This is the third article in a 5-part series discussing different aspects of the current mainstream biomedical approach to mental health diagnosis. For the sake of brevity, I’m assuming readers already have some understanding of what the DSM is, the massive influence it has on the way we address mental health, the industry it has become, and the extraordinary amounts of revenue it generates for the American Psychiatric Association.
There’s an old joke that goes something like this: How many psychologists does it take to change a light bulb? Answer: One – but only if the light bulb wants to change! It’s a cute joke but in the context of discussions about mental health disorders, a better answer might be: One – but only if the psychologist knows when the light bulb needs changing.
People don’t usually change light bulbs that work. A point as obvious as this is easy to miss: to know when a light bulb needs changing is to know the difference between when the light bulb is broken and when it is working normally.
This simple principle can be applied generally. Knowing when something needs fixing or correcting necessarily implies knowing what that something does or what the normal functioning state of that something is.
If you were walking along the beach one day and, washed up on the shore was a strange object you’d never seen before, how would you know whether it worked or needed fixing? Surely to make this assessment you would have to know what the object’s function was. What does it do? It is only with an appreciation of what something does that judgments can be made about whether or not that something needs fixing.
Simple though it may be, this principle appears to have been ignored when it comes to mental illness. Discussions and debates about how best to diagnose or otherwise identify mental disorders are conducted in the absence of any agreement as to what the state of normal functioning is. How can “abnormal”, “dysfunctional”, or “disordered” be understood other than by reference to that which is “normal”, “functional”, or “ordered”?
Defining normal should be primary. Yet, without an understanding of what state or condition people have deviated from, and should be returned to, we do such things as: administering powerful medications; electrically inducing seizures; and, teaching activities to alter the content of cognitive processes. In the midst of all these activities, many people manage to reduce their psychological distress and resume living the life they wish to live. A large number of people, however, do not. A conservative conclusion from this situation would be that, currently, without a robust understanding of human functioning, our treatments help people serendipitously rather than systematically.
In many ways, we appear to have placed the cart in front of the horse. Our first task should be finding normal. What is a “normal” person? What does a normal person do? Is it normal to behave abnormally? If defining normal is an insurmountable problem, then surely defining abnormal becomes impossible or nonsensical (or both).
Two examples will help illustrate this point. Apparently, fluoxetine achieves its effectiveness by altering serotonin activity in the brain but, to do this, it has to impair rather than improve the negative feedback mechanism that normally keeps chemical concentrations at specified levels (Whitaker, 2010). Whitaker says this about the way in which fluoxetine achieves its antidepressant effects: “the medicine clearly doesn’t fix a chemical imbalance in the brain. Instead, it does precisely the opposite. Prior to being medicated, a depressed person has no known chemical imbalance. Fluoxetine then gums up the normal removal of serotonin from the synapse, and that triggers a cascade of changes, and several weeks later the serotonergic pathway is operating in a decidedly abnormal manner.” (p. 81). So, in this instance, we have a treatment for psychological distress working by interfering with normal brain processes.
The SANE Australia website provides a brief overview of Electroconvulsive Therapy, including a link to information from the Epworth Clinic. On this site, there is a further link to their ECT Brochure “Electroconvulsive Therapy (ECT) Information for Patients”. In the Frequently Asked Questions section of this brochure is a heading titled “How Does ECT Work?” which contains the following information: “It is believed ECT acts by altering the complex electrical and chemical processes within the brain that are temporarily impaired in some mental conditions. It is believed it may help return these processes towards the correct balance.” In this instance, it is claimed that ECT “may” help return “impaired processes” to their “correct balance.”
So we seem to have a situation whereby fluoxetine works by retarding normal processes, and ECT works by restoring them. This information, however, is provided without any articulation of what “normal functioning” is. What is the normal level of serotonin in the brain? What is the normal operation of the complex electrical and chemical processes that have been supposedly affected by mental illness and are somehow restored by ECT?
Statements of normal and abnormal are scattered throughout the mental health literature. Mental disorders are considered by some to arise from disordered brain circuits (Insel, 2012) and cognitive therapy apparently works by modifying dysfunctional beliefs and attitudes. But what is an “ordered” brain circuit and what are “functional” beliefs and attitudes?
If my responses on a standardized questionnaire provide a score that indicates I’m in the normal range for depression or anxiety or some other form of psychopathology, does that mean I’m normal? If I score outside this range am I abnormal? What if I hear voices? What if I pursue career goals at the expense of family relationships or family relationships at the expense of career goals? What if I prefer to feel my arms and legs moving rather than sitting still in a desk in a row of desks? What if I want to make my own decisions rather than follow other people’s instructions? What if I get upset because I like to spend time with my primary caregivers instead of being left with strangers for long periods during the day? What if I think I’m normal but other people don’t?
Also, only a proportion of people experiencing problems are ever diagnosed as being abnormal or disordered. To receive a psychiatric diagnosis, and be deemed to have an abnormal, disordered, or dysfunctional psychological state, you have to report, or otherwise display, certain experiences (behaviours, thoughts, feelings, images, and so on), and you have to report or otherwise display them to someone who has the authority to diagnose. Conceivably then, there are lots of people who might be judged to have disordered thinking or be otherwise abnormal but never acquire a psychiatric diagnosis. Ironically, once people receive a psychiatric diagnosis it is rare for them to be undiagnosed regardless of how normally they might behave after they receive the diagnosis.
Without any agreed-upon position regarding normal human functioning, we have developed models and other explanations of abnormal human functioning. And, by and large, these models and explanations are based only on the people who come into contact with mental health services or mental health research activity. So we are currently discussing and debating the best way to classify what is wrong without any clear picture of what is right.
Perceptual Control Theory (PCT; Powers, 2005, 2008; www.pctweb.org) offers one suggestion of normal functioning: normal functioning is a process of control. Entities that live are organised as control systems. Problems occur when control processes are interrupted. A strength of PCT, therefore, is that it starts from a perspective of what could be considered normal or routine.
Perhaps PCT won’t be the way of the future. Perhaps there is a more accurate, more precise way of characterising the process of living. That, surely, is a matter to be settled empirically rather than through appeal to opinion or authority.
What is a normal, garden-variety human being? How does one go about being human? Without robust answers to these questions, discussions of abnormality or psychopathology will be fatally constrained in their ability to bring about lasting and effective solutions. Finding normal, and understanding how it is achieved and maintained, is perhaps the most pressing issue of our time.
