What does abnormality mean? - Chapter 1 (Abnormal Psychology)

Abnormal psychology, frequently called psychopathology, is the study of people suffering from mental, emotional and often physical pain. Although people with psychopathological problems can have unusual experiences, most of the time these experiences are same in nature to other people's experiences but taken to an extreme degree (e.g. sadness turning into depression).

Defining Abnormality

Some behaviours that seem abnormal to us are normal in other cultures or situations. When we determine whether something is normal, we have to look at the context or circumstances in which the behavior occurs. In addition to context, there are a number of criteria that must be taken into account when determining whether certain behavior is abnormal.

Cultural relativism

Cultural relativism theory states that there are no universal standards or rules to judge a behavior as abnormal. Instead, behavior can only be abnormal according to the prevailing cultural norms. Therefore, definitions of abnormality differ between cultures.

Opponents of cultural relativism believe that it can be dangerous if cultural norms dictate what is normal and abnormal. For example, throughout history, different societies have labelled certain individuals and groups as abnormal to provide justification for controlling those groups. Think of what Hitler did to the Jews. Also, such abuse often took place when slavery was legal. For example, slaves who tried to escape were diagnosed with drapetomania, a disease that caused them to desire freedom.

Gender also affects whether something is labelled as abnormal. For example, men who show sadness or fear, or who choose to stay at home with children while their wife works, are often seen as abnormal. Women who are aggressive or who do not want children are also viewed as abnormal. On the other hand, aggression in men and chronic anxiety in women are seen as normal, because these behaviours are in line with societal expectations based on sex.

In any case, it is clear that culture and gender influence the expression of abnormal behavior and the way such behavior is viewed. Furthermore, culture and gender can have an impact on determining which types of treatment for abnormal behaviours are acceptable.

Unusual

Another approach of assessing abnormality is to think of how unusual the behaviour is. Behavior that is deviant or unusual is seen as abnormal, while typical or standard behavior is considered normal. In a sense, such attitude is linked to the relativistic criterion, because the unusual nature of behavior is partly dependent on cultural norms of that behavior.

The relativistic criterion has some shortcomings. For example, how unusual a behavior has to be to call it abnormal? Is a behavior abnormal if less than 10% of the population displays it, or if less than 1% displays it? In addition, plenty of rare behaviours are positive for the individual and society, making it strange to call such behaviours abnormal. People who exhibit such rare but positive behaviours are often called eccentric.

Distress

According to the distress criterion a behavior can be seen as abnormal if it causes a feeling of distress (discomfort) to a person displaying that behavior. According to this criterion, a behavior is not considered abnormal when it violates societal norms but does not cause any inconvenience to the individual. Opponents of this theory state that people are not always aware of the problems that their behavior causes for themselves and for others. In addition, certain behavior can cause a lot of discomfort to others, even if this is not the case with the person himself. In such case we should call the behavior abnormal, even though it does not cause a feeling of discomfort to the individual.

Mental disorders

Some people argue that we should not label behavior as abnormal unless it is part of a mental illness. This implies that a disease process, as high blood pressure or diabetes, is the cause of the behavior. However, there are no biological tests available to diagnose psychological abnormalities. Many theorists believe that this is because mental health problems do not come from some abnormal genes or disease processes and that we can never develop a simple or definitive test to determine if someone has a mental disorder. A diagnosis of such a disorder is simply a label for a set of symptoms. Therefore, a diagnosis does not refer to an identifiable physical process found in all people who have similar symptoms.

The four D's of abnormality

Modern assessments of abnormality are not based on one of the previous criteria, but are influenced by an interplay of four dimensions, often called the four D’s: Dysfunction, Distress, Deviance and Dangerousness.

• Behaviours and feelings are dysfunctional if they hinder someone's functioning in daily life. The more dysfunctional the behavior, the greater the chance that it will be labelled as abnormal.

• Behaviours and feelings that cause distress to the individual and the persons around him are also often seen as abnormal.

• Highly deviant behaviours, such as chronic lying and stealing, lead to assessments of abnormality.

• Behaviours that are dangerous (dangerous) to the individual, such as self-harm, or to others, such as severe aggression, are also seen as abnormal.

Together, these four D's form the professional definition on the basis of which behaviours are assessed as abnormal, or maladaptive. Despite the fact that these criteria provide much clarity, the don't answer all the questions. How much emotional pain or damage does a person have to experience? To what extent must the behavior hamper a person's functioning? We assume that each of the four D's is on a continuum. There is no clear-cut distinction between what is normal and what is abnormal.

Historical perspectives on abnormality

There are three types of theories that have tried to describe the causes of abnormal behavior. The biological theories have conceptualized abnormal behavior as a physical illness caused by problems in the bodily systems. The supernatural theories have conceptualized abnormal behavior as a result of divine intervention, curses, demonic possession or sinning. The psychosocial theories have conceptualized abnormal behavior as a result of traumas, such as the death of a loved one or chronic stress.

Ancient theories

Our understanding of the views on abnormal behavior of prehistoric people is deduced from archaeological findings. Since the invention of written language, people have been writing about abnormal behaviours.

Casting out evil spirits

Historians speculate that even prehistoric men already had a concept of insanity, which probably originated from supernatural beliefs. A person displaying strange behaviour was considered to be possessed by evil spirits. The treatment for this was exorcism - the expulsion of the evil spirit from the body. This was done by making the body unfit for the mind to live in it, which often involved extreme measures, such as starving or beating the person. The "treatment" sometimes involved killing a possessed person or drilling holes in the skull to let evil spirits leave.

Ancient China: the balance of Yin and Yang

The old Chinese medicine doctrine was based on the concept of yin and yang. The human body would contain a positive force (yang) and a negative force (yin), which confronted and complemented each other. When the two forces were in balance, the individual was healthy. If not, illness (including insanity) could be the consequence.

Another theory stated that human emotions were controlled by the internal organs. When the vital air flowed through one of those organs, the individual experienced a certain emotion. Thus, the heart was related to pleasure, the lungs to grief and the liver to anger. This theory encouraged people to live in an orderly and harmonious way in order to promote the proper movement of the vital air. Although these explanations are mainly biological, later religious interpretations of abnormal behavior arose with the dawn of Buddhism.

Ancient Egypt, Greece and Rome: Dominant biological theories

Ancient scripts from Egypt that contain a list of disorders and the treatment used at that time have been found. Disturbances in women were often attributed to a 'walking uterus'. It was assumed that the uterus could become detached and could move through the body, causing it to disrupt the other organs. The later Greeks retained this theory and called it hysteria (from hysteria, which means uterus). Nowadays, the term hysteria refers to physiological symptoms that are probably the result of psychological processes.

Most Greeks and Romans saw craziness as a disease of the gods. The sick retreated into temples of the god Aesculapius, where priests held healing ceremonies. However, Greek physicians usually rejected supernatural explanations of abnormal behavior. For example, Hippocrates believed that abnormal behavior was another disease of the body. According to him, the body consisted of four basic humors (fluids): blood, phlegm, yellow bile and black bile. All diseases, including abnormal behavior, were caused by a poor balance of these four humors. Hippocrates divided abnormal behavior into four categories: epilepsy, mania, melancholy and brain fever. Treatments were aimed at rebalancing the four fluids.

In those times, the state took no responsibility for insane people. There were no asylums or institutions to take care of them. Rights could be taken from those people, such as the right to marry or the right to decide about their possessions.

Medieval perspectives

Although the Middle Ages are often seen as a time when people were obsessed with the supernatural, this was not the case until the late Middle Ages. Many people believed in the supernatural, but there is strong evidence that doctors and government officials associated abnormal behavior with physical causes or traumas and not with witchcraft or demons.

Witchcraft

Some historians say that people accused of witchcraft were probably mentally ill. Those people probably suffered from delusions (false beliefs) or hallucinations - signs of some psychological disorders. However, it is also possible that such confessions were forced by the means of torture or in exchange for a postponement of execution. The theory that 'witches' were actually mentally ill was crushed by the church with the support of the state.

Psychic epidemics

A psychic epidemic is a phenomenon in which a large number of people exhibit unusual behavior that seems to have a psychological cause. In the Middle Ages there was dance frenzies, in which people would be wildly dancing in the house, in the street and in the church, while calling out the names of demons and not paying attention to the fact that others were looking at them. This was often dismissed as possession by the devil.

Even today we observe such psychic epidemics. In 1991 there was great panic at the school in Rhode Island, where many students and teachers thought that they inhaled toxic gases and actually began to show physical symptoms. There was great chaos in which everyone was evacuated and many people were admitted to the emergency room. No gases were found, and the event was eventually perceived as an outbreak of mass hysteria caused by the fear of chemical warfare during the Persian Gulf War.

The dissemination of asylums

Around the eleventh or twelfth century, the first special facilities were created in hospitals for people who exhibited abnormal behavior. In those early hospitals, the mentally ill were often kept against their will and in very harsh, inhuman conditions. The law stated that family members and friends of a mentally ill person were obliged to keep, bind, or chain this person to a house, beat him or take any necessary actions to keep a person in check so that no one is hurt by the mentally ill. It was not until 1774 that a law was passed in England aimed at improving the terrible living conditions of asylum patients. The medical theories of the times also contributed to suffering of the mentally ill. For example, drawing enormous amounts of blood from the body was believed to restore balance of the body and the mind.

Moral treatment in the eighteenth and nineteenth centuries

Fortunately, in the eighteenth and nineteenth centuries a more humane treatment methods were developed for people with mental problems. The theory was that people developed problems because of the stress induced by rapidly changing social situation in the times. Therefore, considered as treatment was relaxation in serene and physically attractive environment. The patients were free to walk through the asylum and received clean, sunny rooms and good food. The approach was exceptionally successful. Many people who had been locked up for years got their behavior under control and were able to live reasonably normal again; some of them could even leave asylums.

Unfortunately, the moral treatment movement grew too rapidly. As more people were admitted to new asylums, practitioners no longer had enough time to give patients the individual attention. As a result, previous big success was followed by a rather modest success and sometimes even by a serious failure. By the beginning of the twentieth century, many asylums again resembled a kind of a storage place for the mentally ill. Effective treatments did not develop until well into the twentieth century.

The rise of modern perspectives

Despite the poor treatment of the mentally ill at the time, in the early twentieth century great progress was made in scientific research on disorders. This research laid the foundation for the biological, psychological and social theories of abnormality that hold today.

The beginnings of modern biological perspectives

In 1845 Wilhelm Griesinger published 'The Pathology and Therapy of Psychic Disorders', in which he stated that all psychological disorders can be explained by the brain pathology. In 1883, one of Griesinger's followers, Emil Kraepelin, published a book in which he developed a scheme for classifying symptoms into discrete disorders. This scheme has served as a basis for the classification systems we use today.

An important discovery was that of syphilis causing a form of insanity. This discovery gave a lot of weight to the idea that biological factors can be the cause of abnormal behavior.

The psychoanalytic perspective

Franz Anton Mesmer developed mesmerism, a method based on animal magnetism. He believed that  a magnetic fluid runs in human body and it needs to be well distributed for people to stay healthy. He treated the hysterical disorders through a ritual. Patients would be sat in the dark room around a container with different chemicals. Then Mesmer would enter, in a special garment, and while playing music, he would touch every patient with the purpose of redistributing their magnetic fluids by his magnetic power and presence. Although Mesmer was eventually convicted as a charlatan, his results continued to be debated. The effects of the treatment are now attributed to the state of trance in which the patients would end up. This was later called hypnosis.

The effects of hypnosis were confirmed by Bernheim and Liebault, led by Charcot, who showed that hypnosis could induce symptoms of hysteria by suggesting these symptoms when the patients were under hypnosis. These experiments have made a significant contribution to the progress of psychological perspectives on abnormality.

One of Charcot's students was Sigmund Freud. In his work Freud became convinced that much of people's mental life takes place outside of consciousness. He worked with Breuer on research into hypnosis and the value of catharsis (a great release of emotion under hypnosis). They found that discussing the patient's problems often goes better under hypnosis because the patient is less censored. Their research became the basis for psychoanalysis, the study of the unconscious.

The roots of behaviourism

While the psychoanalytic theory had arisen, the roots of behaviourism were planted in Europe and later in America. Ivan Pavlov developed methods and theories for understanding behavior in terms of stimuli and responses, rather than in terms of the internal workings of the unconscious mind. His research into drooling dogs when they had to deal with stimuli other than food is world-famous. It gave rise to the theory of classical conditioning. Enthusiastic about classical conditioning, American psychologist John Watson investigated relevant human behaviours (such as phobias) and explained them as acquired solely through conditioning.

At the same time, Thorndike and Skinner investigated how the consequences of behavior influence the likelihood that this behavior will be repeated. They argued that behavior that is followed by positive consequences will be repeated more often than the behavior that is followed by negative consequences. This became known as operant conditioning.

Behaviourism has had a major impact on psychology and it is the basis of many effective psychological treatments that are used today.

The cognitive revolution

In the 1950s, some people argued that behaviourism was limited because it did not take into account the internal thought processes that influence the relationship between stimulus and response. It was not until the 1970s that the focus of psychology shifted to studying cognitions - thought processes that influence emotion and behavior. For example, Bandura argued that the extent to which people think they can influence certain events (self-efficacy beliefs) is crucial for mental health.

Beck introduced rational-emotive therapy. This was controversial, because therapists sometimes had to challenge patients hard to change their irrational thought patterns. The treatment method eventually became very popular and Beck's cognitive therapy has become one of the most commonly used therapies for many disorders.

Modern mental health

In the mid-Twentieth century, much progress was made in the medical treatment of some important forms of abnormality. In particular, the discovery of phenothiazines (which counteract hallucinations and delusions) caused many people who had been in institutions for years to return to society. In addition, new forms of psychotherapy have been developed that are very effective in treating a wide range of psychological problems.

Deinstitutionalization

Patients' rights movement arose around 1960. It postulated that patients with mental problems can recover better if they are integrated into society, with the support of treatment within the community. This was called deinstitutionalization. This process had a huge impact on the lives of people with serious psychological problems. Many patients experienced a major improvement in their quality of life and suddenly had a lot more freedom.

We can still observe this today. The work in the community is often done by social workers, therapists and doctors. In halfway houses patients in a structured environment can get used to living in society, having a job and their family and friends. Day treatment centres ensure that patients receive treatment during the day, but promises to let them be back home by night. People with acute problems can go to inpatients wards of psychiatric hospitals.

A problem with these developments was that community-based treatment centres could not cope with the large numbers of patients who had left the institutions. Many of these patients ended up in care homes or at their family's home, where they were not provided with the right treatment. Others ended up on the streets.

Managed care

Managed care is a collection of methods for a coordinated care that starts with monitoring and ends with determining what kind of care should be provided and financially covered. The goal is to aid with existing medical problems and to prevent future medical problems. Healthcare providers often receive a monthly fixed amount of money per patient and then must decide how they can provide the best care to each patient with that money.

The advantage of this approach is that patient's family doesn't have to search for suitable care, but the primary care provider can find and can ensure that the patient has access to such care. This prevents the patient from slipping between the meshes and falling outside the treatment. Unfortunately, mental health care is not always fully covered by insurance. Many American states have also lowered the subsidy for mental health care, therefore leaving plenty of poor without access to the proper health care needed.