The basic Social Contextual Analysis of ‘mental health behaviours’ is given in Box 2.2. The first parts overlap extensively with the Power Threat Meaning Framework’s approach.
Box 2.2. Basic contextual model of ‘mental health’ (but it is neither ‘mental’ nor about ‘health’)
1. Bad life situations
- Strong oppression or life restrictions
- Many possible alternative ‘normal’ behaviours are blocked
- Living with oppression, bullying or violence
- Living with poverty
- Abuse of all sorts: physical, sexual, power, control
- Other traumatic events of all sorts
2. These shape a lot of life responses
- Escape the bad life contexts
- Fight or physically resist the bad life contexts
- Talk their way out of the bad life contexts
- Change the bad life contexts
- Exit the bad life contexts
- Distract themselves from the bad life contexts
- ‘Put up with’ the bad life contexts
- Merely survive the bad life contexts
- Hide the bad life contexts so at least other people do not make it worse
3. These shape a lot of difficult and often damaging life patterns
- Crime, violence, bullying your way out, etc.
- Escape or exiting the situations
- Avoidance, drugs, or distraction from your situation
- ‘Putting up with it’ hoping for a change
- Talking your way out by conning, exploitation, etc
4. But under special life contexts
- Responses which might be expected in ‘normal’ circumstances to help change the situations are not possible
- Any alternative behaviours are blocked or restricted, usually by people or bureaucracies
- The sources of, or responsibility for, the bad life situations are not easy to observe
5. What are labelled as ‘mental health’ behaviours are shaped
- These are normal behaviours which become exaggerated or morphed when they have no effect to change things
- The behaviours might be unrelated to the immediate situation so they will not ‘make sense’ to casual observers
- The behaviours become chronic if they get locked into the bad life situations
6. Which behaviours occur depends on circumstances and which behaviours are possible
- Behaviours which appear to give some control
- Behaviours which are even possible given the life restrictions and oppressions
- Behaviours already known by observation of others and media
- Behaviours which have been modelled by others around or are salient
- Behaviours which can be exaggerated and morphed if necessary
- Behaviours requiring few resources
The basic idea is that the behaviours of ‘mental health’ do not appear out of nowhere, they are not brain diseases or chemical imbalances, and saying that people had a ‘disposition’ to form them whenever they are observed is completely tautologous. The behaviours of ‘mental health’ are shaped by the life contexts in which people are trying to live, but there are specific conditions which shape this large range of behaviours (the whole DSM).
First. To start (from Box 2.2), the behaviours of ‘mental health’ are found when the person has been living in bad life contexts, whether chronic or short-term (a bad car accident and injuries, for example). The Power Threat Meaning Framework emphasizes chronic situations of abuse, as do the ‘trauma-informed’ approaches, but bad life contexts can mean many things. Box 2.3 show some of these bad life situations.
| Box 2.3. Some bad life contexts | forced displacement |
| violence or crime | unemployment, bad jobs |
| long-term drugs habits | death of close family or friends |
| poverty | lack of opportunities, or silencing |
| traumatic events of all sorts, long term or short | strong restrictions imposed on many behaviours which become blocked |
| abuse of all sorts: physical, sexual, power, control | exclusion or discrimination from social relationships |
| combat and fighting | having disabilities or less flexible behaviour repertoires which restrict opportunities |
| oppression and violent control taken by individuals or groups | the person does just not ‘fit in’ the world they were born into |
| bullying over time, especially at school, work, in family | many bad situations occur through hospitalization itself and through medication |
Of particular interest for this book, the two bad life contexts that are highlighted are not always done through bad or abusive means. People can live in loving households with loving families but have all their behaviours controlled and limited options for doing ‘what they want’. If this is done ‘for the person’s own good’, it can even seem like the person themselves is to blame for their behaviours. A loving household situation is being provided and everything done for the person so why are they doing ‘bad’ behaviours?
We point this out because we will see that this is the life contexts in which all our research participants were raised. While those with other behaviours of ‘mental health’ come from households with abuse, violence, etc., this was not the case for our participants with the behaviours of ‘eating disorders’. So, it must be remembered that ‘bad life contexts’ can also be loving but highly controlling and with limiting contexts.
Second. The next point is that such bad life conditions do not shape only the behaviours of ‘mental health’. As shown in Box 2.2, all sorts of behaviours are shaped that are covered abstractly as escaping, fighting or bullying your way out, talking your way out, changing the bad life situation, exiting the bad life situation, distracting oneself from the situation, putting up with the situation, or merely trying to survive. Probably in many cases these work with little more harm done—a life context becomes bad in some way so the person changes things in the situation, talks their way out, or just leaves—and all is then at least bearable.
Probably many of these are tried by every person in a bad life context. We often ask people with the behaviours of ‘mental health’ about all these strategies shaped in bad life contexts, and they have often tried them all but unsuccessfully.
Third. Not all these shaped strategies lead to the behaviours of ‘mental health’. The same sorts of bad life contexts lead to other patterns of behaviours. Sociology has long researched how bad life contexts lead to criminality or delinquency, but for these to ‘work’ other conditions must be present, such as roles models for such behaviours, somewhere to begin, resources, etc. The correlations between ‘criminality’ or other forms of ‘deviance’ and bad life contexts are very strong, just as is the case for the behaviours of ‘mental health’.
But not everyone in bad life contexts can just ‘take up’ criminal or bullying activities to escape their life situations. Likewise, just exiting the bad life situation, or starting a new form of lifestyle (just move to the country), takes resources and skills, primarily money and social networks, so these cannot just occur in all cases. Finally, many people end up just ‘putting up with it’ and continue their life in bad circumstances and probably unhappy.
Fourth. While we need more contextual research with those who develop the behaviours of ‘mental health’, the special conditions for these seem to be (1) that ‘normal’ responses to change bad life situations are not possible, (2) that alternative behaviours (such as exiting) which could help are being blocked usually by people, and (3) the source of the ‘bad life context’ is not obvious. When the behaviours of ‘mental health’ are shaped it is not usually clear why the bad situation is happening, and often this is attributed to the person themselves.
So, some parents might be controlling all behaviours, but it is not clear why, and they are claiming that they are doing it from love, and it is for your own good. Or there might be a clearly physically abusive father, but it is not clear what makes him do this, why he chooses the recipient, or what it would take to stop it happening. These are situations where it is suggested that the behaviours of ‘mental health’ are shaped, although other behaviours will probably have been tried already to no avail, such as talking your way out, bullying, exiting and distraction.
Fifth. What is then said to occur, in this alternative version, with no other behaviours that could change the bad life contexts being possible, is that almost random (but see sixth) ‘normal’ behaviours which might possibly change the situation or shock it into change, are then shaped into exaggerated forms. These behaviours might not even be related in any direct physical way to the bad life context itself or to changing that situation, so avoid interpretation. All of these properties give the behaviours of ‘mental health’ their surreal qualities, and the idea that they have seemingly sprung out of nowhere (or seem to be a brain malfunction). If these behaviours have some small effect, or no other alternatives arise, then they can become chronic in the bad life context and collateral effects are then likely.
Sixth. The behaviours shaped in the fifth step above are not of course random, but we know little yet about how they arise. We do know that it is never just one behaviour that is shaped but new ones are tried and changed until a chromic situation occurs for a while. But the behaviours which occur need to be available and known to the person in the bad and inescapable life context (even if just through the media), they need to appear to be able to effect some change in the bad life context, or they need to have been modelled previously.
Table 2.1 shows the main behaviours of the major DSM categories put into alphabetical order so that groupings are not made. The majority are ‘normal’ behaviours, but which have been shaped into exaggeration or morphed into a new behaviour. We all do these behaviours in some form or another, and it was pointed out earlier that just observing the behaviour tells us nothing with the context.
Table 2.1. The behaviours found in the DSM-5 descriptions put into an alphabetical sequence, thereby making the list independent of disorders, in order to help reverse the intense categorisation learned from the DSM.
| acute discomfort in close relationships | generalized anxiety | opposition behaviour |
| affective instability | grandiose ideas | orderliness preoccupation |
| agoraphobia | grandiosity | overactivity |
| anxiety, appear anxious or fearful | grossly disorganized or abnormal motor behaviour | overestimating threat |
| appear dramatic, emotional, or erratic | hallucinations | over-importance of thoughts |
| appear odd or eccentric | hallucinations or delusions | panic attacks |
| argumentativeness | hopelessness | perception disrupted from normal |
| attention seeking | hypersensitivity to negative evaluation. | perfectionism |
| being awake throughout the night, decreased sleep | identity disrupted from normal | perfectionism preoccupation |
| being reckless | impulsivity. | phobias |
| body representation disrupted from normal | increased alcohol and drug use | preoccupation |
| cognitive or perceptual distortions | increased energy | problems in the self-control of emotions that brings the individual into significant conflict |
| concentration difficulties | increased physical health complaints | racing thoughts |
| consciousness disrupted from normal | increased sex drive | rapid speech |
| crying spells | increased spending | recurrent and persistent thoughts |
| defiance | inflated sense of responsibility | repetitive behaviours applied rigidly |
| delusions | intermittent explosive anger | repetitive mental acts applied rigidly |
| desperation | intermittent explosive behaviours | restricted range of emotional expression |
| detachment from social relationships | intermittent explosive irritation | sad mood, sadness |
| disorganized thinking | interpersonal relationships instability | self-control problems that bring the individual into significant conflict |
| disregard for the rights of others | intolerance of uncertainty | self-image instability |
| distrust and suspiciousness of others’ motives | intrusive and unwanted thoughts | sleeping troubles |
| disturbance of eating, or eating-related behaviour | irritability | slowing down of thoughts and actions |
| dysfunctional beliefs | lack of empathy | social inhibition |
| eccentricities of behaviour | lack of enjoyment, loss of interest in pleasurable activities | somatic changes that affect the individual’s capacity to function |
| emotion disrupted from normal | memory disrupted from normal | spending less time with friends and family |
| empty mood | moodiness that is out of character | staying home from work or school |
| excessive emotionality | motor control disrupted from normal | submissive and clinging behaviour |
| excessive fear and anxiety | need for admiration | suicide thoughts |
| feeling overwhelmed | need to control thoughts | unable to adjust a particular stressor |
| feelings of inadequacy | negative symptoms | worry |
| finding it hard to take minor personal criticisms | nervousness |
As a useful comparison, Table 2.2 shows the main behaviours which used to be diagnosed as ‘hysteria’ in the late 1800s, taken from various authors. Note the differences between Table 2.1 and Table 2.2, and compare these to the criteria in Box 2.2, Sixth. The 1800s showed much less in the way of language behaviours, and more physical behaviours, for example. The task is to relate these to what was ‘available’ and which had been modelled to these different groups of people. Was ‘talking your way out’ not an option for the mainly working-class women who presented with these symptoms in the 1800s, so exaggerated language behaviours were simply not going to happen? Notice also that ‘eating problems’ have always been available behaviours to try and change your life situations, even in the 1800s.
Table 2.2. The behaviours of ‘hysteria’ in the 1800s and early 1900s. Most older texts go on to classify these in some way, but we are interested in just the behaviours themselves. (Charcot, 1885-1887; Janet, 1901, 1907; Scull, 2009)
| loss of speech | one of both eyes blind | alterations of body |
| loss of sight | all dramatic | defects of anaesthesia |
| paralysis of hands, arms, legs | fits | ‘emotional’ changes |
| inability to swallow | dramatic passions | character changes |
| ‘swelling’ in abdomen or throat | no reactions if pricked or pinched | suggestable |
| sense of suffocation | not seeing or hearing | fixed and rigid ideas |
| odd breathing | difficulty attending | tics |
| loss of sensations and reflexes | weak memory | fits and attacks somnambulism |
| odd facial expressions | laziness, hesitation | alternative states |
| odd postures | slowness, indecision | dissociation |
| writhing | weakening or simplification of voluntary movements | forgetfulness when out of alternative state |
| vocal tics | motor disturbances | alternative identities |
| pains | catalepsies | tremors |
| insensibilities | rigidity of limbs | eating problems |
| palsy and contractions | loss of voice, hiccups, vomiting | other senses disappear |
| fainting | memories of inflammation | insensible patches on skin (used by witchfinders) |
Alternative views of treatment and recovery
We will not go into detail, since this is not a book about treatment (Guerin, 2023), but the ‘treatment’ clearly needs to focus on stopping or ameliorating the bad life situations of the person and reducing the collateral effects of having been in a chronic bad life situation. This cannot be done by talking alone but requires a new way to think about treatments of ‘mental health’, which can also learn from studies in criminality and other ‘deviant’ behaviours. It also cannot be done by a single person—a single therapist.
What also becomes clear is the outcomes of ‘treatment’ will differ from those of the current mainstream medical and psychological models. Box 2.4 shows these. Medical models assume a cure is the best outcome, when the behaviours stop. For a Social Contextual Analysis and other alternative approaches, the behaviour changes when the life context changes. This means that the behaviours do not disappear or get cured, but stop being shaped unless that context returns. Learned behaviours ‘remain’ regardless of whether they are currently shaped into action or not, and many of the behaviours of ‘mental health’ are useful in some life situations. Those in therapy often remark, especially for hearing voices, that they do not want to get rid of the behaviours but want to have them appear only in contexts where they are useful.
How to explore life contexts?
What this means for both research and therapy with the behaviours of ‘mental health’ is not to diagnose into some category system, but to find out the past and current life contexts for the person and matching what has happened to the person to Box 2.2. This has to be far more detailed than current ‘client backgrounds’ and formulations carry out, although newer forms of formulations, some based on the Power Threat Meaning Framework, are similar (Ball & Ritchie, 2021; Boyle & Johnstone, 2020; Johnstone, 2018; Johnstone & Dallos, 2014; La Roche & Bloom, 2018; Randall, Johnson & Johnstone, 2020).
That, in a nutshell, is what this research and book are about. What can we learn from extensive talking to nine women about the life contexts that shaped their behaviours of ‘eating disorders,’ and then their recoveries?
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