training centers were in Veterans Administration hospitals, the training of clinical psychologists continued to occur primarily in psychiatric settings, which were steeped in both biological models and psychoanalytic models. Third, the United States National Institute of Mental Health was founded in 1947. Given the direction that the NIMH took from the beginning, perhaps it should have been named the National Institute for Mental Illness. Regardless of the name, very soon “thousands of psychologists found out that they could make a living treating mental illness” (Seligman & Csikszentmihalyi, 2000, p. 6). By the 1950s, clinical psychologists in the United States had come “to see themselves as part of a mere subfield of the health professions” (Seligman & Csikszentmihalyi, 2000, p. 6), and the practice of clinical psychology was grounded firmly in the illness ideology and was characterized by four basic assumptions about its scope and nature of psychological adjustment and maladjustment (Barone et al., 1997).

First, clinical psychology is concerned with psychopathology—deviant, abnormal, and maladaptive behavioral and emotional conditions. Thus, its focus is not on facilitating mental health but on alleviating mental “illness,” and not on the everyday problems in living experienced by millions, but on severe conditions experienced by a relatively small number of people. Common problems in living became the purview of counseling psychology, social work, and child guidance. Counseling psychology, in fact, because of its concern with everyday problems in living, gradually shifted away from an intrapsychic illness approach and toward interpersonal theories (Tyler, 1972), thus making counseling psychologists less enamored with the illness ideology and with formal psychiatric diagnoses such as those described in the DSM.

Second, psychopathology, clinical problems, and clinical populations differ in kind, not just in degree, from normal problems in living, nonclinical problems, and nonclinical populations. Psychopathologies are disorders, not merely extreme variants of common problems in living and expected human difficulties and imperfections. As such, understanding psychopathology requires theories different from those theories that explain normal problems in living and effective psychological functioning. This separation became concretely evident in 1965 when the Journal of Abnormal and Social Psychology was split into the Journal of Abnormal Psychology and the Journal of Personality and Social Psychology.

Third, psychological disorders are analogous to biological or medical diseases in that they reflect distinct conditions inside the individual; moreover, these internal conditions cause people to think, feel, and behave maladaptively. This illness analogy does not hold that psychological disorders are necessarily directly caused by biological dysfunction. Instead, it holds that the causes of emotional and behavioral problems are located inside the person, rather than in the person's interactions with his or her environment (including his or her relationships with other people and society at large). Thus, to understand psychological problems, it is more important to understand and measure the fixed properties of people (e.g., personality traits) than to understand and assess the complex interactions between the person and the wide range of his or her life situations.

Fourth, following from the illness analogy, the psychological clinician's task, similar to the medical clinician's task, is to identify (diagnose) the disorder (disease) inside the person (patient) and to prescribe an intervention (treatment) for eliminating (curing) the internal disorder (disease). This treatment consists of alleviating conditions, either biological or psychological, that reside inside the person and that are believed to be responsible for the symptoms. Even if the attempt to alleviate the problem is a purely verbal attempt to educate or persuade, it is still referred to as treatment or therapy, unlike often equally beneficial attempts to educate or persuade on the part of teachers, ministers, friends, and family (see also Szasz, 1978). In addition, these psychotherapeutic interactions between clinicians and their patients differ in quality from helpful and distress-reducing interactions between the patient and other people in his or her life, and understanding these psychotherapeutic interactions requires special theories (see also Maddux, 2010).

Once clinical psychology became pathologized, there was no turning back. Albee (2000) suggests that “the uncritical acceptance of the medical model, the organic explanation of mental disorders, with psychiatric hegemony, medical concepts, and language” (p. 247) was the “fatal flaw” of the standards for clinical psychology training in the United States. These standards were established in 1950 by the American Psychological Association at a conference in Boulder, Colorado. At this same conference, the “scientist-practitioner” model of clinical psychology training was established. Albee (2000) argues that this fatal flaw “has distorted and damaged the development of clinical psychology ever since” (p. 247).

Little has changed since 1950. The basic assumptions of the illness ideology continue as implicit guides to clinical psychologists' activities, and they permeate the view of clinical psychology held by the public and policy makers. In fact, the influence of the illness ideology has increased over the past three decades as clinical psychologists have fallen more and more deeply under the spell of the American Psychiatric Association (APA)'s Diagnostic and Statistical Manual of Mental Disorders (DSM; APA, 2013). First published in the early 1950s, the DSM (APA, 1952) is now in its fifth edition (actually the seventh, if one counts as “editions” the “text revisions” of the third and fourth editions, in 1987 and 2000, respectively), and its size and influence have increased with each revision. The influence of the first two editions (1952 and 1968) on research, practice, and clinical training was negligible, but its influence increased exponentially after the publication of the greatly expanded third edition in 1980.

The influence of the DSM has increased with the increasing size and scope of the subsequent revisions. The first edition (including all appendices) ran 130 pages; the fifth edition is just over 900 pages. The number of official mental disorders recognized by the American Psychiatric Association has increased from six in the mid-19th century to close to 300 in the DSM-5 (Frances & Widiger, 2012). The DSM continues to provide the organizational structure for almost all textbooks and courses on abnormal psychology and psychopathology, as well as almost all books on the assessment and treatment of psychological problems for practicing clinical psychologists. The growth in the role of third-party funding for mental health services in the United States during this same period fueled the growth of the influence of the DSM as these third parties began requiring a DSM diagnostic label as a condition for payment or reimbursement for mental health services. Nowhere is the power of the illness ideology over clinical psychology more evident than in the dominance of the DSM. (Although we acknowledge the international importance and influence of the World Health Organization's International Classification of Disease [ICD-10; WHO, 1992], it has not generated the heated ideological and professional controversies that have been sparked by the DSM.)

Although most of the previously noted assumptions of the illness ideology are disavowed in the DSM-5 introduction (APA, 2013), most of the manual is nonetheless inconsistent with this disavowal. For example, still included in the revised definition of mental disorder is the notion that a mental disorder is “a dysfunction in the individual” (p. 20). Numerous common problems in living are viewed as mental disorders (Frances, 2013), and several others are listed as “conditions for further study” (e.g., persistent complex bereavement disorder, caffeine use disorder, Internet gaming disorder), and therefore are likely to find their way into DSM-6.

In addition, “diagnostic fads” are sparked by each new edition. Allen Frances, responsible for the fourth edition, notes four “epidemics” that were sparked by changes from DSM-III to DSM-IV: autism, attention deficit/hyperactivity disorder, childhood bipolar disorder, and paraphilia not otherwise specified (Frances, 2013). He also warns that DSM-5 threatens to provoke new epidemics of at least four new disorders that emerged in DSM-5: disruptive mood dysregulation disorder, binge-eating disorder, mild neurocognitive disorders, and “behavioral addictions” (Frances, 2013; see also Paris, 2013).

We acknowledge that DSM-5 is an improvement over DSM-IV in its greater attention to alternative dimensional models for conceptualizing psychological problems and its greater attention to the importance of cultural considerations in determining whether a problematic pattern should be viewed as a “mental disorder.” Yet it remains steeped in the illness ideology for most of its 900 pages.

So closely aligned are the illness ideology and the DSM, and so powerful is the influence of the DSM over clinical psychology (at least in the United States), that clinical psychology's rejection of the illness ideology must go hand in hand with its rejection of DSM as the best way to conceive of psychological difficulties.

The Social Construction of Psychological Wellness and Illness

Positive clinical psychology rejects the illness ideology as the most accurate or effective approach for conceiving of the psychologically problematic aspects of human life. As such, positive clinical psychology refutes the illness ideology's premise that normal problems in living are symptoms of psychopathologies—that is, psychological illnesses, diseases, or disorders—and that giving a person a formal diagnosis for a problem in living adds any additional understanding to that person and his or her problem (see also Williams, 2012, for a discussion of mental disorder theory versus psychosocial problem theory). This refutation is based on the assumption that the illness perspective is not a scientific theory or set of facts but rather a socially constructed ideology. The process of social constructionism involves “elucidating the process by which people come to describe, explain, or otherwise account for the world in which they live” (Gergen, 1985, pp. 3–4; see also Gergen, 1999). Social constructionism is concerned with

examining ways in which people understand the world, the social and political processes that influence how people define words and explain events, and the implications of these definitions and explanations—who benefits and who loses because of how we describe and understand the world. (Muehlenhard & Kimes, 1999, p. 234)

From this perspective, our ways of thinking about human behavior and our explanations for human problems in living “are products of particular historical and cultural understandings rather than…universal and immutable categories of human experience” (Bohan, 1996, p. xvi). Because the prevailing views depend on who has the power to determine them, universal or “true” conceptions and perspectives do not exist. The people who are privileged to define such views usually are people with power, and their conceptions reflect and promote their interests and values (Muehlenhard & Kimes, 1999). Therefore, “When less powerful people attempt to challenge existing power relationships and to promote social change, an initial battleground is often the words used to discuss these problems” (Muehlenhard & Kimes, 1999, p. 234). Because the interests of people and institutions are based on their values, debates over the definition of concepts often become clashes between deeply and implicitly held beliefs about the way people should live their lives and about differences between right and wrong.

The social constructionist perspective can be contrasted with the essentialist perspective that is inherent in the illness ideology. Essentialism assumes that there are natural categories and that all members of a given category share important characteristics (Rosenblum & Travis, 1996). For example, the essentialist perspective views our categories of race, sexual orientation, and social class as objective categories that are independent of social or cultural processes. It views these categories as representing “empirically verifiable similarities among and differences between people” (Rosenblum & Travis, 1996, p. 2). In the social constructionist view, however, “reality cannot be separated from the way that a culture makes sense of it” (Rosenblum & Travis, 1996, p. 3). In social constructionism, such categories represent not what people are but rather the ways that people think about and attempt to make sense of differences among themselves. Social processes also determine what differences among people are more important than other differences (Rosenblum & Travis, 1996).

Thus, from the essentialist perspective, the distinctions between psychological wellness and illness and among various so-called psychopathologies and mental disorders are natural distinctions that can be discovered and described. From the social constructionist perspective, however, these distinctions are abstract ideas that are defined by people and thus reflect cultural, professional, and personal values. The social constructionist view of the illness ideology and its various presumed psychopathologies and mental disorders is that they are not scientifically verifiable “facts” or even scientifically testable theories. Instead, they are abstract ideas that have been constructed by people with particular personal, professional, and cultural values. The meanings of these and other concepts are not revealed by the methods of science but are negotiated among the people and institutions of society who have an interest in their definitions. What people often call “facts” are not truths but reflect reality negotiations (or social constructions) by those people who have an interest in using “the facts” (see Snyder & Higgins, 1997).

Not surprisingly, we typically refer to psychological concepts as constructs because their meanings are constructed and negotiated rather than discovered or revealed (Maddux, 1999). The ways in which conceptions of basic psychological constructs such as the “self” (Baumeister, 1987) and “self-esteem” (Hewitt, 2002) have changed over time and the different ways they are conceived by different cultures (e.g., Cross & Markus, 1999; Cushman, 1995; Hewitt, 2002) illustrate this process. Thus, in social constructionism, “all categories of disorder, even physical disorder categories convincingly explored scientifically, are the product of human beings constructing meaningful systems for understanding their world” (Raskin & Lewandowski, 2000, p. 21).

Therefore, our basic thesis is that conceptions of psychological normality and abnormality, along with our specific diagnostic labels and categories, are not facts about people but social constructions—abstract concepts reflecting shared world views that were developed and agreed upon collaboratively over time by the members of society, including theorists, researchers, professionals, their clients, the media, and the culture in which all are embedded. For this reason, the illness ideology, its conception of “mental disorder,” and the various specific categories of mental disorders found in traditional psychiatric diagnostic schemes (such as the DSM and ICD) are not psychological facts about people, nor are they testable scientific theories. Instead, they are social artifacts that serve the same sociocultural goals as do our constructions of race, gender, social class, and sexual orientation—maintaining and expanding the power of certain individuals and institutions, as well as maintaining social order as defined by those in power (Beall, 1993; Becker, 1963; Parker, Georgaca, Harper, McLaughlin, & Stowell-Smith, 1995; Rosenblum & Travis, 1996). As are these other social constructions, our concepts of psychological normality and abnormality are tied ultimately to social values—in particular, the values of society's most powerful individuals, groups, and institutions—and the contextual rules for behavior derived from these values (Becker, 1963; Parker et al., 1995; Rosenblum & Travis, 1996).

Reznek (1987) has demonstrated that even our definition of physical disease “is a normative or evaluative concept” (p. 211) because to call a condition a disease “is to judge that the person with that condition is less able to lead a good or worthwhile life” (p. 211) as defined by the person's society and culture. If this is true of physical disease, it certainly is true of psychological “disease.” Because our notions of psychological normality–abnormality and health–illness are social constructions that serve sociocultural goals and values, they are linked to our assumptions about how people should live their lives and what makes life worth living.

The socially constructed illness ideology and associated traditional psychiatric diagnostics schemes, also socially constructed, have led to the proliferation of “mental illnesses” and to the pathologization of human existence (e.g., Frances, 2013). Given these precursors, it comes as no surprise that a highly negative clinical psychology evolved during the 20th century. The increasing heft and weight of the DSM, which has been accompanied by its increasing influence over clinical psychology, provides evidence for this. As the socially constructed boundaries of “mental disorder” have expanded with each DSM revision, more relatively mundane human behaviors have become pathologized; as a result, the number of people with diagnosable “mental disorders” has continued to grow. This growth has occurred largely because mental health professionals have not been content to label only the obviously and blatantly dysfunctional patterns of behaving, thinking, and feeling as “mental disorders.” Instead, they (actually, we) have gradually pathologized almost every conceivable human problem in living. As a result of the growing dominance of the illness ideology among both professionals and the public, eventually everything that human beings think, feel, do, and desire that is not perfectly logical, adaptive, efficient, or “creates trouble in human life” (Paris, 2013, p. 43) will become a “mental disorder” (Frances, 2013; Paris, 2013). This is not surprising, given that Frances notes that in his more than two decades of working on three DSMs, “never once did he recall an expert make a suggestion that would reduce the boundary of his pet disorder” (Frances & Widiger, 2012, p. 118). DSM-5 has made normality “an endangered species” partly because we live in a society that is “perfectionistic in its expectations and intolerant of what were previously considered to be normal and expectable distress and individual differences” (Frances & Widiger, 2012, p. 116), but also partly because pharmaceutical companies are constantly trying to increase the market for their drugs by encouraging the loosening and expanding of the boundaries of mental disorders described in the DSM (Frances, 2013; Paris, 2013). Essentially, DSM-5 “just continues a long-term trend of expansion into the realm of normality” (Paris, 2013, p. 183). As it does, “with ever-widening criteria for diagnosis, more and more people will fall within its net [and] many will receive medications they do not need” (Paris, 2013, p. 38).

The powerful sociocultural, political, professional, and economic forces that constructed the illness ideology now continue to sustain it. In this ongoing saga, however, the debate over the conception of psychological wellness and illness is not a search for “truth.” Rather, it is a struggle over the definition of a socially constructed abstraction and over the personal, political, and economic benefits that flow from determining what and whom society views as normal and abnormal. The most vivid and powerful embodiment of the illness ideology is the DSM, and the struggle is played out in the continual debates involved in its revision (Frances, 2013; Kirk & Kutchins, 1992; Kutchins & Kirk, 1997).

These debates and struggles are described in detail by Horwitz (2002):

The emergence and persistence of an overly expansive disease model of mental illness was not accidental or arbitrary. The widespread creation of distinct mental diseases developed in specific historical circumstances and because of the interests of specific social groups… By the time the DSM-III was developed in 1980, thinking of mental illnesses as discrete disease entities…offered mental health professionals many social, economic, and political advantages. In addition, applying disease frameworks to a wide variety of behaviors and to a large number of people benefited a number of specific social groups including not only clinicians but also research scientists, advocacy groups, and pharmaceutical companies, among others. The disease entities of diagnostic psychiatry arose because they were useful for the social practices of various groups, not because they provided a more accurate way of viewing mental disorders. (p. 16)

Wilson (1993) offered a similar view. He argued that a noncategorical dimensional/continuity view of psychological wellness and illness posed a basic problem for psychiatry because it “did not demarcate clearly the well from the sick” (p. 402). He also argued that psychosocial modes of psychological difficulties posed a problem for psychiatry because “if conceived of psychosocially, psychiatric illness is not the province of medicine, because psychiatric problems are not truly medical but social, political, and legal” (p. 402; see also Szasz, 1974). According to Wilson (1993), the DSM-III gave psychiatry a means for marking its professional territory. Kirk and Kutchins (1992; Kutchins & Kirk, 1997) reached the same conclusion from their review of the papers, letters, and memos of the various DSM working groups—namely, that many of the most important decisions made about the inclusion or exclusion of certain “disorders” or certain “symptoms” were political decisions arrived at through negotiation and compromise rather than through an objective analysis of scientific facts (see also Frances, 2013, for a similar discussion). Of course, once a condition finds itself called a “disorder” in a diagnostic manual, it becomes reified and treated as if it were a natural entity existing apart from judgments and evaluations of human beings (Hyman, 2010).

The Illness Ideology and the Categories Versus Dimensions Debate

Embedded in the illness ideology's conception of psychological wellness and illness is a categorical model in which individuals are determined to either have or not have a disorder—that is, to be either psychologically well or psychologically ill—and, if they do have a disorder, that it is a specific type of disorder. An alternative model is the dimensional model, which assumes that normality and abnormality, wellness and illness, and effective and ineffective psychological functioning lie along a continuum. In this dimensional approach, so-called psychological disorders are simply extreme variants of normal psychological phenomena and ordinary problems in living (Keyes & Lopez, 2002; Widiger, 2012). The dimensional model is concerned not with classifying people or disorders but with identifying and measuring individual differences in psychological phenomena such as emotion, mood, intelligence, and personal styles (e.g., Lubinski, 2000; Williams, 2012). Great differences among individuals on the dimensions of interest are expected, such as the differences we find on formal tests of intelligence. As with intelligence, divisions made between normality and abnormality may be demarcated for convenience or efficiency, but they are not to be viewed as reflecting a true discontinuity among types of phenomena or types of people.

Empirical evidence for the validity of a dimensional approach to psychological adjustment can be found in research on personality disorders (Coker & Widiger, 2012; Costello, 1996; Maddux & Mundell, 2004; Trull & Durrett, 2005), the variations in normal emotional experiences (e.g., Oatley & Jenkins, 1992), adult attachment patterns in relationships (Fraley & Waller, 1998), self-defeating behaviors (Baumeister & Scher, 1988), children's reading problems or dyslexia (Shaywitz, Escobar, Shaywitz, Fletcher, & Makuch, 1992), attention deficit/hyperactivity disorder (Barkeley, 1997), posttraumatic stress disorder (Anthony, Lonigan, & Hecht, 1999), depression (Costello, 1993a), somatoform disorders (or somatic symptom disorders) (Eifert, McCormack, & Zvolensky, 2012), anxiety disorders (Williams, 2012), sexual dysfunctions and disorders (Gosselin, 2012), and schizophrenia (Claridge, 1995; Costello, 1993b). Even the inventor of the term schizophrenia, Eugen Bleuler, viewed so-called pathological conditions as being continuous with so-called normal conditions, and he noted the occurrence of schizophrenic symptoms among normal individuals (Gilman, 1988). In fact, Bleuler referred to the major symptom of schizophrenia, thought disorder, as simply “ungewohnlich,” which in German means “unusual,” not “bizarre,” as it was translated in the first English version of Bleuler's classic monograph (Gilman, 1988).

Understanding the research supporting the dimensional approach is important because the vast majority of this research undermines the illness ideology's assumption that we can make clear, scientifically based distinctions between the psychologically well or healthy and the psychologically ill or disordered. Inherent in the dimensional view is the assumption that these distinctions are not natural demarcations that can be discovered; instead, they are created or constructed “by accretion and practical necessity, not because they [meet] some independent set of abstract and operationalized definitional criteria” (Frances & Widiger, 2012, p. 111).

Social Constructionism and Science in Clinical Psychology

A social constructionist perspective is not anti-science. To say that conceptions of psychological wellness and illness are socially constructed rather than scientifically constructed is not to say that human psychological distress and suffering are not real. Nor is it to say that the patterns of thinking, feeling, and behaving that society decides to label as “ill”—including their causes and treatments—cannot be studied objectively and scientifically. Instead, it is to acknowledge that science can no more determine the proper or correct conceptions of psychological wellness and illness than it can determine the proper and correct conceptions of other social constructions such as beauty, justice, race, and social class. We nonetheless can use science to study the psychological phenomena that our culture refers to as “well” or “ill.” We can use the methods of science to understand a culture's conception of psychological wellness and illness, how this conception has evolved, and how it affects individuals and society. We also can use the methods of science to understand the origins of the patterns of thinking, feeling, and behaving that a culture considers psychopathological and to develop and test ways of modifying those patterns.

The science of medicine is not diminished by acknowledging that the notions of health and illness are socially constructed (Reznek, 1987), nor is the science of economics diminished by acknowledging that the notions of poverty and wealth are socially constructed. Likewise, the science of clinical psychology will not be diminished by acknowledging that its basic concepts are socially and not scientifically constructed. We agree with Lilienfeld and Marino (1995) that it is important to “make the value judgments underlying these decisions more explicit and open to criticism” (p. 418). We also agree that

heated disputes would almost surely arise concerning which conditions are deserving of attention from mental health professionals. Such disputes, however, would at least be settled on the legitimate basis of social values and exigencies, rather than on the basis of ill-defined criteria of doubtful scientific status. (Lilienfeld & Marino, 1995, pp. 418–419)

Beyond the Illness Ideology: Positive Clinical Psychology

The solution to this problem is not to move even closer to pathology-focused psychiatry. Instead, the viability and survival of clinical psychology depends on our ability to build a positive clinical psychology that breaks with its pathological past. Heretofore, clinical psychologists always have been “more heavily invested in intricate theories of failure than in theories of success” (Bandura, 1998, p. 3). If we are to change our paradigm, we need to acknowledge that “much of the best work that [we] already do in the counseling room is to amplify strengths rather than repair the weaknesses of [our] clients” (Seligman & Csikszentmihalyi, 2000, p. 8). The illness ideology and its medicalizing and pathologizing language are inconsistent with positive psychology's view that “Psychology is not just a branch of medicine concerned with illness or health; it is much larger. It is about work, education, insight, love, growth, and play” (Seligman & Csikszentmihalyi, 2000, p. 7).

In building a positive clinical psychology, we must adopt not only a new ideology, but also a new language for talking about human behavior. In this new language, ineffective patterns of behaviors, cognitions, and emotions are construed as problems in living, not as disorders or diseases. Likewise, these problems in living are construed not as located inside individuals but in the interactions between the individual and other people that are embedded in situations that include rules for behavior that are, in turn, embedded in the larger culture. Also, those who seek assistance in enhancing the quality of their lives are clients or students, not patients. The professionals who specialize in facilitating psychological health are teachers, counselors, consultants, coaches, or even social activists, not clinicians or doctors. Strategies and techniques for enhancing the quality of lives are educational, relational, social, and political interventions, not medical treatments (see also Tarragona, Chapter 15, this volume; Vossler, Steffen, & Joseph, Chapter 26, this volume). Finally, the facilities to which people will go for assistance with problems in living are centers, schools, or resorts, not clinics or hospitals. Such assistance might even take place in community centers, public and private schools, churches, and people's homes rather than in specialized facilities.

The positive psychology ideology emphasizes goals, well-being, satisfaction, happiness, interpersonal skills, perseverance, talent, wisdom, and personal responsibility. It is concerned with understanding what makes life worth living, with helping people become more self-organizing and self-directed, and with recognizing that “people and experiences are embedded in a social context” (Seligman & Csikszentmihalyi, 2000, p. 8; see also Duckworth, Steen, & Seligman, 2005).

These principles offer a conception of psychological functioning that gives at least as much emphasis to mental health as to mental illness and that gives at least as much emphasis to identifying and understanding human strengths and assets as to human weaknesses and deficits (see Lopez & Snyder, 2003). More specifically, a positive clinical psychology is as much concerned with understanding and enhancing subjective well-being and effective functioning as it is with alleviating subjective distress and maladaptive functioning. This does not entail a shift away from a focus on relieving suffering to a focus on enhancing positive emotions and positive functioning but rather “an integrated and equally weighted focus on both positive and negative functioning in all areas of research and practice” (Wood & Tarrier, 2010, p. 819).

A shift to a greater emphasis on the positive and healthy aspects of functioning also has great practical value. Research suggests that

Positive characteristics (a) can predict disorder above and beyond the predictive power of the presence of negative characteristics; (b) buffer the impact of negative life events on distress, potentially preventing the development of a disorder, (c) can be promoted in nonclinical population to promote resilience, (d) can be fostered to treat clinical disorders, (e) offer opportunity for clinical psychologists to use their unique skills in new domains of life, and (f) have the potential to rapidly expand the knowledge base of clinical psychology. (Wood & Tarrier, 2010, p. 820)

Consistent with our social constructionist perspective, we are not arguing that the positive psychology ideology is more “true” than the illness ideology. Both ideologies are socially constructed views of the world, not scientific theories or bodies of facts. We argue, however, that positive psychology offers an ideology that is more useful to clinical psychology than the obsolete illness ideology. As Bandura (1978) has observed:

Relatively few people seek cures for neuroses, but vast numbers of them are desirous of psychological services that can help them function more effectively in their everyday lives… We have the knowledge and the means to bring benefit to many. We have the experimental methodology with which to advance psychological knowledge and practice. But to accomplish this calls for a broader vision of how psychology can serve people, and a fundamental change in the uses to which our knowledge is put. (p. 99–100)

Conclusion

As we indicated at the beginning, this chapter has presented no new facts or research findings intended to persuade the reader of the greater the efficacy of clinical psychological interventions grounded in positive psychology over those grounded in the illness ideology. Conceptions themselves do not offer new facts and findings instead, they are concerned with what one views as facts and as findings, how one organizes existing facts and findings, and, perhaps most important, what questions one considers worthy of attention. The illness ideology is more concerned with telling us what should be changed than with how it should be changed. The same is true of positive psychology. The greater utility of the positive psychology ideology for clinical psychology is found in its expanded view of what is important about human behavior and what we need to understand about human behavior to enhance people's quality of life, which results in an expanded view of what clinical psychology has to offer society (see also Duckworth et al., 2005).

Unlike a traditional negative clinical psychology based on the illness ideology, a positive clinical psychology is concerned not only just with identifying weaknesses and treating or preventing disorders, but also with identifying human strengths and promoting mental health (see also Maddux, Feldman, & Snyder, in press.) It is concerned not just with alleviating or preventing “suffering, death, pain, disability, or an important loss of freedom” (APA, 2000, p. xxxi), but also with promoting health, happiness, physical fitness, pleasure, and personal fulfillment through the free pursuit of chosen and valued goals.

A clinical psychology that is grounded not in the illness ideology but in a positive psychology ideology rejects (a) the categorization and pathologization of humans and human experience; (b) the assumption that so-called mental disorders exist in individuals rather than in the relationships between the individual and other individuals and the culture at large; and (c) the notion that understanding what is worst and weakest about us is more important than understanding what is best and bravest. Rejecting these notions paves the way for a new mission for clinical psychology and new roles of functions for clinical psychologists that go beyond those to which the science and profession have traditionally limited themselves.

Positive psychological assessments will emphasize the evaluations of people's strengths and assets along with their weaknesses and deficiencies (Joseph & Wood, 2010; Keyes & Lopez, 2002; Lopez, Snyder, & Rasmussen, 2003; Wood & Tarrier, 2010; Wright & Lopez, 2002). More often than not, strategies and tactics for assessing strengths and assets will borrow from the strategies and tactics that have proven useful in assessing human weaknesses and deficiencies (Lopez et al., 2003; Wood & Tarrier, 2010). Positive psychological interventions will emphasize the enhancement of people's strengths and assets in addition to, and at times instead of, the amelioration of their weaknesses and deficiencies, secure in the belief that strengthening the strengths will weaken the weaknesses. The interventions often will derive their strategies and tactics from traditional treatments of traditional psychological disorders (Wood & Tarrier, 2010). The efficacy of this new focus in improving the human condition remains to be examined. The major change for clinical psychology, however, is not a matter of strategy and tactics, but a matter of vision and mission.

Summary Points

• The roles and functions of clinical psychologists (and other mental health professionals) are determined not so much by theories of psychological wellness and illness but of conceptions of psychological wellness and illness that determine which human conditions are considered healthy or well and which are considered unhealthy or ill.
• Conceptions of psychological wellness and illness cannot be subjected to tests of empirical evaluation because they are not scientific terms but social constructions determined by social and cultural values, norms, and rules of behavior that themselves cannot be proven true or false by the methods of science.
• For most of its 100+-year history, the field of clinical psychology has been dominated by conceptions of wellness and illness that not only braces a medical model that places the cause of psychological problems inside the person, but also an illness ideology that dictates that the focus of our attention should be on what is weak and ineffective about people rather than on what is strong and healthy.
• This illness ideology has greatly limited the roles and functions of clinical psychology to the detriment of the profession and the people it serves and needs to be replaced by a positive psychology ideology that emphasizes health, happiness, and human strengths in addition to the traditional emphasis on dysfunction and disorder.
• The rejection of the illness ideology and the transition to a positive psychology ideology will be facilitated by clinical psychology's rejection of categorical schemes of psychological problems (such as the DSM and the ICD) that artificially divide illness from wellness, artificially divide psychological problems into distinct disorders or diseases, and continually expand the number of expected problems in living and the expected range of human diversity that are classified as illnesses.
• A vast and growing body of research supports replacing the categorical approach with a dimensional approach that rejects the assumption that we can clearly demarcate between psychological illness and wellness and between types of psychological illness and embraces the assumption that such categories are not scientifically constructed but socially constructed.
• A dimensional view that rejects the distinction between illness and wellness provides an intellectual foundation for integrating positive psychology's focus on health and human strengths with clinical psychology's traditional focus on disorder, disease, and psychological pathology.
• Research indicates that adding an emphasis on positive functioning to clinical psychology's traditional emphasis on negative functioning will enhance the effectiveness of clinical psychological assessment and interventions.

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