J 1464-0597 2008 00354 X

APPLIED PSYCHOLOGY: AN INTERNATIONAL REVIEW, 2008, 57, 5470
doi: 10.1111/j.1464-0597.2008.00354.x
Positive Psychology and the Illness Ideology:

Toward a Positive Clinical Psychology
MADDUX
Original
POSITIVE
Articles
CLINICAL
PSYCHOLOGY
Blackwell
Oxford,
Applied
APPS
1464-0597
0269-994X
XXX
International
UK
Psychology
Publishing
Association
Ltd
for Applied Psychology, 2008
James E. Maddux*
George Mason University, USA
This article challenges traditional views of the proper subject matter of clinical
psychology, the nature of psychological adjustment and maladjustment, and
the roles and functions of clinical psychologists. Toward this end, the article
discusses clinical psychologists conceptions of psychological adjustment and
maladjustment and of the difference between psychological adjustment and
maladjustment. It describes and challenges the illness ideology that has prevailed in clinical psychology for the past centuryan ideology that has been
socially constructed rather than scientically constructed. This ideology
consists of not only a set of assumptions about the nature of psychological
adjustment and the territory of clinical psychology but also a language that
inuences the way clinical psychologists and others think about the eld. It
then offers a statement of a new mission for and vision of clinical psychology
based on the values of positive psychology.
Cet article interroge lapproche traditionnelle des questions spcifiques la
psychologie clinique, la nature de ladaptation et de linadaptation psychologiques,
et les rles et fonctions des psychologues cliniciens. A cette fin, on examine les
conceptions des cliniciens concernant ladaptation et linadaptation psychologiques,
ainsi que la diffrence entre ces deux notions. On dcrit et conteste lidologie
de la maladie qui a prvalu en psychologie clinique au cours du dernier sicle,
une idologie qui a t labore socialement plutt que scientifiquement. Cette
idologie renvoie non seulement une srie daffirmations sur la nature de
ladaptation psychologique et le territoire de la psychologie clinique, mais
aussi un langage qui influence la faon dont les psychologues cliniciens
(et dautres aussi) abordent ce domaine. On propose ensuite, partir des
valeurs de la psychologie positive, une vision de la psychologie clinique
dbouchant pour elle sur une nouvelle mission.
INTRODUCTION
My main purpose in this article is to challenge traditional views of the
proper subject matter of clinical psychology, the nature of psychological
adjustment and maladjustment, and the roles and functions of clinical
* Address for correspondence: James E. Maddux, Department of Psychology, George
Mason University, Fairfax, VA 22030, USA. Email: jmaddux@gmu.edu
2008 The Author. Journal compilation 2008 International Association of Applied
Psychology. Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ,
UK and 350 Main Street, Malden, MA 02148, USA.
POSITIVE CLINICAL PSYCHOLOGY
55
psychologists. I will also offer a statement of a new mission for and vision
of clinical psychology based on the values of positive psychology. Toward
this end, I will be concerned with clinical psychologists conceptions of
psychological adjustment and maladjustment and especially with conceptions
of the difference between psychological adjustment and maladjustment. More
specically, I will be concerned with how clinical psychologists traditionally
have conceived of this difference and how positive psychology suggests they
should conceive of this difference.
A conception of the difference between psychological adjustment and maladjustmentor between healthy and pathological psychological functioning
(psychopathology)is not a theory of healthy or pathological psychological functioning (Wakeeld, 1992). A conception of the difference between
healthy and pathological psychological functioning attempts to dene these
terms and to delineate which human experiences are to be considered healthy
(and therefore encouraged) and which are to be considered pathological
(and therefore discouraged or treated). More specically, a conception of
psychopathology does not try to explain the psychological phenomena
that are viewed as pathological but instead tells us what psychological phenomena should be viewed as unhealthy or pathological and therefore need to
be explained and eliminated through treatments. Explaining those psychological phenomena and experiences that have been identied by the conception as pathological is the function of theories of psychopathology (see also
Maddux, Gosselin, & Winstead, 2007).
Conceptions of psychological health and pathology are important for a
number of reasons. As medical philosopher Lawrie Reznek (1987) has said,
Concepts carry consequencesclassifying things one way rather than another
has important implications for the way we behave towards such things (p. 1).
In speaking of the importance of the conception of disease, Reznek wrote:
The classication of a condition as a disease carries many important consequences. We inform medical scientists that they should try to discover a
cure for the condition. We inform benefactors that they should support such
research. We direct medical care towards the condition, making it appropriate to treat the condition by medical means such as drug therapy, surgery,
and so on. We inform our courts that it is inappropriate to hold people
responsible for the manifestations of the condition. We set up early warning
detection services aimed at detecting the condition in its early stages when it
is still amenable to successful treatment. We serve notice to health insurance
companies and national health services that they are liable to pay for the
treatment of such a condition. Classifying a condition as a disease is no idle
matter. (p. 1)
Likewise, how we conceive of psychological health and pathology has wideranging implications for individuals, medical and mental health professionals,
Psychology.
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MADDUX
government agencies and programs, and society at large. It determines what

behaviors we consider it necessary to explain with our theories, thus determining the direction and scope of our research efforts. It also determines
how we conceive the subject matter of clinical psychology, the roles and
functions of clinical psychologists, and the people with whom they work.
Unlike theories of psychological health and pathology, conceptions of
psychological health and pathology cannot be subjected to empirical validation. One cannot conduct research to determine if one conception is more
valid or true than another. They are social constructions grounded in values,
not science, and socially constructed concepts cannot be proven true or
false. (I will return to this issue later in this article.)
THE ILLNESS IDEOLOGY AND CLINICAL PSYCHOLOGY

The conception of psychological health and pathology that has held sway
over clinical psychology for at least the past century is the illness conception
or illness analogy (sometimes referred to as the medical analogy or medical
model ). The inuence of the illness conception on clinical psychology
begins with the term clinical psychology itself. Clinical derives from the
Greek klinike or medical practice at the sickbed, and psychology derives
from psyche, meaning soul or mind (Websters Seventh New Collegiate
Dictionary, 1976). Long after the ancient roots of the term clinical psychology have been forgotten, they continue to inuence our thinking about the
discipline. Although few clinical psychologists today literally practice at
peoples 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 in an illness analogy
as evidenced by the fact that the language of medicine remains the language
of clinical psychology. Terms such as symptom, disorder, pathology, illness,
diagnosis, co-morbidity, treatment, doctor, patient, clinic, clinical, and clinician
are all consistent with the ancient assumptions captured in the term clinical
psychology and with an analogy of illness and disease.
Clinical psychology is steeped in more than just an illness analogy; it is
steeped in an illness ideology. Although the illness analogy prescribes a
certain way of thinking about psychological pathology (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.
Specically, 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. It emphasises abnormality over normality, poor adjustment
over healthy adjustment and sickness over health. It promotes dichotomies
between normal and abnormal behaviors, between clinical and non-clinical
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57
problems, and between clinical and non-clinical populations. It locates human

adjustment and maladjustment inside the person rather than in the persons
interactions with the environment and encounters with social and cultural
values and societal institutions. Finally, it portrays people who seek help for
psychological and behavioral difculties as passive victims of intra-psychic
and biological forces beyond their direct control. As a result, they are relegated to the passive reception of an experts care.
Despite the illness ideologys 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 rst psychological
clinic in the United States at the University of Pennsylvania by Lightner
Witmer (Reisman, 1991). Witmer and the other early clinical psychologists
worked primarily with children who had learning or school problemsnot
with patients with mental disorders (Reisman, 1991; Routh, 2000). Thus,
they were more inuenced by psychometric theory and its emphasis on careful
measurement than by psychoanalytic theory and its emphasis on psychopathology and illness. Following Freuds momentous 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 eld. 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 psycho-diagnosticians under the direction of psychiatrists trained in medicine and psychoanalysis. Second, after
World War II, the United States Veterans Administration encouraged the
American Psychological Association to establish standards of training and
practice for doctoral-level clinical psychologists and then developed training
programs consistent with those standards. 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).
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By the 1950s, clinical psychologists in the United States had come to see
themselves as part of a mere subeld of the health professions (Seligman
& Csikszentmihalyi, 2000, p. 6). By this time, the practice of clinical psychology was grounded rmly in the illness ideology and was characterised
by four basic assumptions, described below, about its scope and the nature
of psychological adjustment and maladjustment (Barone et al., 1997).
First, clinical psychology would be concerned with psychopathology
deviant, abnormal, and maladaptive behavioral and emotional conditions.
Thus, the focus was not on facilitating mental health but on alleviating mental
illness; 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.
Second, psychopathology, clinical problems, and clinical populations differ
in kind, not just in degree, from normal problems in living, non-clinical problems, and non-clinical populations. Psychopathologies are disorders, not
merely extreme variants of common problems in living and expected human
difculties 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 similar in important ways to biological
or medical diseases in that they reect 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 persons 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 xed 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 clinicians
task, similar to the medical clinicians task, is to identify (diagnose) the
disorder (disease) inside the person (patient) and to prescribe an intervention (treatment) to eliminate (cure) the internal disorder (disease). This
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59
treatment consists of alleviating the internal conditions, either biological or

psychological, that are presumed to be responsible for the external 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 successful 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 are
thought to 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.
Once clinical psychology became pathologised, 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 aw 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 scientistpractitioner model of clinical psychology training was established. Albee
argues that this fatal aw 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 inuence of the illness ideology has grown over the past two and
half decades as clinical psychologists have fallen more and more deeply
under the spell of the American Psychiatric Associations Diagnostic and
Statistical Manual of Mental Disorders (DSM) (APA, 2000). First published
in the early 1950s (APA, 1952), the DSM is now in its fourth edition (actually
the sixth if one counts as editions the revisions of the third and fourth
editions, in 1987 and 2000 respectively), and its size and inuence have
increased with each revision. Through the rst two editions (1952 and 1968),
the inuence of the DSM on research, practice, and clinical training was
negligible, but it increased exponentially after the publication of the greatly
expanded 3rd edition in 1980.
The inuence of the DSM has increased with the increasing size of the
subsequent revisions. The DSM now provides the organisational 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 inuence 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
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MADDUX
power of the illness ideology over clinical psychology more evident than in
the dominance of the DSM.
Although most of the assumptions of the illness ideology noted previously
are explicitly disavowed by the DSM-IVs introduction (APA, 1994), practically every word thereafter is inconsistent with this disavowal. For example,
mental disorder is dened as a clinically signicant behavioral or psychological syndrome or pattern that occurs in an individual (p. xxi, emphasis
added), and numerous common problems in living are viewed as mental
disorders. So steeped in the illness ideology is the DSM-IV that, for example,
afliation, anticipation, altruism, and humor are described as defense
mechanisms (p. 752). So closely aligned are the illness ideology and the
DSM, and so powerful is the inuence of the DSM over clinical psychology
(at least in the United States) that a rejection of the illness ideology would
require the rejection of the DSM as the best way to conceive of psychological difculties.
The illness analogy and the illness ideology have outlived their usefulness
for clinical psychology. Decades ago, the eld of medicine began to shift its
emphasis from the treatment of illness to the prevention of illness; moreover, more recently medicine has moved from the prevention of illness to the
enhancement of health (Snyder, Feldman, Taylor, Schroeder, & Adams, 2000).
Furthermore, almost three decades ago, the new eld of health psychology
acknowledged the need to emphasise 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 two or three decades (Wilson, 1993). It is time to abandon
the illness ideology and replace it with a positive psychology approach that
is grounded in positive psychologys emphasis on health, happiness, and
human strengths. 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 ideologys premise that normal problems in living are
symptoms of psychopathologiesthat is, psychological illness or disease.
THE SOCIAL CONSTRUCTION OF CONCEPTIONS OF

PSYCHOLOGICAL HEALTH AND PATHOLOGY
The refutation of the illness ideology is based on the assumption that the
illness ideology is not a scientically testable theory but rather is a socially
constructed set of assumptions and values. 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. 34; see also Gergen, 1999). Social constructionism is concerned
with examining ways in which people understand the world, the social and
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political processes that inuence how people dene words and explain
events, and the implications of these denitions and explanationswho
benets 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 assumptions and values depend on who has the
power to determine them, universal or true conceptions and perspectives
do not exist. The people who are privileged to dene such views usually are
people with power, and their conceptions reect and promote their interests
and values (Muehlenhard & Kimes, 1999). Because the interests of people
and institutions are based on their values, debates over the denition of
concepts often become clashes between deeply and implicitly held beliefs
about the way the world should work, the way people should live their lives,
and even the difference between right and wrong and moral and immoral.
Not surprisingly, we typically refer to psychological concepts as constructs
because their meanings are constructed and negotiated rather that discovered or revealed (Maddux, 1999). The ways in which conceptions of basic
psychological constructs such as the self (Baumeister, 1987) and selfesteem (Hewitt, 2002) have changed over time and the different ways they
are conceived by different cultures (e.g. Cushman, 1995; Hewitt, 2002; Cross
& Markus, 1999) illustrate this process. Thus, from a social constructionist
perspective, all categories of disorder, even physical disorder categories
convincingly explored scientically, are the product of human beings constructing meaningful systems for understanding their world (Raskin &
Lewandowski, 2000, p. 21).
The social constructionist perspective can be contrasted with the essentialist
perspective that is inherent in the illness ideology. The essentialist perspective on human diversity assumes that there are natural categories or people
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 based on empirically veriable similarities among and differences
between people (Rosenblum & Travis, 1996, p. 2) that are independent of
social or cultural processes. 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) and therefore such categories represent not what
people are but rather the ways that people think about and attempt to make
sense of differences among peopleincluding what differences among
people are viewed as more important than other differences (Rosenblum &
Travis, 1996).
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Thus, from the essentialist perspective, the distinctions between psychological health and pathology and the differences 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 dened by people and thus
reect 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 scientically veriable facts or even
scientically testable theories. 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 denitions.
The social construction of psychopathology works something like this.
Someone observes a pattern of behaving, thinking, feeling, or desiring that
deviates from some social norm or ideal or identies a human weakness or
imperfection that, as expected, is displayed with greater frequency or severity
by some people than others. A group with inuence and power decides that
control, prevention, or treatment of this problem is desirable or protable.
The pattern is then given a scientic-sounding name, preferably of Greek or
Latin origin. The new scientic name is capitalised. Eventually, the new
term may be reduced to an acronym, such as OCD (Obsessive-Compulsive
Disorder), ADHD (Attention-Decit/Hyperactivity Disorder), and BDD
(Body Dysmorphic Disorder). The new disorder then takes on an existence
of its own and becomes a disease-like entity. As news about it spreads,
people begin thinking they have it; medical and mental health professionals
begin diagnosing and treating it; and clinicians and clients begin demanding that health insurance policies cover the treatment of it. Once the
disorder has been socially constructed and dened, the methods of science
can be employed to study it, but the construction itself is a social process,
not a scientic one. In fact, the more it is studied, the more everyone
becomes convinced that it really is something.
Mental health professionals have not been content to label only obviously
and blatantly dysfunctional patterns of behaving, thinking, and feeling as
mental disorders. Instead, we have dened the scope of psychopathology
to include many common problems in living. Consider some of the mental
disorders found in the DSM-IV. Cigarette smokers have Nicotine Dependence. If you drink large quantities of coffee, you may develop Caffeine
Intoxication or Caffeine-Induced Sleep Disorder. If you have a preoccupation with a defect in appearance that causes signicant distress or impairment in . . . functioning (p. 466), you have a Body Dysmorphic Disorder.
A child whose academic achievement is substantially below that expected
for age, schooling, and level of intelligence (p. 46) has a Learning Disorder.
Toddlers who throw tantrums have Oppositional Deant Disorder. Not
wanting sex often enough is Hypoactive Sexual Desire Disorder. Not wanting
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sex at all is Sexual Aversion Disorder. Having sex but not having orgasms
or having them too late or too soon is an Orgasmic Disorder. Failure (for
men) to maintain an adequate erection . . . that causes marked distress or
interpersonal difculty (p. 504) is Male Erectile Disorder. Failure (for
women) to attain or maintain an adequate lubrication or swelling response
of sexual excitement (p. 502) accompanied by distress is Female Sexual
Arousal Disorder.
The past few years have witnessed media reports of epidemics of internet
addiction, road rage, job burnout, and shopaholism. Discussions of
these new disorders have turned up at scientic meetings and in courtrooms.
They are likely to nd a home in the next revision of the DSM if the media,
mental health professions, and society at large continue to collaborate in
their construction and if treating them and writing books about them
become lucrative.
Therefore, conceptions of psychological normality and abnormality and
specic diagnostic labels and categories are not facts about people but socially
constructed abstract concepts that reect shared worldviews that were
developed and agreed upon collaboratively over time by the members of
society (e.g. theorists, researchers, professionals, their clients, the media,
and the culture in which all are embedded). For this reason, the illness
ideology, its conception of psychology health and pathology, and the various specic 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 scientic theories. Instead, they are heuristic social artifacts that serve the same social and cultural goals as do our
constructions of race, gender, social class, and sexual orientation, such as
maintaining and expanding the power of certain individuals and institutions
and maintaining the social order as dened by those in power (Beall, 1993;
Becker, 1963; Parker, Georgaca, Harper, McLaughlin, & Stowell-Smith,
1995; Rosenblum & Travis, 1996). As with these other social constructions,
our concepts of psychological normality and abnormality are tied ultimately
to social valuesin particular, the values of societys most powerful individuals,
groups, and institutionsand the contextual rules for behavior derived from
these values (Becker, 1963; Parker et al., 1995; Rosenblum & Travis, 1996).
Resnek (1987) has demonstrated that even our denition 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). If this is true of physical
disease, it certainly is true of psychological disease. Because our notions
of psychological normalityabnormality and healthillness are social constructions that serve social and cultural goals and values, they are linked to
our assumptions about how people should live their lives and what makes
life worth living.
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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 pathologising of human existence.
The increasing heft and weight of the DSM, which has been accompanied
by its increasing inuence over clinical psychology, provides evidence for
this. From 1952 to 1994, the DSM increased from 86 to almost 900 pages,
and the number of mental disorders increased from 106 to 297. As the
socially constructed boundaries of mental disorder have expanded with
each DSM revision, more relatively mundane human behaviors have become
pathologised; 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) gradually have pathologised
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, or efcient will become a mental disorder.
The powerful social, cultural, 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 denition
of a socially constructed abstraction and over the personal, political, and
economic benets that ow 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 (see Kirk & Kutchins, 1992; Kutchins &
Kirk, 1997).
These debates and struggles are described in detail by Allan Horwitz in
Creating Mental Illness (2002). According to Horwitz:
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 specic historical circumstances and because of
the interests of specic 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 beneted a number of specic 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)
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65
Psychiatrist Mitchell Wilson (1993) offered a similar view. He argued that

a non-categorical, 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 difculties 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). According to Wilson, 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 scientic facts.
A social constructionist perspective is not anti-science. To assume that
conceptions of psychological health and pathology are socially constructed
rather than scientically derived is not to assume that human psychological
distress and suffering are not real nor that the patterns of thinking, feeling,
and behaving that society decides to label as pathological cannot be studied
objectively and scientically. It is to acknowledge, however, that science can
no more determine the true or correct conceptions of psychological
health and pathology than it can determine the true and correct conception of other social constructions such as beauty, justice, race, and social
class. We nonetheless can use the methods of science to study the psychological phenomena that our culture refers to as healthy and pathological
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. We also can use the methods of science to
understand a cultures conception of psychological wellness and illness, how
this conception has evolved, and how it affects individuals and society.
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 scientically constructed. As Lilienfeld and Marino (1995) note, it
is important to make the value judgments underlying these decisions more
explicit and open to criticism (p. 418). They also note that although heated
disputes would almost surely arise concerning which conditions are deserving
of attention from mental health professionals [these] disputes . . . would at least
be settled on the legitimate basis of social values and exigencies, rather than on
the basis of ill-dened criteria of doubtful scientic status (pp. 418419.)
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BEYOND THE ILLNESS IDEOLOGY: POSITIVE

CLINICAL PSYCHOLOGY
The viability of clinical psychology depends on our ability to build a positive
clinical psychology. 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 their clients (Seligman
& Csikszentmihalyi, 2000).
In building a positive clinical psychology, we must adopt not only a new
approach and set of values 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,
including the larger culture. Also, those who seek assistance in enhancing
the quality of their lives are clients or students, not patients. The professionals
who specialise 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. 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 peoples homes rather than in specialised facilities.
Positive psychology emphasises 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-organising and self-directed, and with recognising
that people and experiences are embedded in a social context (Seligman
& Csikszentmihalyi, 2000, p. 8).
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 decits (see Lopez &
Snyder, 2003). More specically, 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.
A clinical psychology that is grounded not in the illness ideology but in the
values of positive psychology rejects: (1) the categorising and pathologising
of humans and human experience; (2) the assumption that so-called mental
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67
disorders exist in individuals rather than in the relationships between the

individual and other individuals and the culture at large; and (3) the notion
that understanding what is worst and weakest about us is more important
than understanding what is best and bravest.
Psychological assessments and clinical interventions grounded in positive
psychology will not differ from those grounded in the illness ideology as much
in the how? as in the what? The most important differences are not in
strategies or tactics of assessments and interventions. Instead, they are in the
domains of psychological functioning that are the focus of assessment and
in the kinds of changes in human psychological functioning that interventions
are designed to facilitate. Positive psychological assessment will emphasise
the evaluations of peoples strengths and assets along with their weaknesses
and deciencies (Keyes & Lopez, 2002; Lopez, Snyder, & Rasmussen, 2003;
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 deciencies
(Lopez et al., 2003). Positive psychological interventions will emphasise the
enhancement of peoples strengths and assets in addition to, and at times
instead of, the amelioration of their weaknesses and deciencies, secure in
the belief that strengthening the strengths will weaken the weaknesses. The
interventions most often will derive their strategies and tactics from traditional treatments of traditional psychological disorders. The efcacy of
this new focus in improving the human condition remains to be examined.
Consistent with the social constructionist perspective, I am not arguing
that the positive psychology approach is more true than the illness ideology. Both are socially constructed views of the world, not scientically
testable theories. I am arguing, however, that positive psychology offers a
set of values that is more useful to clinical psychology than is the obsolete
illness ideology. I have no new facts or research ndings that I can use
to persuade the reader of the greater efcacy of clinical psychological interventions grounded in positive psychology over those grounded in the illness
ideology. Conceptions themselves do not offer new facts and ndings;
instead, they are concerned with what one views as facts and as ndings,
how one organises existing facts and ndings, and, perhaps most important, what questions one considers worthy of attention. The illness ideology
is concerned with telling us what should be changed, not with how it should
be changed. The same is true of positive psychology. The greater utility of
positive psychology 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 peoples quality of life. Unlike a negative
clinical psychology based on the illness ideology, a positive clinical psychology
is concerned not just with identifying weaknesses and treating or preventing
disorders, but also with identifying human strengths and promoting
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MADDUX
mental health. 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 tness,
pleasure, and personal fulllment through the free pursuit of chosen and
valued goals.
The major change for clinical psychology, however, is not a matter of
strategies and tactics for how to change behavior, but a matter of vision and
mission. As Bandura (1978) observed three decades ago:
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 benet 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. (pp. 99100).
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APPLIED PSYCHOLOGY: AN INTERNATIONAL REVIEW, 2008, 57, 5470

Positive Psychology and the Illness Ideology:

POSITIVE CLINICAL PSYCHOLOGY

government agencies and programs, and society at large. It determines what

THE ILLNESS IDEOLOGY AND CLINICAL PSYCHOLOGY

POSITIVE CLINICAL PSYCHOLOGY

problems, and between clinical and non-clinical populations. It locates human

POSITIVE CLINICAL PSYCHOLOGY

treatment consists of alleviating the internal conditions, either biological or

THE SOCIAL CONSTRUCTION OF CONCEPTIONS OF

POSITIVE CLINICAL PSYCHOLOGY

POSITIVE CLINICAL PSYCHOLOGY

POSITIVE CLINICAL PSYCHOLOGY

Psychiatrist Mitchell Wilson (1993) offered a similar view. He argued that

BEYOND THE ILLNESS IDEOLOGY: POSITIVE

POSITIVE CLINICAL PSYCHOLOGY

disorders exist in individuals rather than in the relationships between the

mental health. It is concerned not just with alleviating or preventing

POSITIVE CLINICAL PSYCHOLOGY

Becker, H.S. (1963). Outsiders. New York: Free Press.

2008 The Author. Journal compilation 2008 International Association of Applied

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