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CONCEPTS OF NORMALITY

BY: DR. ROBIN VICTORPGT, DEPT. OF PSYCHIATRY

2 PLAN OF PRESENTATION

DEFINING NORMALITY DEFINING MENTAL HEALTH HISTORICAL ASPECTS CONCEPTS OF NORMALITY MODELS OF MENTAL HEALTH CONCLUSION BIBLIOGRAPHY

3 DEFINING NORMALITY

Normality is even more difficult to define than abnormality particularly in rapidly changing & complex society such as ours.

The WORLD HEALTH ORGANIZATION (WHO) considers normality to be a state of complete physical, mental, and social well-being.

Normality has been defined as patterns of behavior or personality traits that are typical or that conform to some standard of proper and acceptable ways of behaving and being.

The use of terms such as typical or acceptable, however, has been criticized because they are ambiguous, involve value judgments, and vary from one culture to another.

4 GEORGE MORA, devised a system to describe behavioral

manifestations that are normal in one context but not in another, depending on how the person is viewed by the society.

Normality in Context

LIMITATION- It give too much weight to peer group observations and judgments.

TERM CONTEXTAutonormal Person seen as normal by his or her own societyAutopathological Person seen as abnormal by his or her own

societyHeteronormal Person seen as normal by members of another

society observing him or herHeteropathological Person seen as unusual or pathological by

members of another society observing him or her

5 THOMAS SZASZ in his book, The Myth of Mental

Illness, states that normality can be measured only in terms of what persons do or do not do and that defining normality is beyond the realm of psychiatry. He claims that a belief in mental illness is asking to believing in witchcraft or demonology.

Psychiatry has been criticized over the years by certain groups for its portrayal of normality.

The psychology of women, for example, has been criticized as sexist because it was formulated initially by men

6 DEFINING MENTAL HEALTH Mental well-being presumes the absence of mental disorder

defined in the text revision of the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR).

“A mental disorder is a behavioral or psychological syndrome or pattern associated with distress (e.g., a painful symptom), or with a significantly increased risk of suffering, death, pain, disability, or an important loss of freedom. In addition, the syndrome or pattern must not be merely an expected and culturally sanctioned response to a particular event”

7 DEFINING MENTAL HEALTH

In Mental Health: A Report of the Surgeon General, mental health is defined as “the successful performance of mental functions, in terms of thought, mood, and behavior that results in productive activities, fulfilling relationships with others, and the ability to adapt to change and to cope with adversity.”

8 CAUTIONARY STEPS NEED TO BE TAKEN WHILE DEFINING POSITIVE MENTAL HEALTH

1. AVERAGE IS NOT HEALTHY- It always includes mixing in with the healthy the prevalent amount of psychopathology in.

2. WHAT IS HEALTHY SOMETIMES DEPENDS ON GEOGRAPHY, CULTURE, AND THE HISTORICAL MOMENT.

3. TO MAKE CLEAR WHETHER ONE IS DISCUSSING TRAIT OR STATE.4. TO APPRECIATE THE TWOFOLD DANGER OF “CONTAMINATION BY

VALUES.”

The best way to enrich our understanding of what constitutes mental health is to study a variety of healthy populations from different perspectives, in different cultures, and for a long period of time.

9 The commonly accepted and widely used definition of mental health

adapted from Campbell's Psychiatric Dictionary

“Psychically normal persons are those who are in harmony with themselves and with their environment. They conform with the cultural requirements or injunctions of their community. They may possess medical deviation or disease, but as long as this does not impair their reasoning, judgment, intellectual capacity, and ability to make a harmonious personal and social adaptation, they may be regarded as psychically sound or normal.”

10 HISTORICAL ASPECTS OF NORMALITY ADOLPHE QUETELET in 1835

published the first important book on normality.

Rather than focus on pathology, he tried “to approach more closely to what is good and beautiful,” and his goal was the statistical analysis of healthy humans.

He challenged generations of future investigators with his introductory sentence: “Man is born, grows up, and dies, according to certain laws which have never been properly investigated.”

11 After World War II, In1941 JOHN CLAUSEN and his coworkers were commissioned to

assess mental health for the draft board.As a way of assessing the mental health of recruits they focused on the absence of psychosomatic symptoms.

Questions about psychosomatic symptoms still form an important part of the Hopkins Symptom Checklist (SCL-90).

Other influential works on normal adaptive behaviour include— Roy Grinker and John Spiegel's - Men under Stress Robert White's - Lives in Progress Leo Sroles - Mental Health in the Metropolis Alexander and Dorothea Leightons' - Cove and Woodlot

12 Many Postwar psychiatrists continued to agree

with Freud, who had dismissed mental health as “an ideal fiction.”

In the late 1950s two of the world's most distinguished psychiatrists dismissed the term entirely:

Sir Aubrey Lewis wrote in 1958, “Mental health is an invincibly obscure concept.”

1957 Fritz Redlich asserted, “We do not possess any general definition of normality and mental health from either a statistical or a clinical viewpoint.”

13 MARIE JAHODA suggested : (1) That mentally healthy individuals should be in touch with their

identity and their feelings. (2) They should be oriented toward the future, and over time they

should remain fruitfully invested in life. (3) Their psyches should be integrated and provide them resistance

to stress. (4) They should possess autonomy and recognize what suits their

needs. (5) They should perceive reality without distortion and yet possess

empathy. (6) They should be masters of their environment—able to work, to

love, and to play and to be efficient in problem solving.

14 MENNINGER PSYCHOTHERAPY PROJECT Lester Luborsky devised a behavioral guide (Health-

Sickness Rating Scale [HSRS]) to assess psychological functioning on a scale of 0 to 100.

In 1976 two of the architects of DSM-III developed a revision of the HSRS called the Global Assessment Scale (GAS).

A modified version of the GAS was introduced in DSM-III-R as the Global Assessment of Functioning (GAF).

On Luborsky's scale a score of 95 to 100 reflected “an ideal state of complete functioning integration, of resiliency in the face of stress, of happiness and social effectiveness.”

15 On the GAF a score of 95 to 100 corresponded to “no symptoms, superior

functioning in a wide range of activities; life's problems never seem to get out of hand; patient is sought out by others because of his warmth and integrity.” The words differ, but the melody is the same.

By 1978 The Report to the President by the President's Commission on Mental Health forcefully introduced the importance of defining clearly what is meant by mental health.

It was 15 years later, evidence emerged to support the validity of Axis V of DSM-IV, did psychiatry finally possess a metric for the measurement of “above-average” mental health.

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17 CONCEPTS OF NORMALITY

MAINLY TWO BROAD CATEGORIES: FUNCTIONAL PERSPECTIVES OF NORMALITY PSYCHOANALYTIC THEORIES OF NORMALITY

18 FUNCTIONAL PERSPECTIVES OF NORMALITY

Described by Daniel Offer and Melvin Sabshin Four functional perspectives. Each perspective is unique and has its own definition and

description. The perspectives complement each other. They represent the totality of the behavioral science and social

science approaches to the subject.

19 FUNCTIONAL PERSPECTIVES OF NORMALITY

NORMALITY AS HEALTH Most physicians equate normality with health and view health as

an almost universal phenomenon. Behavior is assumed to be within normal limits when no manifest

psychopathology is present. If all behavior were to be put on a scale, normality would

encompass the major portion of the continuum, and abnormality would be the small remainder.

John Romano – “healthy person as one who is reasonably free of undue pain, discomfort, and disability.”

20NORMALITY AS UTOPIA Conceives normality as that harmonious and optimal blending of the

diverse elements of the mental apparatus that culminates in optimal functioning.

This approach can be traced back to Sigmund Freud, who when discussing normality stated, “A normal ego is like normality in general, an ideal fiction.”

Although this approach is characteristic of many psychoanalysts, it is by no means unique to them.

It can also be found among other psychotherapists in the field of psychiatry and among psychologists of quite different persuasions.

21 NORMALITY AS AVERAGE Is based on a mathematical principle of the bell-shaped curve. This approach considers the middle range normal and both

extremes deviant. The normative approach based on this statistical principle describes

each individual in terms of general assessment and total score. Variability is described only within the context of groups, not within

the context of the individual. This approach is more commonly used in psychology than in

psychiatry

22 NORMALITY AS PROCESS States that normal behavior is the end result of interacting systems. Temporal changes are essential to a complete definition of normality.

In other words, the normality-as-process perspective stresses changes or processes rather than a cross-sectional definition of normality.

A typical example of the concepts in this perspective is Erik Erikson's conceptualization of the epigenesis of personality development and the developmental stages essential in the attainment of mature adult functioning.

23 PSYCHOANALYTIC THEORIES OF NORMALITY Some psychoanalysts base their concepts of normality on the

absence of symptoms. Accordingly, most psychoanalysts view a capacity for work and

enjoyment as indicating normality or, as Freud put it, the ability “to love and to work.”

24HEINZ HARTMANN Conceptualized normality by describing the

“autonomous functions of the ego” Autonomous functions of the ego is present since

birth that develop independently of intrapsychic conflict between drives and defenses.

These functions include perception, learning, intelligence, intuition, language, thinking, comprehension, and motility.

In the course of development, some of these conflict-free aspects of the ego may eventually become involved in conflict.

25MELANIE KLEIN Normality is characterized by

strength of character, the capacity to deal with conflicting emotions, the ability to experience pleasure without conflict, and the ability to love.

26KARL JASPERS KARL JASPERS, a German psychiatrist and

philosopher, described a “personal world”- the way a person thinks or feels ”that could be either normal or abnormal”.

The personal world is abnormal when:1. It springs from a condition that is recognized

universally as abnormal, such as schizophrenia.2. It separates the person from others emotionally.3. It does not provide the person with a sense of

“spiritual and material” security.

27ERIK ERIKSON Normality is the ability to master the periods of life. Trust vs. Mistrust(0- 18 m) Autonomy vs. Shame and doubt(18m-36m) Initiative vs. Guilt(3-5 years) Industry vs. Inferiority(5-13years) Identity vs. Role confusion(13-20 years) Intimacy vs. Isolation(20-40 years) Generativity vs. Stagnation(40-60 years) Ego integrity vs. Despair(> 60 years)

28LAURENCE KUBIE Normality is the ability to learn

by experience, to be flexible, and to adapt to a changing environment.

29KARL MENNINGER Normality is the ability to adjust to the

external world with contentment and to master the task of acculturation.

Acculturation explains the process of cultural change and psychological change that results following meeting between cultures.

30ALFRED ADLERThe person's capacity to develop social feeling and to be productive is related to mental health; the ability to work heightens self-esteem and makes one capable of adaptation.

31R. E. MONEY-KRYLENormality is the ability to achieve insight into one's self, an ability that is never fully accomplished.

32OTTO RANK Normality is the capacity to live

without fear, guilt, or anxiety and to take responsibility for one's own actions

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W. SOMERSET MAUGHN The normal is an ideal. It is a picture that one fabricates---

and to find them all in a single man is hardly to be expected.

34 MODELS OF MENTAL HEALTH Six different empirical approaches to mental health. It can be

conceptualized as :1. Above normal and a mental state that is objectively desirable.2. Maturity from the viewpoint of healthy adult development.3. Positive psychology—as epitomized by the presence of multiple

human strengths.4. Emotional intelligence and successful object relations.5. Subjective well-being—a mental state that is subjectively

experienced as happy, contented, and desired.6. Resilience, as the capacity for successful adaptation and

homeostasis.

35 MODEL A: MENTAL HEALTH AS ABOVE NORMAL It differs from the traditional medical approach to health and

illness. If one were to put all individuals on a continuum, normality would

encompass the major portion of adults, and abnormality would be the small remainder.

Health refers to a reasonable, rather than an optimal, state of functioning.

Mental health is not normal; it is above average. The absence of illness and the presence of health overlap but do

not always coincide.

36 MODEL B: MENTAL HEALTH AS MATURITY

Unlike other organs of the body that are designed to stay the same, the brain is designed to be plastic.

Optimal brain development requires almost a lifetime, so does the assessment of positive mental health.

Statistically, physically healthy 70-year-olds are mentally healthier than they were at 30 years in absence of any pathology .

Erik Erikson in 1950 provided the first model of adult social development. He viewed each of his well-known eight “stages” of human development as a “criterion of mental health.”

Jane Loevinger provided a model of adult ego development,

37 Lawrence Kohlberg provided a model of adult moral

development. James Fowler provided a model of spiritual development. Implicit in all of these models is the assumption that greater

maturity reflected greater mental health. The association of mental health to maturity is probably mediated

not only by progressive brain myelinization but also by the evolution of emotional and social intelligence through experience.

Erikson conceptualized that such development produced a “widening social radius.”

Life after age 50 years was no longer to be a staircase leading downward, but a path leading outward.

38 Erikson's model the adult social radius expanded over time through the mastery of the four tasks of:

“Identity versus Identity Diffusion,” “Intimacy versus Isolation,” “Generativity versus Stagnation,” “Integrity versus Despair.” Vaillant added two more tasks—Career

Consolidation and Keeper of the Meaning—to Erikson's four).

The mastery of such tasks appears to be relatively independent of education, gender, social class, and probably culture.

39 MODEL C: MENTAL HEALTH AS POSITIVE OR “SPIRITUAL” EMOTIONS

In the 19th century came concepts like “moral insanity” and “good character,” and mental health was deemed related to morality and religious observance.

There was relationship between morality and health. Model C is a reflection of positive (“spiritual”) emotions. Positive emotions arise from the inborn prosocial mammalian

capacity for unselfish parental love. Thus, they are grounded in our evolutionary heritage.

Limbic system is associated with generation of emotions.

40 Love, hope, joy, forgiveness, compassion,

faith, awe, and gratitude comprise the important positive and “moral” emotions included in this model.

All these emotions involve human connection. None of the eight emotions listed is just about the self.

Five other positive emotions—excitement, interest, contentment (happiness), humor, and a sense of mastery limited to self for a person can feel these latter five emotions alone on a desert island.

41POSITIVE EMOTIONS NEGATIVE EMOTIONSGenerated in the limbic system Generated in hypothalamus &

elaborated in the amygdalaFree the self from the self All about “me.” More expansive and help us to broaden and build. They widen one's tolerance for strangers, expand one's moral compass, and enhance one's creativity.

Crucial for survival in time.

Make thought patterns more flexible, creative, integrative, and efficient.

Narrows attention

Activates parasympathetic nervous system

Activates sympathetic autonomic nervous system.

42 MODEL D: MENTAL HEALTH AS SOCIOEMOTIONAL INTELLIGENCE

High socioemotional intelligence reflects above-average mental health in the same way that a high intelligence quotient (IQ) reflects above-average intellectual aptitude.

Aristotle defined socioemotional intelligence as follows:

“Anyone can become angry—that is easy. But to be angry with the right person, to the right degree, at the right time, for the right purpose, and in the right way—that is not easy.”

43 Suggests that instinct and object relations are equal partners. Primary emotions exist to assist basic survival. These include: Anger Fear Excitement Interest Surprise Disgust Sadness. The capacity to identify these different emotions in ourselves and in

others plays an important role in mental health.

44 Empathic children, without being more

intelligent, do better in school and are more popular than their peers.

Early school success was achieved not by intelligence but by knowing what kind of behavior is expected, knowing how to rein in the impulse to misbehave, being able to wait, and knowing how to get on with other children.

The more one is skilled in empathy, the more one will be valued by others, and so the greater will be social supports, self-esteem, and intimate relationships.

45 Social and emotional intelligence can be defined by the following

criteria: Accurate conscious perception and monitoring of one's emotions. Modification of emotions so that their expression is appropriate.

This involves the capacity to self-soothe personal anxiety and to shake off hopelessness and gloom.

Accurate recognition of and response to emotions in others. Skill in negotiating close relationships with others. Capacity for focusing emotions (motivation) toward a desired goal.

This involves delayed gratification and adaptively displacing and channeling impulse.

46 ADVANCES IN STUDYING EMOTIONAL INTELLIGENCE Three important empirical steps to understand the relationship of

socio-emotional intelligence to positive mental health: First step-fMRI and ingenious neurophysiological experimentation

have led to advances in our understanding of the integration of prefrontal cortex with the limbic system, especially with the amygdala and its connections.

The second step forward has been our slow but steady progress in the conceptualizing and even the measuring of “emotional intelligence.”

The third advance is the use of videotape to chart emotional interaction. Videos of sustained family interactions reveal that the most important aspect of healthy infant development, of adolescent development, and of marital harmony is how partners or parents respond to emotion in others.

47 MODEL E: MENTAL HEALTH AS SUBJECTIVE WELL-BEING

Positive mental health does not just involve being a joy to others; one must also experience subjective well-being.

Subjective well-being is never categorical. Subjective well-being is not just the absence misery, but the

presence of positive contentment. Happiness that comes from joy or from unselfish love, self-control

and self-efficacy, play and “flow” (deep but effortless involvement) reflects health.

Happiness that comes from spiritual discipline and concentration, humor, or being relieved of narcissistic focus on shame, resentments, and the “poor-me's” is a blessing.

48 Subjective happiness can have maladaptive as well as adaptive

facets. Pleasures can come easily and be soon gone. Illusory happiness is seen in the character structure associated with

bipolar and dissociative disorders. Such maladaptive happiness can bring temporary bliss but has no

sticking power. Examples of maladaptive “happiness” can be the excitement of risk

taking, from being “high” on drugs and from “turning-on” to any unmodulated but gratifying primitive need like binge eating, tantrums, promiscuity, and revenge.

49 MODEL F: MENTAL HEALTH AS RESILIENCE In 1856, CLAUDE BERNARD, a French

physiologist imporved the understanding of positive health when he wrote

“We shall never have a science of medicine as long as we separate the explanation of the pathological from the explanation of normal, vital phenomena.” It is not stress that kills us, but healthy

mastery of stress that permits us to survive.

50 In 1925, ADOLF MEYER, a founder of

modern American psychiatry, contributed to the understanding of mental health when he asserted that there were no mental diseases, there were only characteristic reaction patterns to stress.

Meyer's point was that although adaptive mental “reaction patterns” like denial, phobias, and even projections can appear to reflect illness, they may in fact be “normal, vital phenomena” related to healing.

Involuntary coping mechanisms heal by distorting mental processes.

51 Mental illness are the outward manifestations of homeostatic

struggles to adapt to life. Three broad classes of coping mechanisms that humans use to

overcome stressful situations: First, there is the way in which an individual elicits help from

appropriate others. Namely consciously seeking social support. Second, there are conscious cognitive strategies that individuals

intentionally use to master stress. Third, there are adaptive involuntary coping mechanisms (often

called “defense mechanisms”) that distort our perception of internal and external reality in order to reduce subjective distress, anxiety, and depression.

52 5 of the models described here are capable of being assessed

psychometrically— Above-average normality by the GAF (Axis V) Maturity by the presence or absence of Generativity, Positive emotions by the PANAS( Positive and Negative Affect

schedule). Subjective well-being by scaled self-report Resilience by defense level on the optional DSM-IV axis. Measures to assess psychometrically socioemotional intelligence

are under development.

53 CONCLUSION MENTAL HEALTH MUST BE BROADLY DEFINED IN TERMS THAT ARE

CULTURALLY SENSITIVE AND INCLUSIVE. THE CRITERIA FOR MENTAL HEALTH MUST BE EMPIRICALLY AND

LONGITUDINALLY VALIDATED. VALIDATION MEANS PAYING SPECIAL ATTENTION TO CROSS-CULTURAL

STUDIES. ALTHOUGH MENTAL HEALTH IS ONE OF HUMANITY'S IMPORTANT VALUES,

IT SHOULD NOT BE REGARDED AS AN ULTIMATE GOOD IN ITSELF. WE MUST REMEMBER THAT THERE ARE DIFFERENCES BETWEEN REAL

MENTAL HEALTH AND VALUE-RIDDEN MORALITY, BETWEEN HUMAN ADAPTATION AND MERE PREOCCUPATION WITH DARWINIAN SURVIVAL OF THE FITTEST.

54 BIBLIOGRAPHY

1 SYNOPSIS OF PSYCHIATRY 10TH EDITION KAPLAN & SADOCKS2 COMPREHENSIVE TEXT BOOK OF PSYCHIATRY, KAPLAN & SADOCKS 9TH EDITION3 INTERNET SOURCES

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