NORMALITY AND PATHOLOGY –
A FINE LINE THAT CONNECT AND DIVIDE
Marina Tomasevic

Abstract:
How we conceptualise the nature and cause of abnormal behaviour has important
implications for how we conceptualise treatment, the clinician's role, and the client's
role. To a certain extent each concept captures a different aspect of the meaning of
abnormality. When we talk about abnormality we inevitably invoke one or more of
these definitions, either explicitly of implicitly, but we do use some definition. It is
unavoidable and it is necessary.

When we choose a definition, we do so in part based on feelings, emotions,
convenience, custom, appeal and ethics and it is a value judgment in the final
moment. There is an inherent non-scientific arbitrariness in this choice. The potential
result is that psychologist A and psychologist B could be talking about very different
things when using the word "abnormal". Confusion and controversy exist, especially
if the definitions remain implicit.

One alternative orientation is to use a difference model. The basic assumptions are
changed. The question is no longer what is wrong with the person, but what are the
strengths of this person and how can they be used. The goal changes from
rehabilitating the person, to finding a setting into which the person could fit and use
his/her abilities, and where he/she could develop new abilities. It could be called a
psychology of strengths rather than weaknesses.

Modernity's 'problem of pathology' manifested itself in the era's preoccupation both
with the rehabilitation of various practices and ideals or normality, and with a
relentless fascination concerning the identity and nature of the deviant, maladjusted,
monstrous or 'otherly'. In fact, the 20th Century has seen varieties and
manifestations of abnormality and pathology, and concurrently, the rise of social and
medical disciplines intent on the classification of such transforming behaviours and
identities.

The idea that there are normal and abnormal ways for people to be and to behave is
a very familiar one. So also is the idea that abnormality or deviance is something
regrettable, deplorable, and even, in some cases, punishable. Here, however, our
main concern would be to consider what might be meant by the claim that a person
is, in some respect, normal. There is, no doubt, an unsophisticated usage according
to which what is normal is what is familiar, and the unfamiliar is feared or condemned
as abnormal.

The terms normal, abnormal, benign and malignant are established clichés of
modern medicine, and pathology. These terms necessarily express an opinion and
hence a judgment. While the lay and the learned, patients and the doctors, have
come to accept these terms as some kind of norm, a critical analysis reveals them to
be judgmental jargon, relevant to semantic and scientific basis.
Normality is the range and not the average and hence inapplicable to an individual
reading of any parameter. (Ardrey, 1970)

In examining the implications of defining one act as abnormal compared to another
there are a multitude of ethical and practical problems. Firstly, (assuming judgments
are necessary at all) who judges? And secondly, who judges the judges? Someone
initially decides who is able to give an objective definition of normality; and must then
decide the judges are indeed objective. In this context the judges are legal and
medical experts who judge themselves. In attributing values to behaviour there is a
considerable grey area. Statistically abnormal behaviour (Goertzel, Fashing, 1981)
occurs infrequently; otherwise it would not be statistically abnormal. No value
judgment is made between the rare behaviours of a serial killer who uses an unusual
weapon and a unique pioneering experimental surgeon. They are both abnormal so
far as the numbers go. Deviation from statistical norms allows acceptability, but is
still based around morality.

One approach is to identify normality first. According to wide literature (Busfield,
1986), normality is about:

· The absence of mental illness - pretty tautological! What are mental illness-
but being ‘not normal’?
· Being capable of introspection - not useful, as any mental activity, however
" deranged" could be introspection
· Growth, development and "self-actualisation" - this is too idealistic; few
individuals achieve such heights of development; the famed psychologist
Maslow admitted, "there are no perfect human beings"
· Integration of all aspects of self - again an ideal, failure to achieve this would
not indicate mental impairment, as the vast majority of us aren’t ‘there’ yet (if
ever).
· Ability to cope with stress - negative coping mechanisms such as alcoholism
would not be a healthy way to cope, but are acceptable under this
explanation, despite their pathology.
· Autonomy and control over own life- again a matter of degree and subjective
perceptions.
· Seeing the world as it really is - who judges reality?
· Environmental mastery: capacity to cope and adjust perfectly in interpersonal
relationships -again, an ideal for many.

The majority of mankind is abnormal compared to the above, but as already stated,
majorities cannot be abnormal, statistically.

Social class also affects definition: "eccentricity" in one class may be decried in a
lower class. The context of behaviour is important; a child playing with toys in the
home is normal; an adult playing alone with children's toys may be labelled
abnormal; doubly so if this took place in the middle of a busy street, as the situation
would also be inappropriate.

The great psychiatry-reform crusader Szasz (1961) believed health should only be
judged biologically, pointing out that moral philosophy is not brought to bear on
physical illnesses, such as blame for catching flu and so should not be aimed at
" mental illness" either. Psychiatric diagnosis was often a relative moral-cultural
process, not a medical one and it has a stigma as if there were some personal blame
attached. A life-threatening heart attack prompts no shame, not so mental illness.

The patient becomes a bad marriage, job and credit risk; facing a double blow:
disease and social stigma. Labelling is impersonal; a patient will be labelled as ‘a
manic depressive’ - an object; rather than "a person with manic depression", which is
dehumanising. Reinforcement of the label on a regular basis may be sufficient to
create or prolong health problems (Kelly, 1955).

It has been suggested that personal distress (Oltmanns, Emery, 2000) at one's own
behaviour could indicate abnormality, however not all subjects show distress, i.e.
psychotic patients without insight into feelings, or manic patients, whose grandiose
behaviour may be pleasurable to them. Those considered being dangerous to
themselves and/or others are liable to physical removal to secure hospitals for
psychiatric evaluation and/or treatment. Other patients arrive voluntarily, but the
means of initial assessment (Treatment Protocol, 2000) seem rather subjective. A
visual appraisal of clothing is made, covering suitability, cleanliness, "appropriate
fashion" and state of repair, plus general physical hygiene. This imposes
discrimination: a patient with any illness may be unemployed, perhaps also be
homeless and unable to afford clothes or washing facilities, but be mentally well. And
one thought that ‘fashion police’ was a metaphor….

In DSM-IV (1994), each of the mental disorders is conceptualised as a clinically
significant behavioural or psychological syndrome or pattern that occurs in an
individual and that is associated with present distress (i.e., a painful symptom) or
disability (i.e., impairment in one or more important areas of functioning) or with a
significantly increased risk of suffering death, pain, disability, or an important loss of
freedom. In addition, this syndrome or pattern must not be merely an expectable and
culturally sanctioned response to a particular event, for example, the death of a
loved one. Whatever its original causes, it must currently be considered a
manifestation of a behavioural, psychological, or biological dysfunction in the
individual. Neither deviant behaviour (e.g., political, religious, or sexual) nor conflicts
that are primarily between the individual and society are mental disorders unless the
deviance or conflict is a symptom of a dysfunction in the individual.

A common misconception is that a classification of mental disorders classifies
people, when actually what are being classified are disorders that people have. For
this reason, the text of DSM-IV avoids the use of such expressions as "a
schizophrenic" or "an alcoholic" and instead uses the more accurate, but admittedly
more readily, "an individual with Schizophrenia" or "an individual with Alcohol
Dependence."

A key point of the psychiatric view is that a legitimate "mental illness" requires
underlying "behavioural, psychological, or biological dysfunction in the individual"
(DSM-IV, 1994). According to The Concise Oxford Dictionary (1996), dysfunction is
an abnormality or impairment of function.

So, there must be an abnormality or impairment of behaviour, biology or psychology
that manifests from the mental illness (which is never observed, and completely
assumed). Strangely, the entire field has never, not once, defined what normal or
ideal functioning would mean in these areas! What would be an ideal condition for
the psychological function known as attention? Memory? Imagination? Or intention?
How might we strive to achieve these states? The raw truth is that the field has never
examined these things, much less with an interest in ascertaining how these operate,
and how these things could be improved and strengthened - an obvious desirable
goal for any group tending to deal with the mind.

A basic and very large error in psychiatry's fundamental approach to this subject is
obvious in the above line, "the term mental disorder unfortunately implies a
distinction between "mental" disorders and "physical" disorders that is a
reductionistic anachronism of mind/body dualism." (DSM-IV, 1994) The attitude
contained in psychiatry is that "we have advanced past the old and over simplistic
notion of man having a mind and a body, and that these two things are different."
(ibid). Actually and factually the mind and the body are two different things,
according to them, with observably different functions and following quite different
laws. They do affect each other, and there are observable interrelations between the
mind, body, and the environment, but they are fundamentally unique and different
phenomena. Psychiatry would like us to believe mental disorders are all physical

because this fits in nicely with their theories of genetic and chemical-biophysiological
causes for all mental illness. This ideological slant has led to a very incomplete
picture of Man and society. Modern psychiatry ignores the entire realm of mind
except as a category used in diagnosing mental illness, does not directly address the
mind in any attempt to cure or empower a mind, and instead observes and attempts
to manipulate behaviour and symptoms exclusively.

Yet, while ignoring the mind and refusing to address it directly, the modern subjects
of psychiatry and psychology pretend to deal with mental health, mental hygiene,
mental illness and mental disorders. What can these terms possibly mean when the
subject itself has abandoned the mind? There are no clear definitions of these terms
anywhere in the related psychiatric literatures, because the truth is that these terms
are surrounded by vagueness and based upon very faulty notions.

Moreover, although the DSM (1994) provides a classification of mental disorders, it
must be admitted that no definition adequately specifies precise boundaries for the
concept of mental disorder. The concept of mental disorder, like many other
concepts in medicine and science, lacks a consistent operational definition that
covers all situations. All medical conditions are defined on various levels of
abstraction - for example, structural pathology (e.g., ulcerative colitis), symptom
presentation (e.g., migraine), deviance from a physiological norm (e.g.,
hypertension), and aetiology (e.g., pneumococcal pneumonia). Mental disorders
have also been defined by a variety of concepts (e.g., distress, disadvantage,
disability, inflexibility, irrationality, syndrome pattern, aetiology, and statistical
deviation). Each is a useful indicator for a mental disorder, but none is equivalent to
the concept, and different situations call for different definitions.

Psychiatry, as with many other modern fields, attempts to attack and destroy the
negative and unwanted conditions, assuming that doing so somewhere leaves a
positive and desirable condition. This is not so. Destroying the unwanted does not
and is not the same thing as creating the positive.

Psychiatry uses mental concepts (ideas concerned with a mind) largely as an excuse
to label people (Kelly, 1955) with mental illnesses. Examples: he has moderate
attention dysfunction (his mind wanders); she has mild memory impairment (she has
trouble recalling some things); he has fixated attention on sexual imaginings
(fantasies). These things are used only to justify a diagnosis of illness.
Normal is the common denominator of average acceptable behaviour. There is
nothing desirable about it. Psychiatry has developed an entire science dependent
upon labelling people abnormal or impaired because people deviate from their
extremely biased concepts of what is acceptable and normal. What are termed
mental disorders and illnesses often envelope what more accurately fall under the
umbrella of individual differences, personal uniqueness, eccentricity and individuality
(Oltmanns, Emery, 2000). Unusual sometimes? Yes. Strange? Maybe. A "mental
illness"? No! For conditions that do have obviously harmful aspects to the person,
the true cause lies in the mind which psychiatry pays no attention to as a thing to be
addressed and corrected in it.

Psychiatry would have us accept and believe we "have" depression or anxiety
disorder like we "have" a wart, a pimple or a stomach ache. While depression, as
one example of many, may have certain characteristics and even similar repeated
behaviours, statements such as factually characterize the actual state of depression:

I "feel" despondent
My "thoughts" are always negative and I can't control them
I "want" to kill myself
Life has no value or meaning for me

Each of these almost exclusively has to do with the realm of emotion and thought,
but depression and hundreds of other supposed mental disorders are never dealt
with addressing the realm of emotions or the mind.

Where else (DSM-IV, 1994) would one find "coffee drinking" (292.9 Caffeine-Related
Disorder) turned into a mental illness! Smoking is now classified as a mental illness
also! You'll find it under category 305.10 Nicotine Dependence, and 292.0 Nicotine
Withdrawal. Yes, smoking does have an addictive aspect. No, drug addiction is not a
mental illness! It's simply drug addiction - the reaction physically and mentally to drug
taking. "Withdrawal" is a physiological reaction to stopping the taking of a drug. It is
not a mental illness either!

The dominant model today (at least within psychiatry) is the medical model of
psychopathology (Treatment Protocol, 2000). The basic assumption is that
psychological disorders are diseases. The nature of onset, distribution of cases,
development and course, treatment response, and associated features seen in
psychological disorders are seen to be parallel to what occurs in physical diseases.
This model assumes diseases of any sort to be fully understood in terms of abnormal
biological variables, thus, a psychological disorder can be explained in terms of (and
actually is) a disorder of underlying physical mechanisms. Of the aetiological factors
that we have examined, the biological realm is primary. To understand
psychopathology, we do not need to look beyond the biological level. This approach
embraces reductionism (Bickle, 1991): a philosophical view that complex
phenomena (such as thoughts, behaviours, emotions) can be completely understood
and explained in terms of a more basic level. That is, in this case, thoughts,
behaviours and emotions can be reduced to the more basic level of biological
processes. A thought is a neurological event in the brain. Psychopathology is a
biological phenomenon (ibid).

This model has been criticized as being insufficient for truly understanding
psychopathology. Biology simply can't account for psychological disorders. A model
of psychological phenomena must be based on other levels of data, levels that
involve psychological processes at cognitive and social levels. At the very least, to
truly understand a psychological disorder, we need to integrate knowledge from
these various levels with the biological level. We need to recognize that each level
has its own strengths, but also its own limitations. Biological levels do pretty good at
providing explanations of form, that is, it answers "how" questions - how a particular
disease process occurs and what its mechanisms are. Biological explanations do
not, however, provide explanations of the function of the disorder. That is, biology
does not address the "why" questions. Why did this disorder occur, what is its
meaning, purpose or function? Both sets of questions are important in
understanding a phenomenon. Both approaches need to be assimilated.

Historically, medicine hoped that biological causes (Berrios, Porter, 2001) would be
found for all psychological problems. But as we will see, there is a growing body of
evidence that certain abnormal behaviours cannot be fully explained without looking
at the psychology of the problem. Conversion hysteria results from a person's
attempt to unconsciously cope with strong unwanted emotions such as anxiety. The
definition implies health as absence of disease. According to the World Health
Organization (Treatment Protocol, 2000), health is "a state of complete physical,
mental and social well being and not merely the absence of disease and infirmity." In
other words, the absence of X doesn't necessarily mean the presence of Y.

Using a definition is unavoidable and it is necessary. But choosing one is a value
judgment in the final moment. When we choose a definition, we do so in part based
on feelings, emotions, convenience, custom, appeal and ethics. There is an inherent
non-scientific arbitrariness in this choice. The potential result is that
psychologist/therapist A and psychologist/therapist B could be talking about very
different things when using the word abnormal. Confusion and controversy exist,
especially if the definitions remain implicit. However, as professionals, we ideally
make our definitions explicit and then attempt to clarify and modify these definitions
through scientific/methodological rigor, with an eye always open to the exception and
alternative explanations.

What is abnormal ("norm violating") in one society (Oltmanns, Emery, 2000) may be
perfectly normal ("norm consistent") in another. The raw behaviour has not changed,
but the society has. Each culture is different from the other. By which culture's
standards do we judge behaviour to be abnormal? In addition, even in a single, small
society such as New Zealand, there are a myriad of subcultures. Add to this the fact
that norms change through the years so that what is normative in one generation,
may not be in another. This definitional stance implies that normality is the same as
conformity to the mainstream, when in fact there are many streams. The term
abnormality thus loses any firm referent.

What critics claim is that the shift from the medical model to the biopsychosocial
model (Engel, 1980) really made no fundamental change in orientation. The
underlying nature of these two models is the same: the deficit model. The victim
blaming (Ryan, 1976), meta-messages and self-fulfilling prophecies that the two
imply are just the same. They both are models that conceptualise the "patient" as
defective or deficient in some way. One alternative orientation is to use a difference
model (Rappaport, 1977). The basic assumptions are changed. The question is no
longer what is wrong with the person, but what are the strengths of this person and
how can they be used. The goal changes from rehabilitating the person, to finding a
setting into which the person can fit and use his/her abilities, and where he/she can
develop new abilities. These critics are calling for a psychology of strengths rather
than weaknesses.

From this perspective, we would approach the schizophrenic person, for example, in
a very different manner than we did in the other models. The focus now emphasize
an individual rather than a patient status, treat person as responsible human being,
rather than providing treatment (so person can fit back into society), restructure
society so there are more opportunities and resources available for the person and
what skills s/he does have, it is as much other people's responsibility to change as it
is the "patient's" (ibid).

No one definition is the correct or the best definition. To a certain extent each one
captures a different aspect of the meaning of abnormality. When we talk about
abnormality, or when we study it or treat those suffering from it, we inevitably invoke
one or more of these definitions, either explicitly of implicitly, either we are aware of
the definition(s) we are using or we are not. But we do use some definition. All of us
have some definition in our heads about what psychological abnormality is, whether
or not we could clearly state it. In any event, it is important, especially as therapists,
that we make as explicit as possible the definition(s) we use, and acknowledge any
limitations. To operate implicitly hinders our ability to develop further - our
awareness is limited because as long as our definitions are implicit, they remain
unchallengeable, we ignore alternatives, we don't "stretch" ourselves. And each
definitional stance can certainly be challenged.

Any definition of abnormality is extremely problematic, unusual behaviour attracts
ethical value judgments often based on moral or philosophical grounds without
relevance to medicine or psychology, and the practical applications of such
judgments cause great dispute.

There are major social, cultural and class issues affecting judgment of normality.
There is disparity in methods for diagnosis of specific conditions; lending credence to
the feeling that mental health issues are presently almost entirely subjective.
However this great scope for improvement in categorisation of mental health
diagnoses may simply await both further advances in medical science and advances
in how we all behave towards each other.

Great social power exists in labelling, as abnormalities attract stigma (Kelly, 1955),
which often far outlast any illness. Abuse of this procedure has been a means of
social control and suppression of dissent. Public ignorance of mental health only
serves the efficacy of such abuses, along with creating problems with the patient's
reintegration into society, even if their abnormality was nothing much in the first
place. Overcoming the label can often be harder than overcoming any disease.
It truly is a self-perpetuating leviathan. More disorders gives us more psychiatrists
and increased funding, which then gives us more disorders, and round and round it
goes.

Across The Borderline Lyrics
(by Ry Cooder, Jim Dickinson and John Hiatt)

There’s a place where I’ve been told
Every street is paved with gold
And it’s just across the borderline
And when it’s time to take your turn
Here’s a lesson that you must learn
You can lose more than you ever hope to find.
When you reach that broken promised land
Where every dream slips through your hand
Then you’ll know that it’s too late to change your mind
Cause you’ve paid the price to come so far
Just to wind up where you are
And you’re still just across the borderline
Up and down the Rio Grande
A thousand footprints in the sand
Breathe a secret no one can define
The river flows on like a breath
In between our life and death
(Tell me) Who’s the next to cross the borderline?
But hope remains when pride is gone
And it keeps you movin’ on
Calling you across the borderline
And when you reach the broken promised land
Where every dream slips through your hand
Then you’ll know that it’s too late to change your mind
Cause you’ve paid the price to come this far
Just to wind up where you are
And you’re still just across the borderline.

About the Author
Marina Tomasevic
I hold Master’s Degree in Medicine, Social Psychiatry and am studying towards my
doctorate degree. A major part of my professional interest is psychopathology and
its critical evaluation.

I Work as a senior lecturer/programme coordinator on degree and diploma courses
in New Zealand, teaching various subjects from the psychology, mental health and
counselling field. To keep up to date with theory and practice, I run a small
psychotherapy practice and have regular clinical supervision. The PhD proposal has
been accepted at the School of Psychology, Victoria University, New Zealand. The
thesis “Injunctions and social stigma in developing personality disorders” has been
presented at the ITAA Conference in Mexico, 2003.

Contact:
108 Richmond Street
Petone, Wellington 6008
New Zealand
Telephone: *64 4 589 1150
Mobile: *64 21 127 0007
E-mail: marina.tomasevic@weltec.ac.nz

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William Ryan, W. (1976). Blaming the victim. New York: Vintage Books