health: An Interdisciplinary Journal

for the Social Study of Health,

Illness and Medicine
Copyright © 2009 SAGE Publications
(Los Angeles, London, New Delhi,
Singapore and Washington DC)
DOI: 10.1177/1363459308099686
Vol 13(2): 235 –254
The centrality of personal
relationships in the creation
and amelioration of mental
health problems: the current
interdisciplinary case

David Pilgrim, Anne Rogers and Richard Bentall

University of Central Lancashire, University of Manchester,
University of Bangor, UK

a b s t r a c t An interdisciplinary case is made for the centrality of personal

relationships in the creation and amelioration of mental health problems.
Taking the work of John Bowlby as a starting point, the article summarizes
accumulating evidence from the past 50 years about the link between childhood
adversity and adult mental health problems. Evidence is also reviewed about
contemporary interpersonal impacts on adult mental health from natural
social settings and in professional therapy. These empirical summaries are
then discussed in the context of dominant trends in professional knowledge
about bio-determinism within psychiatry and the emphasis upon models
and techniques in professional and political advocates of the psychological
therapies. It is concluded that the latter trends are diverting us from policies,
which properly concede the importance of relationships for improving the
mental health of the population.

keywords child neglect and abuse; mental health; social capital

a d d r e s s Professor David Pilgrim, Faculty of Health and Social Care,

University of Central Lancashire, Preston, PR7 2HE, UK.
[E-mail: DPilgrim@uclan.ac.uk]

Introduction
This article examines two contested fields of inquiry. The first is about how
mental health problems might arise in some but not all of us. The second
relates to what works in ameliorating such problems and in increasing
well-being. The main aim of the article is to address one specific dimension
of environmental determinants of mental health–personal relationships.

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We take it for granted that a wider evidence base exists for the social
and environmental determinants of mental health problems (Rogers and
Pilgrim, 2003). Our concern is only to focus on the role of personal relation-
ships inside that evidence.
As will be clear below, there has been no shortage of relevant research
for our task. However it has emerged in relatively discrete silos in medical
sociology, clinical psychology, psychoanalysis and psychiatry. The inten-
tion of the article then is to summarize this diverse picture in order to
construct a strong interdisciplinary case for the importance of personal
relationships. In so doing, the case brings into question both an emphasis
upon genetic causation and the techno-centric emphasis on treatments
preferred by professionals and policy makers.

The health and social care context of the mid-20th century

The argument that our early personal relationships affect our later mental
health is commonplace in the lay arena (Rogers and Pilgrim, 1997). The
systematic professional investigation of that commonsense linkage has a
long and wide history. Here we summarize a number of relevant forms
of knowledge claim in this regard. We start with two important versions of
psychological determinism, which dominated psychological thought in the
20th century: behaviourism and psychoanalysis.
Although behaviourism and psychoanalysis became mutually hostile
therapeutic factions by the middle of the 20th century (Eysenck, 1952), they
had in common an assumption that early experience shaped later mental
functioning. In the case of behaviourism, this was largely about people ex-
periencing and expressing the legacies of particular ‘reinforcement histories’.
‘Experimental neurosis’, in animals and humans, was demonstrated in
the laboratory in the early 20th century by champions of behaviourism
(Watson and Rayner, 1920; Pavlov, 1957). These demonstrations became
a given starting point for subsequent clinical applications. Later a theory
of learned helplessness was developed by Seligman (1975) to account for
depressed reactions. The emphasis here was on how adverse environmental
circumstances left the person with no room for self-determination. In such
circumstances people give up and slump into depression.
While classical psychoanalysis focused on pleasure seeking and the ver-
bal child’s eventual need to rescind their desire for their parent of the
opposite sex, later ‘environmentalist’ object-relations theory focused more
and more on the centrality of secure relationships in pre-verbal infancy
(Balint, 1952; Fairbairn, 1952; Laing, 1960; Winnicott, 1965). Their argument
was that, contra Freud, the newborn child is not pleasure seeking but ‘object-
seeking’. The term ‘object’ is confusing to the psychoanalytically uninitiated,
as it refers not to objects but to people or ‘subjects of experience’ (Guntrip,
1977: 373). The headline consensus in these British object-relations the-
orists was that self-confidence for life was a product of the mother’s care
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in the first year – what Balint called ‘primary love’ and Winnicott ‘primary
maternal preoccupation’.
By 1950, behaviourist and psychoanalytical ideas came together via the
bridge of ethology (the study of animal behaviour in natural settings); in
this case attachment behaviour was the focus. Its main champion in the field
of mental health was John Bowlby, a child psychiatrist and psychoanalyst.
Applying the findings to humans of ethologists like Tinbergen and Lorenz,
as well as the ethically controversial laboratory studies on maternal de-
privation in monkeys from Harlow, Bowlby (1969, 1978, 1980) went on to
produce a series of publications on the role of neglect and failed or disrupted
attachments. He argued that these predicted a range of short-term and
long-term problems of anxiety, depression and delinquency.
These theoretical arguments and empirical findings stimulated a robust
debate about the validity of Bowlby’s original monograph published by
the World Health Organization (Bowlby, 1951), with responses being pub-
lished 10 years later by the Organization and containing contributions by
luminaries from sociology, psychology, psychoanalysis and anthropology
(World Health Organization, 1961). As Margaret Mead noted in that con-
tribution, Bowlby had triggered an important international discussion about:
(a) the potentially pernicious role of institutional care and of maternal
hospitalization on the well-being of children; and (b) the putative universal
need for sustained benign maternal care in the early years.
Mead (1961) endorsed the first of these but was much more ambivalent
about the second, on cross-cultural anthropological grounds. More empiricist
doubts came from Prugh and Harlow (1961) who argued that Bowlby was
correct to highlight the role of maternal care but other environmental factors
might be relevant to consider. Moreover, they introduced a still debated
question about the meaning of the experienced deprivation to the growing
child (a cognitive mediator which might vary between children suffering
similar adverse experiences).
None of these critical reactions attempted to demolish Bowlby’s case
outright. Instead, they all introduced cultural or empirical cautions into
a field that was vulnerable (then and now) to single factor reductionism
(Lebovici, 1961). Indeed, each conclusion of the authors broadly, albeit
sometimes grudgingly, endorsed the groundbreaking work of Bowlby and
his immediate predecessors, who had studied the same topic (Levy, 1937;
Edelston, 1943; Goldfarb, 1945; Spitz, 1945). However, between them the
critics made a reasonable plea for non-reductionism and argued for sen-
sitivity about time and place; arguments that remain pertinent today.
The cautious endorsement for the need for more intricate empirical
work of this sort was expressed most forcibly in reaction to Bowlby’s work
by Barbara Wootton (1959, 1961). Mary Ainsworth (1961), Bowlby’s close
collaborator, noted and responded to these main concerns from his critics
under a series of headings, which summarized the points of contention. The
list referred to challenges about: defining maternal deprivation; the impact

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of multiple mothering; the extent of damage done by degrees of deprivation;

specific versus general effects of deprivation; permanent versus temporary
effects; and the role of deprivation in explaining delinquency.

Childhood adversity
With these early critiques in mind, the confluence of psychoanalytical and
behaviourist ideas, expressed in Bowlby’s attachment theory, triggered the
prospect of empirical investigations, which might track the nuanced link
between adversity in childhood and later mental health problems. A major
elaboration and revision of Bowlby’s work has been offered by Michael
Rutter (1981) and his colleagues since the 1970s.
Cicchetti (1987) noted that childhood maltreatment implicates dysfunc-
tional parent–child–environment transactions. Research on neglect and
abuse in childhood has revealed a number of long-term (as well as short-
term) impacts on mental health (Wurtele, 1998). Children who are physically
abused or neglected are more likely to show intellectual impairment, as a
result of poor stimulation, poor diet, emotional withdrawal and sometimes
direct neurological damage from trauma.
These children show significant delays in comprehension and in expressed
language. Moreover, they go on to manifest a range of behavioural problems
of impulsivity, aggression, oppositional challenges to authority and later
criminality. The risk of abuse of the next generation is also set in chain
by these responses to the victim’s maltreatment. The picture is not limited
though to these conduct problems – in addition they may show a range
of post-traumatic symptoms including depression, anxiety, nightmares and
flashbacks. In other words, the psycho-social presentation of adult victims
of neglect and physical abuse will be complex and often variable within the
same individual over time.
The sexual victimization of children has a number of proven impacts on
later mental health. As well as manifesting post-traumatic symptoms, victims
may become sexually precocious (‘traumatic sexualization’), with the inci-
dence of teenage pregnancies increasing, and they are prone to later sexual
dysfunction and confusion about their sexuality (Kendall-Tackett et al.,
1993). Where the abuse is intra-familial there is an increased risk of chaotic
adult behaviour involving suicidal action, self-harm, substance misuse,
mood swings, dissociation (hysterical fugue states) and dramatic panic about
abandonment in intimate relationships (Browne and Finkelhor, 1986).
This pattern raises the probability of a diagnosis of ‘borderline personality
disorder’ in adulthood.
Reviews of mental health correlates of sexually abused children note
that they are very wide ranging and they are apparent in both clinical and
community samples. Certainly survivors are over-represented in statutory
mental health services. For example, Polusny and Follette (1995) found
that childhood sexual abuse increases the risk of the following psychiatric

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diagnoses in adult survivors: eating disorders; major depression; anxiety dis-

orders; substance misuse; somatization; and personality disorders. These
retrospective reviews of evidence of the linkage between childhood sexual
abuse and a wide range of adult mental health problems have been confirmed
more recently by prospective psychiatric studies (Spataro et al., 2004).
The child sexually victimized by a relative is not just traumatized, they
are also personally betrayed and so their confidence in intimate relation-
ships thereon is chronically affected. In the latter regard, some specific
efforts have been made to situate these phenomena within the tradition
of Bowlby’s attachment theory. Alexander (1992) studied father–daughter
incest and accounted for the mental health outcomes in these terms. The
combination of traumatization and betrayal has led to debates about
whether the mental health outcomes of intra-familial abuse should be under-
stood purely in terms of post-traumatic stress disorder (PTSD) or whether
the distorted attachments involved require a quite separate theorization
(Finkelhor, 1988).
Whereas PTSD can arise from impersonal traumatization (for example
a car crash), intra-familial abuse is dramatically personalized and so the
meanings attached to the experience are predictably different for the sur-
vivor. These personal dimensions to sexual victimization in families are
highlighted by Ussher and Dewberry (1995) in their large survey of female
survivors. They found that:
a range of long-term psychological effects was significantly related to … abuse
perpetrated by father or step-father, abuse which was repeated or prolonged,
presence or threats of violence, blaming the child, saying that disclosure would
split the family and a younger age of onset. (Ussher and Dewberry, 1995: 177)

By and large, these consistent findings about the legacy of abuse in child-
hood have referred to neurotic distress and personality dysfunction. More
recently research has begun to focus as well on the link with psychotic sym-
ptoms. While psychoanalysts and behaviourists settled on versions of envir-
onmental explanations for anxiety and depression (‘common mental health
problems’), which focused on personal transactions in the family or trauma
from without, psychosis was for most a bridge too far.
Early behaviourist accounts of psychosis are hard to come by in the liter-
ature. As for Freud, he eschewed psychotic patients (arguing that they were
incapable of forming a therapeutic transference). But a logical implication
of both object-relations theory and attachment theory was that psychosis
could, or should, be explained by damage in early infancy. Indeed Donald
Winnicott described schizophrenia as an ‘environmental disease’, bound up
with a primary failure in the relationship between mother and baby.
Ronald Laing (1960; Laing and Esterson, 1964) grasped the nettle con-
troversially at the turn of the 1960s and examined the origins of psychosis
first in Winnicottian terms and then later in relation to dysfunctional com-
munications in families. During the 1970s, a backlash ensued. The argument

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that parents might in some way or other be responsible for madness was
provocative and offensive, both to those parents and to mainstream psy-
chiatric thought, which continued to pin its colours to the mast of genetic
aetiology. This reaction disarmed environmentalist researchers, who would
be accused of a form of disgraceful victim blaming (with parents cast in
the role of secondary victims rather than contributors to the genesis of
psychosis).
Recent research has led to a renewed interest in the role of adverse rela-
tionships in explaining the origins of psychosis. Retrospective studies have
consistently reported that psychotic patients report high levels of trauma,
including sexual abuse, during their early lives (Goodman et al., 1997;
Neria et al., 2002), and these findings have been supported by prospective
investigations (Janssen et al., 2004).1 However, other kinds of adverse inter-
personal influences have also been identified. For example, one line of re-
search has focused on parental communication deviance, defined in terms
of vague and unstructured communications between the parent and the
child, as increasing the risk of psychosis.
Although early studies were often criticized on methodological grounds,
subsequent investigations showed that non-psychotic children attending a
child guidance clinic were especially likely to develop psychotic symptoms
if their parents evidenced communication deviance (Goldstein, 1987).
Moreover, a high-risk investigation established that children at genetic
risk of psychosis but who were raised by adoptive parents were more likely
to become psychotic only if the adoptive parents showed communication
deviance (Wahlberg et al., 1997), establishing that this type of influence
is environmental. Other studies have reported that risk of psychosis is
raised if children experience early separation from their parents (Morgan
et al., 2007).
It is noteworthy that these effects may be symptom-specific rather than
specific to any one diagnostic category such as ‘schizophrenia’ and might
imply the need to explain symptoms in context rather than diagnoses of
psychosis. Several large scale studies have reported a specific association
between childhood sexual abuse and hallucinations in patients with a diag-
nosis of schizophrenia (Read et al., 2003), patients diagnosed as suffering
from bipolar disorder (Hammersley et al., 2003) and also in a general
population sample (Shevlin et al., 2007). Given that post-traumatic stress
symptoms often involve intrusive thoughts and images, this observation
suggests possible common mechanisms in hallucinations and PTSD.
Communication deviance, on the other hand, has been specifically asso-
ciated with thought disorder (Wahlberg et al., 1997) (which, despite the
term, is defined in terms of incoherent communication with others).
A final line of research that has causally implicated psychopathology
began with the examination of the relationship between the outcome of
psychiatric disorders and the environment to which patients returned after
discharge from hospital. In an early study by Brown et al. (1958), it was

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found that psychotic patients returning to parents or spouses were more

likely to be readmitted to hospital than patients leaving to live with sibs
or in hostels. Subsequent research identified the ‘high-expressed emotion’
characteristics of family members that are linked to relapse in terms of
criticism, hostility and over-protectiveness (Brown and Rutter, 1966).
Research since has consistently reported an association between familial
expressed emotion in patients with some form of diagnosis of psychosis,
with this effect being particularly evident in those individuals who receive
maximum exposure to high-expressed emotion relatives (Butzlaff and
Hooley, 1998). Recent evidence suggests that self-esteem may be a mediator
between expressed emotion and symptom-exacerbation (Barrowclough
et al., 2003) and that high-expressed emotion relatives are likely to have
experienced insecure attachment to their own parents (Paley et al., 2000),
suggesting a mechanism for the inter-generational transmission of men-
tal ill-health.
Expressed-emotion researchers have usually been at pains to note that,
whereas family environment can affect recovery from psychological dis-
turbance, they do not consider it to play a causal role in psychopathology.
However, parental expressed emotion was assessed alongside commu-
nication deviance in the UCLA high-risk study and was also found to be
a predictor of psychotic symptoms at long-term follow-up. Children from
families with both communication deviance and high-expressed emotion
were especially likely to be affected (Goldstein, 1987).

The interaction of past and current adversity

The investigation of Brown and Harris (1978) about the link between
social context and depression revealed several predictive factors. Within
these, proximal and distal personal relationships were highlighted. For
example, protective factors included ‘high intimacy with husband and no
loss of mother before 11 years of age’. The reverse of these conditions in
a woman’s life was then identified as vulnerability factors which increased
the probability of symptom formation. Other relevant symptom formation
factors for our purposes identified by Brown and Harris included recent
and past loss or separation, with recent expressions of these being deemed
as ‘provoking agents’ and past ones ‘symptom formation factors’.
A major advantage of this framing of past vulnerabilities and current
conditions is that it confirms and complements Bowlby’s work on the per-
sonal disposition to distress, set in childhood. In line with this, Brown and
colleagues suggest that such a disposition culminates in actual symptom
formation according to later contingent interpersonal settings. Thus a
psychologically vulnerable person might be protected from symptom for-
mation by a good marriage or supportive friends. But the same person is
likely to break down if their current relationships are absent, unsupportive
or abusive.

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An important subsequent report was of ‘entrapment’ being salient in
symptom formation (Brown et al., 1995). This point resonates with the
hypothesis put forward by Laing and Esterson (1964) about being unable
to ‘leave the field’ in their work on psychosis. It also chimes with the pheno-
menon of ‘learned helplessness’ offered by Seligman, which emphasizes
how circumstances can overwhelm personal agency, leaving the affected
person in an existential cul-de-sac.
A further subsequent finding, from George Brown and colleagues, links
back to our previous section. Bifulco et al. (1992) found that a sub-group
of depressed women had experienced neglect or physical or sexual abuse
in childhood. This sub-group was twice as likely to be diagnosed with
depression, in a one-year period, than those without these antecedents.
Bifulco and Moran (1998) note the similarities between children trapped
in abusive family systems and political prisoners taken hostage – an ob-
vious analogy drawn from the retrospective accounts of their depressed
adult survivors.
Taken together, these studies highlight the mental health implications
of current and past loss, humiliation and entrapment in the interpersonal
field of those developing mental health problems. Studies of this linkage
have often posited relationships as ‘buffering’ or ‘protective’ in their im-
pact against adversity or cumulative stressors. The work of Brown and col-
leagues about these past–present links has been confirmed by research on
social support (e.g. Cassel, 1976; Cobb, 1976). However, some studying
the latter go further. They point out that the mere absence of current rela-
tionships is the reason people are depressed, even without other evidence
of past or current social adversity (Henderson, 1992).
Social support can be measured ‘from the outside’ by counting inter-
actions and mapping social networks (Pearlin, 1989). However, as Turner
(1999) points out, the subjective perception of support during social
interactions is the final definition. With this point taken as a given, Thoits
(1995) notes that access to this final subjective experience is correlated
with the availability of networks. The latter are necessary even if they are
not sufficient conditions for being socially supported. It is now very clear
that perceived social support is positively correlated with mental health
(e.g. Sarason et al., 1990; Veil and Baumann, 1992). Henderson (1992) re-
ported 35 separate studies of the relationship between social support and
depression – the great majority found a significant (inverse) relationship
between level of perceived social support and frequency of reported de-
pressive symptoms.
The chances of a person enjoying the mental health advantages of social
support increase with their marital status and their socio-economic status.
This suggests a virtuous circle, in which the rich get richer in two senses –
those with an intimate partner enjoy more personal support than single
people and those with more disposable income have richer social networks
(Turner and Marino, 1994; Ross and Mirowsky, 1995). This does not rule out

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the direct impact of poverty on mental health (Rogers and Pilgrim, 2003)
but it strongly suggests that lower levels of income provide fewer opportunity
structures for people to develop social contact and thereby experience per-
sonal support (House, et al., 1988). These opportunity structures include the
access to the purchase of social events, as well as the increased confidence
to interact with others with increasing social status.
Thus economic inequality is important because it sets up relative dis-
advantage, even in developed societies, where very few are starving from
absolute poverty, in a number of ways based around consumption, self-
confidence and social status. Relative disadvantage brings with it envy and
insecurity (Wilkinson, 2005). Moreover, as Layard (2005) has noted about
richer nations, the ‘Hedonic Treadmill’ of consumerism ensures that people
are not even happier when they buy more. He concludes that it is the qual-
ity of relationships, not buying power, which predicts well-being. This
conclusion also highlights the importance of an inner sense of relative
poverty (a person compares their current existential state unfavourably
with an imagined ideal self resulting from more wealth). Thus relative
poverty can be thought of as corrosive to mental health by examining both
objective discrepancies in wealth and the subjective sense of unending
failure as a consumer.
Studies of happy people suggest that domestic intimacy, religious affilia-
tion and employed status are all predictive (Myers, 2000). All three domains
are potential sources of social support. Wilkinson (2005) adds that low socio-
economic status brings with it shame and insecurity. In turn this makes
the low status person more disinclined to make social contact, leading to the
next and complementary point about social affiliation. This is the vicious
circle of insecurity, depression and social isolation.
Low levels of social support ipso facto bring increasing social isolation.
Social isolation predicts the emergence of mental health problems and
relapse in those who have had them in the past. Durkheim’s original the-
orizing about the antecedents of suicide pointed up inter alia the integrative
and protective impact of marriage, parenthood, religious affiliation and
employment. Subsequent research of the ecological wing of the Chicago
School of sociology and beyond confirmed that the incidence of mental
health problems is correlated directly with social integration (Faris and
Dunham, 1939; Srole et al., 1962).
In more recent times, this ecological picture has been confirmed in rela-
tion to the incidence of psychosis, suicide and psychiatric admissions in
ethnic minority patients living in areas with low levels of those from their
background (Boydell et al., 2001). While this point about ‘ethnic density’
specifically helps us to understand mediating processes about ethnic dis-
advantage, it also helps more generally to understand the importance for
mental health of ‘social belonging’.
Taken together, the above findings suggest two important aspects of
the connection between personal relationships and mental health. First,

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the social integration findings suggest that people have a need for group
belonging. A lack of group membership predicts the emergence of men-
tal health problems and relapse. Second, embedded in group belonging
is the opportunity for particular intimate relationships (some of which is
expressed in long-term sexual bonding). These intimate and ‘close confiding’
relationships provide the conditions of stable security emphasized by
Bowlby and other attachment theorists.
Both aspects are important for people who already have mental health
problems. On the one hand, they are prone to stigmatization and social
rejection and on the other they are more likely to live single lifestyles. They
frequently then suffer a double psychological disadvantage to add to their
primary mental health difficulties (the high levels of historical personal
adversity noted in an earlier section of this article). For this reason, suc-
cessful recovery from mental health problems may involve finding ways
of reversing this double impediment to social integration in people whose
childhood experiences were disproportionately adverse (Mental Health
Foundation, 2000).

Relational and technological aspects of mental health

treatments
Outcome research in psychological therapies often entails the investiga-
tion of particular models of therapy like cognitive-behavioural therapy
(CBT) and their effectiveness in remedying particular conditions, such as
depression. However, extensive and repeated research on the link between
process and outcome has demonstrated that the quality of the relationship
consistently predicts outcome, independent of the espoused model or con-
dition being treated. Variability in this regard occurs within and across
models and new therapists can be as effective as more experienced ones.
This suggests that the qualities of the therapist (e.g. benign reliability and
warmth) and the client (e.g. actively expressing the need for trust in a reli-
able helper) are important in interaction. For example, a benign reliable
therapist may use a model that does not make sense to a client who is
seeking help and the client drops out. Thus it is the relationship, rather
than qualities in each party per se, that appears to be important in predict-
ing outcome.
A variety of concepts have been used to describe this aspect of the
relationship. One has been the ‘placebo effect’ and another is the ‘therapeutic
alliance’ (also called the ‘working alliance’ or ‘therapeutic bond’ in the lit-
erature). These terms refer to an interpersonal process, which has some in-
herent power to create health gain. Pentony (1981) argued that some
forms of therapy are explicitly governed by the active power of the placebo
effect (Fish, 1973) and some reviewers have endorsed a pan-model ubiquity
for its role (Frank, 1973) or even drawn attention to the commonalities of
therapists and witchdoctors (Torrey, 1972).

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In line with this reasoning, Carl Rogers (1957), the first promoter of client-
centred counselling, argued that the ‘therapeutic triad’ of genuineness, non-
possessive warmth and accurate empathy were the necessary and sufficient
conditions to bring about positive psychological change. This assumption
seemed to be endorsed by the first wave of process-outcome research in the
1960s (Truax and Mitchell, 1971).
Distinctions between placebo and alliance factors to account for the in-
trinsic beneficial power of the relationship have been much debated. The
placebo notion is mainly derived from bio-medical research on drugs, where
a dummy is used in the ‘placebo arm’ of double-blind randomized con-
trolled trials. Psychotherapy researchers have pointed out that any control
group that entails human contact could contain influential interpersonal
effects and so reject the notion of placebo on logical grounds because
double-blindness is not an option (Horvath and Greenberg, 1995).
One resolution has been to study the more neutral notion of ‘common
factors’ (referring to relationship factors), which can be distinguished from
‘specific factors’ (operationalized from models or techniques of therapy)
in trials (Lambert and Bergin, 1994). With these debates in mind, the
process-outcome research (Bower and Barkham, 2006; Barkham, 2007) has
found that:
• Overall, treatment groups and placebo groups are more effective than no
treatment groups in controlled trials. However, most studies show no differ-
ence or equivocal results when the treatment and placebo groups are com-
pared. This narrow or absent gap between treatment groups and placebo
groups is also found in drug trials about mental health problems, for example
studying anti-depressants, reminding us of the personal dimension to any
receipt of treatment (Dowrick, 2004).
• Patients of effective therapists report feeling well understood. Thus empathy
and a common understanding between the parties predicts outcome. This
empathic connection seems to occur very early in successful therapeutic
partnerships. This is what constitutes the ‘therapeutic alliance’. It includes
rapport, hope, trust, common understanding and bonding and so has linguistic,
social and affective dimensions. The upshot is that a supportive, warm positive
attitude of the therapist, who speaks a language that the client understands,
encountered and trusted by that client, predicts therapeutic success.
• This consistent finding about the therapeutic alliance can be contrasted with
the highly equivocal or absent findings about the positive correlation between
therapeutic success and the therapist’s: preferred model; age or experience;
gender; verbal style; professional background; or ethnicity.

While most of the research on the link between a positive therapeutic alli-
ance and good outcomes has focused on ‘common mental health problems’
of anxiety and depression, a similar pattern is emerging in studies of the
psychological treatment of psychotic patients. However, because the latter
function less well interpersonally in general, this effect of the alliance is
present but less strong and it seems to be a mediator of other important

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aspects of treatment (for example, attendance and completion of agreed
inter-sessional tasks) (Dunn et al., 2006).
These findings highlight the importance of relationality, rather than tech-
nique, in professional services for those with mental health problems. That
conclusion appears to be at odds with the political and professional ad-
vocacy of new technologies that can deliver therapy impersonally (computer-
based therapy).
Computer-based cognitive behavioural therapy (CCBT) has been intro-
duced in recent years without the need for a trained therapist, or with their
minimal involvement. Various versions of this shift towards technology-
mediated self-help exist, which range from completely computerized ver-
sions, such as Beating the Blues, to facilitated self-help by a practitioner
and a model with minimal intervention from a non- or minimally trained
professional. CCBT is seen as an ‘effective first line tool within a stepped
care framework for the management of common mental health problems’
based on self-reported improvements in anxiety and depression (Cavanagh
et al., 2006: 500). However, research on the use of this new technology
suggests that the importance of relationality does indeed become clear,
rather like when a clock stops ticking, if it is suddenly removed.
What is striking is that compared to self-help interventions for physical
complaints or at least those with a large somatic component, such as irrit-
able bowel syndrome, self-help using such a model seems to be relatively
ineffective. Studies using similar self-help technology produced significant
changes for irritable bowel syndrome in terms of reductions in primary care
consultations and in perceived symptom severity (Robinson et al., 2006).
However, in relation to mental health those receiving a self-help booklet did
not provide additional benefit to patients on a waiting list for psychological
therapy (Mead et al., 2005).
One possible reason for this outcome seems to be the importance, or
relevance, given to the role of the therapist. Thus studies exploring the ac-
ceptability of this model for patients in primary care with ‘common mental
health problems’ found that while there was, in principle, an acceptance of
the manual CBT which focuses on symptom resolution, patients were also
keen to seek insights into the cause of their difficulties (Macdonald et al.,
2007). Moreover, subjectively people encountering self-help as an option
find difficulty in limiting the professional role to that of facilitator. Instead,
participants intuitively make assumptions about the presence of a thera-
peutic relationship. They attempt to re-frame and make sense of self-help
through expectations of seeing a therapist and of developing a helping
relationship (Rogers et al., 2004).
In another study of compliance with psychotic patients with medication,
there was further evidence of the recurrent need for relationality. Here the
technical intervention was not CBT but drugs. The researchers were inter-
ested in monitoring and reporting compliance with the latter in the light
of information supplied to encourage and enable patient co-operation.

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 Pilgrim et al.: Personal Relationships and Mental Health Problems

The participants did not attribute help to the information supplied but, in-
stead, emphasized the helpfulness of the patient-centredness of the research
interview itself. The latter was contrasted favourably with the types of con-
versation they were used to during service contact (Rogers et al., 2003).

Re-visiting the health and social care context

For readers of an environmentalist or humanistic persuasion, the brief
summary above of large bodies of knowledge may well invite a ‘so what?’
response. However, the case we present can be set in a professional context,
in which two dominant discourses have existed for the past 100 years about
mental health. The first is the neo-Kraepelinian orthodoxy in psychiatry.
It culminated at the turn of this century with the ‘decade of the brain’, in
which it was promised that all manner of psychological differences and
social problems could be rendered explicable by neuroscience. As one of its
champions, Samual Guze (1989), asked rhetorically: ‘biological psychiatry:
is there any other kind?’ And biological triumphalism appears again here
from a leading psychiatric historian, Edward Shorter (1998: vii): ‘if there is
one central intellectual reality at the end of the 20th century, it is that the
biological approach to psychiatry – treating mental illness as a genetically
influenced disorder of the brain chemistry – has been a smashing success’.
Despite the surface appeal to the authority of up-to-date modern med-
ical science and its breathless incremental breakthroughs, this position,
articulated well by Guze and Shorter, is virtually indistinguishable from
that held at the end of the 19th century. At that time Emil Kraepelin pro-
nounced that mental illnesses were naturally occurring categories involving
forms of genetically determined damage to the nervous system.
The Kraepelinian position was consistent with the eugenic consensus
in Europe and North America of the period. But, with the eugenic logic
finding its place of disgrace in Nazi Germany, when psychiatrists murdered
their patients as part of the final solution to racial imperfection (Meyer,
1988), the bio-determinist legacy for psychiatry was not extinguished. In the
second half of the 20th century the hereditarian approach to mental dis-
order not only persisted within psychiatry, it grew in confidence as a taken-
for-granted fact. The science of psychiatric genetics from 1930s Munich
found its post-war exported champions in Eliot Slater in the UK and Franz
Kallmann in the USA, whose work is still influential globally today in
psychiatry (Pilgrim, 2008).
Our summary of inter-disciplinary evidence, which endorses the centrality
of relationships in understanding mental health, does not imply the need to
reject the role of individual biology. However, it puts skin-encapsulated
factors in a subordinate role. Environmental intra-uterine conditions and
the quality of care in early infancy directly impact on our neurological
development. Trauma and deprivation markedly affect our brain chemistry.
When this occurs in childhood, structural impairment to the nervous system

247
health: 13(2)
occurs, which awaits reactivation in later life by stress, precipitating experi-
enced distress (Heim et al., 2004). Both the impairment and the reactivation
occur in interpersonal contexts, with the dynamics of the reactivation
pointing to those in childhood.
The ‘biopsychosocial model’ triggered by Adolf Meyer (Engel, 1980;
Pilgrim, 2002) still awaits its true and full expression in contemporary psy-
chiatry: psychological, and particularly social, factors tend still to be the
flimsy afterthought of ‘the environment’. A prestigious recent debate with-
in the Royal College of Psychiatrists (Kingdon and Young, 2007) about
biological determinants of mental disorder has demonstrated that a truly
balanced biopsychosocial model has still not become the norm in the pro-
fession. If it had, the debate would not have been needed.
The second contextual point that encourages the need to state or re-
state the case for the centrality of personal relationships in the production
and improvement of mental health implicates the professional competition
to biological psychiatry. A range of psychological technologies emerged
in the 20th century. They brought with them particular ways of formulating
mental health problems and proffered preferred ways of rectifying distress
and dysfunction.
These bids for legitimacy involved the need to demonstrate the particular
value of intervening in this, rather than that, way in the lives of others. This
has culminated in a current policy discourse in which particular models
are idealized or demonized, deflecting us from the repeated evidence that
any model is far less predictive of outcome than the therapeutic alliance
(Lambert, 2007; Jarrett, 2008).
A discomforting implication of our accumulating case in this article is
that maybe particular professional rationales or psychotherapeutic models
are not very persuasive, compared to the personal aspects of their embodied
practice. Despite this conclusion, a strong belief in the ‘technical fix’ for
mental health problems, when models and techniques are privileged over
people-in-relationships persists. Recently the British government has an-
nounced further investment in CBT for common mental health problems
on the grounds that it can ‘cure’ them in the way that an antibiotic cures
an infection. Nothing appeared in this announcement about the evidence
base we highlight about the therapeutic alliance or placebo effect.
If our case in this article is persuasive, then mental health improvements
would arise not from technical fixes (be they biological or psychological)
but in a raft of social policies about child protection and parenting, poverty
reduction, secure employment and those forms of community organization,
which increase the chances of benign supportive networks or social capital.
A further implication of the case we set out is that health and social care
services dealing with people with mental health problems should attend
primarily to the quality of the relationships developed with their clients.
They should not focus narrowly on the particular technological interven-
tions they provide or their ‘commissioner’s’ demand. ‘Evidence-based

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 Pilgrim et al.: Personal Relationships and Mental Health Problems

commissioning’ is naïve and inadequate, when and if it ignores the evidence

about relationality.
The interpersonal nuances of trust, recognition and respect are dispro-
portionately undermined when people are deemed to have lost their reason.
Mental health services thus should focus not on clever technical fixes but
instead play their part in the reversal of the stigmatization and margin-
alization, which diminish the chances of respectful supportive relationships
in the life worlds of people with mental health problems.

Note
1. An exception is the study by Spataro et al. (2004). However, this study was
limited by the inclusion only of individuals whose sexual abuse had been
reported to the police, and by the young age of the sample at the time of
assessment (males = 21.3 years, females = 28.4 years).

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Author biographies
david pilgrim is Professor of Mental Health Policy at the University of Central
Lancashire. His academic interests include the history of mental health services,
mental health legislation and the sociology of the mental health professions. His
books include the SAGE publications Key concepts in mental health, psychotherapy
and society and A short introduction to clinical psychology (with Katherine
Cheshire).

anne rogers is Professor of the Sociology of Health Care, School of Community

Based Medicine, University of Manchester. Her research interests include mental
health and the self-management of long-term conditions. The third edition of her
A sociology of mental health and illness (with David Pilgrim), published by Open
University Press, won the British Medical Association’s Medical Book of the Year
for 2006.

richard bentall is Professor of Clinical Psychology at the University of Bangor.

His particular interests are in the scientific adequacy of psychiatric classification and
the psychological investigation of psychotic symptoms. He has published widely on
the latter topic; his Madness explained: Psychosis and human nature (published by
Penguin) won the British Psychological Society’s book award for 2004.

254
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