Mental Health and Normality Research Paper

1. Definitions of Normality

Within the field of psychiatry, there are multiple definitions of what is normal. Offer and Sabshin (1991) have created a framework for these definitions, which consists of four different perspectives on normality: normality as health; normality as utopia; normality as average; and normality as transactional systems.

1.1 Normality as Health

This model is still predominant throughout medicine and states that normality is equivalent to the absence of disease. Illnesses (or diseases) are categorized and defined; normality (or health) is not defined per se other than stating that all behavior not meeting the criteria for illness can be considered to be normal. When a patient is treated for his or her illness, the goal of the treatment is to remove the illness. When that is accomplished, for all practical purposes the person is considered to be normal (or healthy). In the mental health field, normal behavior is defined as the absence of mental illness. The emphasis is upon the absence of disease rather than upon optimal functioning.

1.2 Normality as Utopia

In this model the criteria for normality (or health) are much higher than ‘the absence of pathology.’ The emphasis is upon optimal functioning, and this type of normality is like a Platonic ideal, to be strived for, but rarely achieved. Most psychoanalysts define the goal of analytic treatment as helping their patients to achieve their full potential of psychological functioning, whatever that might be. Sabshin (1988) has pointed out that psychoanalysis lacks a literal or detailed language and methodology to describe healthy functioning. According to this model, however, and in contrast to the normality as health model, relatively few people are healthy.

1.3 Normality as A erage

This definition utilizes statistical data and essentially states that normal behavior falls within two standard deviations of the mean of whatever behavioral variable is being studied. In this context the boundary between health and illness is arbitrary. One special problem for this definition involves those occasions when the population being studied is dysfunctional as a whole.

1.4 Normality as Transactional Systems

In this approach variables are studied over time so that normality encompasses interacting variables measured more than once. This model differs from the three previous approaches, which utilize cross-sectional measurements. In addition, many systems and their interactions are studied in a longitudinal fashion.

While examples of every perspective can be found in current psychiatric theory and practice, the first model—normality as health—has consistently dominated both research and clinical work. The concept of a ‘normal’ control group, for instance, is based on this view of mental health. Epidemiological studies, by definition, assume that those who are not identified as ill are in fact healthy or normal. Finally, the DSMIV—the gold standard of psychodiagnostics—is based on the supposition that mental health equals the absence of pathology.

1.5 Normatology

The scientific study of normality over the lifecycle is referred to as normatology. The roots of normatology can be found in Offer and Sabshin’s 1963 declaration of a ‘theoretical interest in an operational definition of normality and health’ (1963, p. 428). Since Offer and Sabshin began their work on normatology in the

1960s, they have repeatedly called upon mental health professionals to seriously consider the concept of normality. As Brodie and Banner (1997, p. 13) write in their review of normatology, [Offer and Sabshin’s] genius lies in their insistence that rather than responding casually or thoughtlessly with received wisdom, we seek instead to answer seriously, methodically, empirically, and longitudinally the vast, seemingly unanswerable question that our patients, our colleagues, and our society persists in asking: ‘Doc, is this normal?’

The way in which psychiatrists answer the question ‘Doc, is this normal?’ has implications that extend beyond mere theoretical interest. Indeed, definitions of normality are central to numerous policy debates. One arena in which the question of what constitutes a psychiatric disorder has received much attention is the health insurance debate. Broad definitions of psychiatric illness are of concern to insurance companies, who traditionally view mental health expenditures as a bottomless pit. Fearing endless expenditures for the treatment of psychopathology, insurance carriers have fought particularly hard against it. Claiming that much of what passes as psychiatric treatment is in fact unnecessary, insurers have argued that too many psychiatrists spend their time treating the ‘worried well.’ Recent trends in managed care illustrate the extent to which insurance companies have succeeded in narrowly defining what constitutes a disorder and which disorders warrant treatment. Managed care companies continue to lobby for an ever-expanding universe of normality, in which psychopathology is minimized to reduce costs associated with its treatment.

Definitions of normality are also critical to social policy debates over such issues as homosexuality. Even as homosexuality gains increased acceptance within American society (Vermont’s ruling on domestic partnerships is an example of this trend), there are those who still argue that homosexuality should be considered abnormal, and as such should not be officially sanctioned. Deciding which mental disorders should qualify for Social Security Disability benefits is another example of the ways in which definitions of normality carry serious consequences. When the decision was made to stop providing disability benefits to persons suffering primarily from substance abuse disorders, many people lost their benefits.

In light of the considerable debate over what constitutes normality and what should be considered a psychiatric disorder, Offer and Sabshin have urged researchers to direct their efforts toward answering this question empirically. In The Diversity of Normal Beha ior (1991), their most recent book on the subject, the authors note that interest in the field has developed significantly. They refer to an emerging empirical literature, and point out the impact of normatology on the DSM-IV. The authors attribute this change to a growing movement in psychiatry toward objectifying its nosological base, and to a desire among mental health policymakers to better define mental disorders. In spite of these developments, however, Offer and Sabshin (1991) state that psychiatrists have yet to focus adequately on the normal aspects of their patients’ behavior.

In this research paper we will review current trends in normatology, and will assess the extent to which the field of psychiatry has made efforts to better define what is normal. We will begin by looking at the ways in which researchers have attempted to develop and refine empirically based measurements of psychological normality. We will discuss normatological developments in such disciplines as child therapy, family therapy, and sex therapy. We will also discuss current challenges to the ways in which presumptions about normality influence psychiatric diagnoses and treatment. In order to assess whether normatological concepts are being integrated into the training of new mental health professionals, we will present the results of a review of current psychiatry and psychology textbooks, as well as of a survey of clinical psychology doctoral students. Finally, we will discuss where the field of normatology appears to be headed as we move into the twenty-first century.

2. Current Trends in Research on Normality

2.1 Empirically Based Approaches to Normality

One area that has seen some progress since the 1990s is the development of empirically based approaches to distinguish between the normal and abnormal. While such approaches are not new (the original MMPI is an example of an early attempt), researchers have continued to refine existing instruments and create new ones. Achenbach (1997, p. 94) has been a particularly strong proponent of such an approach. He suggests that in order to distinguish normality from abnormality, both should be seen as existing on a continuum. Placing an individual at a specific point on the continuum, according to Achenbach, requires an ‘empirically based bootstrapping strategy.’ Such a strategy involves ‘lift[ing] ourselves by our own bootstraps’ through an iterative process of progressively testing and refining various fallible criteria for judging the normal versus abnormal.’

Achenbach’s approach places a strong emphasis on psychometric testing. As he points out, however, such tests must be based on standardized data from subjects who are independently judged to be normal as opposed to demographically similar subjects who are judged to be abnormal. Failure to base normal abnormal distinctions on empirically validated measures can lead to misdiagnosis and confusion. As an example, Achenbach points out that when the ‘always on the go’ criterion for Attention Deficit Disorder with Hyperactivity from the DSM-III (1980) was tested empirically, healthy children scored higher than those diagnosed with the disorder.

The most thoroughly researched and widely applied psychometric instrument for differentiating between normal and abnormal personalities is the Minnesota Multiphasic Personality Instrument (MMPI) (Hathaway and McKinley 1943). In 1989, the MMPI was restandardized and updated to the MMPI-2 (Butcher et al. 1989). As Ben-Porath writes in his (1994) review, the MMPI has evolved from a strict typological instrument to a test that places individuals along continua of various personality trait dimensions. In line with the methodology proposed by Achenbach (1997) outlined above, the MMPI-2 is used to quantitatively (rather than qualitatively) classify individuals into distinct groups.

Millon’s model of personality (1981) as well as the psychometric instruments that have grown out of it (e.g., Strack 1991, Millon 1994a, 1994b) also incorporate a quantitative approach to the distinction between normal and abnormal. The underlying assumption of Millon’s work is that abnormal personality traits are distortions or exaggerations of normal ones. Pathology, therefore, is seen as lying on one end of the normal–abnormal continuum. The Millon Clinical Multiaxial Inventory (MCMI) (Millon 1977)—a well-researched and widely used personality instrument—recently underwent its third revision (Millon 1994a). The MCMI is used primarily with clinical populations to assess individual personality characteristics along various continuum points.

The Personality Adjective CheckList (PACL) (Strack 1991), a recent outgrowth of Millon’s work, was designed for use with nonpsychiatric patients. Based on Millon’s principles of personality assessment, the PACL may be used to assess normal versions of the character types frequently encountered in clinical settings. While pathological versions of Millon’s personality types have been well studied, relatively little work has gone into understanding their normal correlates. The PACL was developed in large part to provide researchers with a means of elucidating the normal end of the normal–abnormal continuum. While the development of the instrument is a step toward a better definition of psychological normality, investigators have yet to make use of the PACL in applied research settings.

One relatively new psychometric instrument used to differentiate between normal and abnormal personalities is the Personality Assessment Inventory (PAI) (Morey 1991). Like the PACL and MMPI-2, the PAI assumes that clinical constructs occur in both mild and more severe forms. The PAI was developed in order to provide researchers and clinicians with another tool for distinguishing between individuals at various points of the normal–abnormal continuum. In summarizing the current state of psychodiagnostics with regard to the normal abnormal distinction, Morey and Glutting (1994, p. 411) write that ‘the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, despite attempts to objectify many critical distinctions, is still unclear on distinctions between normal personality, abnormal personality, and clinical syndromes.’ The authors point out, however, that while conceptual difficulties remain in differentiating the normal from abnormal, clear differences exist between psychometric instruments that were designed to measure normal or abnormal constructs. The PAI was designed to primarily measure abnormal constructs in such a way as to capture meaningful variation even within the normal range.

As previously mentioned, a common assumption underlying such psychometric instruments as the MMPI-2, PACL, and PAI is that normal and abnormal characteristics can be seen as lying on opposite ends of the same continua. Eley (1997) calls this assumption into question with her study of childhood depressive symptoms. Looking at 589 same-sex twins eight to 16 years old, Eley found that genetic factors significantly contribute to the etiology of both individual differences and extreme group membership for self-reported depressive symptoms. In other words, Eley’s results suggest that depressed children differ qualitatively from children who are not depressed. These results support a categorical, rather than continual approach to the normal abnormal distinction.

2.1.1 Child and family therapy.

Child and family therapy is an area in which clinicians are frequently asked to make distinctions between normal and abnormal behavior. As a recent study by Cederborg (1995) demonstrates, these distinctions are negotiated through a complicated process involving a number of participants, namely therapist, parent(s), and child. In order to understand better how these participants define and redefine a child’s behavior, Cederborg analyzed the content of 28 family therapy sessions with seven different families. She concludes that rather than classifying children according to psychiatric diagnoses, family therapists (at least those in Sweden) tend to define abnormality in terms of ‘interactional problems.’ What might initially be defined as psychiatric problems, writes Cederborg, are transformed through therapy into social phenomena in the child’s environment.

Nevertheless, as Gardner (1988) points out, for all children referred to psychiatric treatment, a level of classification has already taken place. This classification occurs at the level of difference. For instance, a parent might contrast the behavior of their child with that of the child’s peers. One criterion that is often used to classify childhood behavior, writes Gardner, is whether a child’s behavior is gender-appropriate. In order to determine how gender norms affect distinctions between normal and abnormal children, Gardner studied 15 boys and 15 girls, six to nine years old who were referred to a child guidance clinic in the UK (southwest England). She found that for over half of the sample, the problem behavior that resulted in the original referral was considered by the children’s mothers to be gender-inappropriate. Gardner concludes that mental health professionals working with children should ‘consciously increase [their] gender awareness and knowledge about the individual variability of behaviors and so encourage others to be more flexible and less judgmental about deviations from the norm’ (Gardner 1988, p. 80).

Walsh (1993, pp. 3–4), in her review of normal family processes, comes to a conclusion in keeping with the findings of Cederborg (1995) and Gardner (1988): namely, that ‘all views of normality are socially constructed.’ As a result, Walsh writes that it is ‘imperative to examine the explicit and implicit assumptions about family normality that are embedded in our cultural and clinical belief systems.’ A study conducted by Kazak et al. (1989, pp. 289–90) supports Walsh’s assertion. In Kazak et al.’s study, four samples (20 families with young children, 172 college undergraduates, 24 grandmothers, and 21 therapists) completed a battery of standardized family assessment instruments. All participants were asked to indicate on the instruments how a ‘normal’ family would respond. The investigators found significant and substantial differences in perceptions of normality according to developmental variables, ethnic background, and gender. Of particular interest in this study is the gap between the therapists’ perceptions of normality and those of the other subjects. The authors suggest that these differences point to ‘inherent tensions between the values and expectations that therapists have, and those of families.’

As McGoldrick et al. (1993, p. 405) point out, one result of the cultural basis for judgements of normality is that as times change, so do perceptions of what is normal. ‘… our dramatically changing family patterns’ write the authors, ‘which in this day and age can assume many varied configurations over the life span, are forcing us to take a broader view of both development and normalcy. It is becoming increasingly difficult to determine what family life cycle patterns are ‘‘normal’’ …’

2.1.2 Sex and marital therapy.

Another area in which culturally driven judgments of normality affect psychiatric treatment is sex and marital therapy. Kernberg (1997) writes that when normality is equated with predominant or average behavior (re: normality as average), treatment may become a matter of ‘adjustment,’ and normality may lose its usefulness as a standard of health. However, if normality represents an ideal pattern of behavior (re: normality as an ideal fiction), then treatment may become ideologically motivated. Warning of the risks of ideologically and culturally biased treatment, Kernberg reminds us that ‘only a hundred years ago psychoanalysis was at one with a scientific community that regarded masturbation as a dangerous form of pathology …’ and ‘that our literature lumped homosexuality and sexual perversions together for many years without a focus on their significantly differentiating features’ (p. 20).

2.2 Review of Current Psychiatry and Psychology Textbooks

Graduate education provides future mental health professionals with an opportunity to become acquainted with normatological concepts. This process may occur formally through coursework and lectures, or informally through clinical experience and observations. Graduate training is a time when professional conceptualizations of normality are first formed; how this happens is of critical importance to an understanding of current and future trends in normatology. Indeed, what graduate students learn about normality today is perhaps the best barometer of how the field will view normality tomorrow.

In order to assess how normatological concepts are being formally introduced to current graduate students, we reviewed the most up-to-date psychiatry and psychology textbooks available at a private medical school in a major mid-Western city in the USA. In all, we examined 11 textbooks (many of which are used at medical schools throughout the USA): six general psychiatry textbooks (Sadock and Sadock 2000, Stoudemire 1998, Goldman 1995, Waldinger 1997, Nicholi 1999, Hales et al. 1999); two general clinical psychology textbooks (Heiden and Hersen 1995, Hersen et al. 1991); two abnormal psychology textbooks (Turner and Hersen 1997, Peterson 1996); and one developmental psychopathology textbook (Luthar et al. 1997).

We searched the indexes of these textbooks for the following entries: ‘normality’; ‘mental health’; ‘mental illness’; and ‘mental disorder.’ Of the 11 textbooks, only three included entries for ‘normality’ (27 percent); one included ‘mental health’ (9 percent); two included ‘mental illness’ (18 percent); and four included ‘mental disorder’ (36 percent). In all, it appears that a student searching the indexes of these textbooks for terms relating to normality would find disappointingly little.

We then examined the textbooks in order to determine whether they explicitly addressed the concept of psychological normality. Of the 11 textbooks, only four (36 percent) included sections that dealt explicitly with normatological issues.

In order to determine what messages these textbooks are conveying—explicitly or implicitly—about normality, we divided the textbooks into groups based on the models of normality outlined in Sect. 2 (normality as health; normality as utopia; normality as average; and normality as transactional systems). Textbooks that stated either directly or indirectly that normality equals the absence of pathology were placed in the first group, and so on. The results of our analysis are as follows: five textbooks (45 percent) supported the ‘normality as health’ model; none (0 percent) supported ‘normality as utopia’; four (36 percent) supported ‘normality as average’; and one (9 percent) supported ‘normality as transactional systems.’ Additionally, one text (9 percent) listed Offer and Sabshin’s five models of normality without favoring any particular viewpoint.

It appears, therefore, that the majority of the introductory psychiatry and psychology textbooks currently used by students of at least one major medical school teaches students that normality equals either the absence of pathology, or that which lies in the middle of the bell-shaped curve. It also appears that explicit information relating to normatological concepts is in short supply, at least as far as graduate textbooks are concerned. Needless to say, the implications of our review are limited by the small number of textbooks examined, as well as by the fact that we focused on only one school. Nevertheless, our results raise serious concerns about the extent to which normality is overlooked by the authors of introductory psychiatry and clinical psychology textbooks.

2.3 Survey of Clinical Psychology Doctoral Students

In order to learn more about how current mental health professionals-in-training view normality, we conducted a survey of clinical psychology doctoral students at two mid-Western universities. The brief nine-question survey was sent out by e-mail to all of those students who had at least six months of clinical training. A total of 53 students received the survey. The students’ response rate was 64 percent.

Respondents had an average of 30 months of clinical experience. Seventy-nine percent of the respondents were involved in clinical work when they answered the survey. During the course of their clinical work, 91 percent of the students said that a patient had asked them ‘Am I normal?’ Only 52 percent of those asked directly answered their patient’s question.

Ninety-four percent of the respondents said that they believed that an understanding of normality was necessary for their future clinical work. Only 62 percent of the respondents stated that they had taken a course in graduate school that dealt with issues of normality. Of those students who had taken such a class, 91 percent reported that they found the course helpful.

With regard to the models of normality outlined in Sect. 2, the majority of the respondents (56 percent) aligned themselves with the ‘normality as transactional systems’ approach. Twenty-seven percent of the students agreed with the ‘normality as average’ perspective. Twelve percent viewed normality as a utopian ideal, and the rest (6 percent) agreed with the ‘normality as health’ model.

Seventy-seven percent of the students believed that the ‘normality as health’ perspective was the dominant view within the field of mental health. The rest of the students were nearly evenly divided between the ‘normality as utopia,’ ‘normality as average,’ and ‘normality as transactional systems’ models with regard to what view they felt dominated (6, 9, and 9 percent, respectively).

These findings suggest that the vast majority of current clinical psychologists-in-training who responded to our survey are directly confronted with issues of normality in their clinical work. Just over half of those confronted, however, deal with the issue explicitly. Moreover, while nearly all of those students asked believe that an understanding of normality is necessary to their clinical work, less than two-thirds of them had actually taken a class that dealt with the subject. In keeping with the results of the previous section, it would seem as though graduate training in psychology is not meeting the needs of students where normatological issues are concerned.

While over half of those students who responded to our survey believed that the ‘normality as transactional systems’ approach is the correct one, over three-quarters of them saw the ‘normality as health’ model as dominating the field. One wonders if this discrepancy is indicative of a forthcoming shift in how mental health professionals approach issues of normality.

As with our review of textbooks in the previous section, a cautionary note is in order with regard to generalizing beyond those students who responded to our survey. At the very least, however, the results of this survey raise important questions about the way in which clinical psychology graduate training addresses questions of normality.

3. Summary

Defining mental health has always been a more difficult task for mental health professionals than defining mental illness. Within the field of psychiatry, there are multiple, competing perspectives on normality. As outlined by Offer and Sabshin (1991) these perspectives are: normality as health; normality as utopia; normality as average; and normality as transactional systems. While examples of every perspective may be found in current psychiatric theory and practice, ‘normality as health’ continues to dominate the field.

Normatology is the scientific study of normality over the lifecycle. Recent developments in normatology have occurred in the areas of psychometrics, child and family therapy, and sex and marital therapy, among others. A number of writers have been increasingly critical of current nosological assumptions about normality, especially with regard to the DSMIV.

A review of introductory psychiatry and psychology textbooks found few references to normality. Most of the textbooks reviewed explicitly or implicitly supported the ‘normality as health’ and ‘normality as average’ models.

A survey of clinical psychology doctoral students found a general interest in normatological issues, despite a lack of formal training on the subject. The majority of those students who responded to the survey aligned themselves with the ‘normality as transactional systems’ model, perhaps signaling a future shift away from the ‘normality as health’ perspective.

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