Part IV of my paper "The Question of Normal"
A more common view of mental health is well illustrated by psychiatrist Sally Satel (2009) in her article “To Fight Stigmas, Start With Treatment.” Satel wrote about how comprehensive treatment and subsequent societal success is the best way to resolve stigma toward the mentally ill. Her article examined the British television show, “How Mad Are You?”, the objective of which was for a group of psychiatrists to distinguish five people with mental disorders from a group of ten, the point being that appearance alone is not enough to determine mental illness. Only two of the mentally ill participants were properly identified, proving that even trained professionals cannot reliably identify mental disorders by appearance alone. Although this program was highly praised for encouraging viewers to “re-examine their preconceptions” (p. 2), Satel, criticized the show, asking “what would re-examination yield? The belief that people with serious mental illness are no different from everyone else? I hope not.”
Satel went on to acknowledge other anti-stigma campaigns, but only insofar as they fail to abolish mental illness. According to her, only treatment and subsequent success in society can diminish stigma. Finally, and rather subjectively, Satel suggested that altering the public’s view of mental illness depends entirely upon the successful treatment of the symptoms that set the mentally ill apart from the status quo. In Satel’s opinion, “treatment [is] the most effective destigmatizing force there is” (p. 2).
A more positive view of mental illness is offered by Martin Gayford (2005) in his article “Society Should Recognize Mental Illness as a Source of Creativity.” Having begun by recounting the tragic suicide of architect Francesco Borromini, who’s architecture was thought to be “too original for the age or reason” (p. 91), Gayford went on to mention the tragic lives and deaths of such artists as Vincent van Gogh and Virginia Woolf. He asked: could there have been “a relation between [their] mental peculiarities and [their] imaginative achievements?” (p. 85). He quoted poet John Dryden in saying “Great wits are sure to madness near allied/And thin partitions do their bounds divide.” He mentioned the plights of composer Hugo Wolf and poet William Cowper, who were plagued by bipolar disorder and depression respectively. Gayford asserted that artists affected by mental illness have the capacity to feel more than most of us, allowing them the enhanced intensity of experience that can lead to creativity. He included Plato’s position that poets are inspired by “divine fury” and Aristotle’s assertion that poets, philosophers, and artists tend to be “melancholic” (p. 85). Gayford observed that mental illness is neither necessary nor sufficient for creativity (p. 91), however, by having cited numerous historical examples of renowned artists who were, in fact, mentally ill, he proved the existence of a connection indeed. Though Gayford failed to insist upon the acceptability - daresay normalcy - of such uncustomary inspiration, he adeptly illustrated one walk of life where mental “instability” is actually accepted and perhaps desired. In the field of creativity, could mental illness actually be closer to the norm?
Dr. Peter Kramer (2009) furthered the discussion of normality with his article, “What is Normal?” Right away, Kramer stated that “diagnostic labels are proliferating, and mental disorders seem to be annexing ever more territory.” He even acknowledged psychiatry’s “narrowing of the normal,” agreeing that doctors abuse their degree-granted privilege to define normality (p. 76). He reinforced the report given by The National Institute of Mental Health that in a given year, over a quarter of Americans are diagnosed with a mental illness, while over a lifetime that number climbs to nearly half (p. 76). “To constrain normality is to induce conformity,” he warned, admitting that “the fate of normality is very much in the balance.” (p. 76). Having acknowledged the failure of doctors to recognize individuality, Kramer introduced the concept of “cosmetic psychoparmacology,” the current practice by psychiatrists of moving a person from one “normal” yet disfavored personality state, to another “normal” yet rewarded state — such as the transition from humility to self-assertion (p. 76). In such a way, even “normal” behaviors are being treated for their undesirability. Kramer discussed the current unreliable methods of diagnosis, suggesting that time may “push” this categorical model of mental health aside (p. 78). According to Kramer, if a divergence from the “norm” “confers some degree of vulnerability to dysfunction,” then we may all find ourselves “defective in one fashion or another” (p. 78).
The article “Am i NoRmaL?” by A. Paul (2005) is an interesting addendum to this concept. From Paul’s perspective, “what we call metal illness might once have had, and may still serve, highly adaptive functions” (para. 5). Paul (2005) introduced the notion that what we refer to as personality disorders are simply a series of traits in extreme - traits we all have to some extent. He suggested that “human nature can be refracted through personality traits” (para. 4), and that dysfunctional personalities aren’t as rare as once thought - affecting as many as one person in seven. He discussed the difference between personality types and personality disorders, concluding that the distinction lies mainly in the extremity of traits.
He noted that “many psychologists are shifting from the old you-have-it-or-you-don’t perspective on personality disorders (the ‘categorical’ model) to the more nuanced ‘dimensional’ model” (para. 10). In this new model, personality exists along a continuum with healthy traits on one end, and disordered traits on the other — with “innumerable gradations in between” (para. 10). Paul pointed out that the line dividing “normal” and “abnormal” has become far less important, and in some cases, even ignored by proponents of this new dimensional model. Paul contended that “context is everything” (para. 15), proposing that many of the behaviors belonging to personality disorders are actually adaptations once needed for survival. He noted, “that personality disorders once had their uses could explain why they are so prevalent today” (para. 22). Paul likened personality disorder treatment to that of a carpenter removing rough edges, adding that “the goal is to turn a personality disorder into a personality style—to help the personality-disordered patient become a functioning, healthy human being, with quirks and idiosyncrasies intact” (para. 30). “A person,” he concluded, “that is, a lot like you and me” (para. 30).
In “Shyness: How Normal Behavior Became a Sickness,” Christopher Lane (2007) outlined the ways in which shyness has, over the past couple of decades, progressed clinically from a “normal” behavior into an “illness” of pandemic proportions. He began by discussing the overwhelmingly large number of Americans now said to be affected by a “social phobia” or “social anxiety” (para. 2). Having explored data collected by Psychology Today, he confirmed that 18.7% of Americans currently suffer from a shyness-related disorder (para. 12). Lane noted that one reason for this is that psychiatrists require a “very low burden of proof” for their diagnoses (para. 4). Lane compared the pandemic of shyness to that of depression, signifying that the former is the “third-most-common psychiatry disorder behind only depressive disorder and alcohol dependence” (para. 12). He considered the process by which the DSM “assumed global authority” (para. 6), noting its method of “tackling a vast array of human experience, the[n] drain[ing] it of complexity and boil[ing] it down to blunt assertions that daily determine the fate of millions” (para. 6). Lane’s position is clear: “some shyness is expected in everyone” (para. 9). As lamented to Lane by a psychoanalyst, “we used to have a word for sufferers of ADHD. We called them boys” (para. 7).
In “Psychopathology: A Simple Twist of Fate or a Meaningful Distortion of Normal Development? Toward an Etiologically Based Alternative for the DSM Approach,” Professor Patrick Luyten (2006) discussed the assumptions behind the DSM, noting that “over the past decades, empirical studies have consistently failed to validate almost all of the major assumptions underlying the DSM approach” (p. 523). Though some argue for DSM reform, others, such as Luyten, call for a fundamental change in the approach itself. Luyten outlined the current assumptions underlying the DSM, including the initial assertion that “Disorders are categorically distinct from subclinical disorders and from normality” (p. 523). Much like Paul, Luyten asserted that “empirical research does not support a categorical view for most disorders” (p. 524). Instead, he argued, most disorders tend to be situated along a continuum (p. 524). This is made evident by the overwhelming number of individuals treated for personality problems that could not be officially diagnosed by the DSM. Luyten also explored the high rates of comorbidity, disproving the DSM’s rule that “Symptom disorders (coded on Axis I) are independent from personality disorders (coded on Axis II)” (p. 523). Luyten noted that the DSM’s “over-reliance on [only] manifest symptoms” has resulted in “poor validity” of diagnosis (p. 525). “The almost exclusive focus on symptoms in the DSM has also led to a preoccupation with symptom relief as the major expression and measure of the efficacy and effectiveness of treatment strategies,” he continued (p. 525).
Luyten (2006) analyzed Sidney Blatt’s view that “psychological disorders should be seen as the result of various distortions of the normal dialectic interaction between the development of self-definition and relatedness” (p. 526). In other words, that psychological disorders stem from an inaccurately developed perception of one’s relationship between oneself and others. According to Blatt (2004), both underlying vulnerabilities and cognitive-affective schemas should be considered in both assessment and treatment. Blatt proposed that we begin treating individuals rather than disorders, taking care not to neglect the biopsychosocial factors potentially involved. For example, a “disorder” could be the result of adapted behavior used to defend against underlying emotions from childhood. Finally, Luyten noted that “Blatt’s views clearly suggest that the disease metaphor is inadequate for most, if not all, mental disorders” (p. 531). Blatt purported that individuals should not be viewed as “hosts” to certain “pathogens,” but rather as active contributors to the creation and persistence of their existing stressors (p. 531). In conclusion, Luyten stated that “psychopathology should not be seen as a ‘simple twist of fate’… . but as the outcome of a complex interaction between vulnerability and resilience throughout life associated with two fundamental dimensions of human existence, self-definition, and relatedness and thus a possibility that resides in us all” (p. 533).
Dr. Thomas S. Szasz (2006) advances this notion of remembering the individual’s contribution to the disorder afflicting them. In “Mental Illness: Sickness or Status?” he contended that “the term ‘mental illness’ refers to unwanted behavior, not medical malady” (para. 1). In short, that there is no such thing as mental illness at all. In his position, “it is as foolish to look for the causes or cures of the behaviors we call ‘mental illnesses’ as it would be to look for the causes and cures of the behaviors we call ‘religions’” (para. 11).
Szasz’s article “Mental Illness is Still a Myth” (1995) took this concept further. Playing off the title of his earlier book, The Myth of Mental Illness, published in 1961, Szasz’s main argument revolved around his position that the term “mental illness” is, in fact, a metaphor. From his view, “if mental illnesses are diseases of the central nervous system, then they are diseases of the brain, not the mind; and if they are the names of (mis)behaviors, then they are not diseases” (para. 8). Szasz compared the metaphor of mental illness to the metaphor of the drink called a screwdriver, stating that “a screwdriver may be a drink or an implement. No amount of research on orange juice and vodka can establish that it is a hitherto unrecognized form of a carpenter’s tool” (para. 8). Szasz (1995) also compared mental illness to religion, suggesting that “psychiatric metaphors play the same role in therapeutic societies as religious metaphors play in theological societies” (para. 9). Having assailed religion, he added, “religion is the denial of the human foundations of meaning and the finitude of life… . similarly, psychiatry is the denial of the reality of free will and of the tragic nature of life” (para. 10). In Szasz’s opinion, “both religion and psychiatry are the products of our own minds. Hence, the mind is its own opiate; and its ultimate drug is the word” (para. 10).
To Szasz, what we call “mental illness” is actually a name for problems in living. His article “The Myth of Mental Illness” that proceeded his book of the same name, explained it best. In it, Szasz (1960) noted that we regard mental disorders as the cause of human disharmony when, in fact, “living is an arduous process” (para. 6). Not far from the conception of vMemes, Szasz suggested that “the concept of illness, whether bodily or mental, implies deviation from some clearly defined norm” (para. 7). “Who defines the norms and hence the deviation?” (para. 8). According to Szasz, it may be the individual who determines that they deviate from a given norm, or someone other than the individual who decides that the latter is deviant (para. 8). Either way, Szasz recapitulated by stating, “in actual contemporary social usage, the finding of a mental illness is made by establishing a deviance in behavior from certain psychosocial, ethical, or legal norms” (para. 10). Thus, it becomes clear that a psychiatrist’s socioethical orientation will heavily influence their ideas of what is wrong with a patient (para. 12).
Ultimately, Szasz (1960) considered what people call mental illnesses to be nothing more than “communications expressing unacceptable ideas” (para. 15). Essentially, that “instead of calling attention to conflicting human needs, aspirations, and values, the notion of mental illness provides an amoral and impersonal ‘thing’ (an ‘illness’) as an explanation for problems in living” (para. 17). Having referenced historical myths, Szasz concluded that “our adversaries are not demons, witches, fate, or mental illness. We have no enemy whom we can fight, exorcise, or dispel by ‘cure’” (para. 24). We have only “normal” people in a continuous struggle, “not for biological survival, but for a ‘place in the sun,’ ‘peace of mind,’ or some other human value (para. 22).
Unfortunately, the evolution required to move from a view such as Satel’s (2009) to a position like Szasz’s (2006) is considerable. Most people find it far easier to keep normality contained in the neat, categorized box in which it came. For such spectators of life, an example far more lucid exists for their perusal. The critically acclaimed 1976 film One Flew Over the Cuckoo’s Nest, originally a book of the same name by Ken Kesey (1962), illustrated the question of normal quite perfectly. The film documented the hero’s journey of Randle Patrick McMurphy, a man convicted of statutory rape and sentenced to a relatively short prison term who decided to pretend to be “mad” in order to receive what he believed to be the lesser punishment of institutionalization. His plan rapidly backfired, however, as he made a quick enemy of the head nurse, Ratched, and learned that many of the other patients were actually there voluntarily. The situation escalated as McMurphy defied the rules and attempted to liberate the other patients of their perceived problems, until ultimately, McMurphy is punished for his “abnormal” behavior. First with electroconvulsive therapy, and finally by way of a lobotomy that left him totally incapacitated, McMurphy’s deviance was silenced. The film raised a pertinent question: what exactly is mental illness? McMurphy, “normal” at the film’s commencement, is reduced to yet another mental patient by the film’s end, by way of what psychiatrists call a “self-fulfilling prophesy.” The story caused viewers to wonder, what is responsible for mental illness, the patient themselves, or their environment? As the tagline for the film adeptly states, “If he’s crazy, what does that make you?”
