Who decides what is “normal”?

by on Tuesday, 20 November 2012 5263 hits Comments
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Perhaps, everyone has a crazy side; it’s just the extent to which it manifests that is different. If this is the case, how can we then draw a clear line between normal and abnormal?

When compared to other diseases that can be diagnosed in a clear-cut way, mental illness has always been an unsolved riddle. What makes people sink into insanity? Is this insanity a disease? These are problems that psychiatry is constantly faced with. Psychiatry has been a specialized subject for less than a hundred years; however, in the space of this short history, it has already experienced several paradigm shifts. Obviously these questions are always under scrutiny, and there have been no definite answers thus far.

Examining “insanity” throughout different paradigm shifts

Since ancient times, humankind has tried to explain “insanity” from every possible angle. In excavations of Mesopotamian Civilization remains, human skull bones that had been bored into have been unearthed, which reflects the belief of this ancient people that madness was a consequence of evil spirits entering the body. Because of this, it was necessary to bore a hole into the persons head to allow the evil spirits to escape. This kind of religious explanation has never quite completely disappeared. A few years ago the Catholic Church reinstated the practice of exorcism for believers with mental disorders.

However, following the rising popularity of the “rationalization” movement, and the Ancient Greek explanation of Humoral medicine, people began to believe that madness was brought about by an imbalance in bodily fluids. At the end of the sixteenth century, with the rise of dissections and anatomical medicine, the Humoral medicine model was superseded, and “insanity” began to be attributed to problems with the nervous system, and attempts were made to find lesions through dissection; but in the end it was not possible to determine a clear cause in this way, so mental illness began to be described as a problem with the “functionality” of the nervous system. After that there was the theory about the degeneration of the nervous system which was in vogue in the latter half of the nineteenth century and the first half of the twentieth century. This theory believed that this kind of degeneration was hereditary and could be passed on from generation to generation.

In addition, psychoanalysis and other such theories have attempted to explain mental illness from the point of view of psychology (which was once the main theory of psychiatry), particularly in this age where biological medicine is still unable to propose theories and treatments capable of convincing people. In the last few decades, psychological medicine has been slowly declining whereas biological psychiatry (which investigates mental illness from an organic approach, and believes that the cause for the disease is biological, for example an imbalance in brain neurotransmitters, brain lesions, or a change in the balance of the chemicals found within the body) is gradually increasing in popularity.

It can be said that humankind’s search for the cause of mental illness has never really ceased. Of course, the transformations aren’t necessarily dramatic, but rather have been developing consistently over time; the power of rationalization has always existed.

Bendu health

The blurry line between normal and abnormal

As the main school of thought in psychiatry today, biological psychiatry reflects the fate of psychiatry as a whole. Since the nineteenth century, it has wanted to become a genuine scientific discipline, yet it is still unable to reach its goal. Psychiatry can never treat sickness by just putting out a clear-cut diagnosis in the way that general medicine and surgery do. This inherent problem is very hard to resolve.

Throughout the seventies and eighties, the challenges that psychiatry was faced with were the exact opposite of those it has now. At the time, anthropology and psychology questioned the validity of psychiatry by saying that the change of someone going from normal to abnormal is on a gradual continuum, whereas psychiatry, due to its status as a medicinal science, and it’s concept of dealing with the disease, requires that a clear-cut judgment of whether there is an illness present or not be made. This inherent problem is hard to resolve. They also criticize the fact that the line separating normal from abnormal is completely manmade, lacking any biological basis whatsoever. Because of this, at that time, there were some anti-psychiatry campaigns, which believed that psychiatry was just a way for society to control things, labelling those actions that mainstream society deemed unacceptable as a disease.

Psychiatry, therefore, faced challenges from all walks of life, and at the same hadn’t really achieved a definite position in medicine, which caused it to react in a slightly paradoxical manner; because others criticized it for being too subjective, it decided to become arbitrary to the extreme. Psychiatry began anew, standardizing its diagnostic process in order to strictly define every disease, eventually giving shape to a set of standards, so that there would never again be room left for personal interpretation. In this way, stricter, more artificial classifications were created.

Does a standardised method take into account differences between patients?

This kind of mental illness diagnostic method frequently looks over the different backgrounds and causes of people and their illness, and groups everyone who exhibits the same symptoms together. Moreover, these subjective symptoms are often voiced by the patient itself, so the communication between the doctor and the patient needs to be based on the same semantic constructs in order to be successful. This means that diagnostic criteria need to be translated into a method that is common for the whole world, which requires mutual communication throughout the process.

The reason the number of people diagnosed with depression is increasing is actually because the language doctors and patients are using is moving closer to being identical. In reality, in the diagnosis of mental illness, it is often enough to simply follow certain indicators to reach a conclusion, doctors don’t conduct checkups which offer up anything to the patient about his mental and physical condition that he or she doesn’t already know; the patient can probably figure it out without even coming to the doctor. This is very different from our usual concept of disease, and depends on too many factors, and there are too many differences in opinion from different people included in its definition. The intrinsic structure of this logic is actually rather absurd, and can also cause problems to arise during diagnosis.

But amongst the many different kinds of mental illness, there are those that are hard to identify and those that are easy. Some serious conditions such as schizophrenia cause a big gap with normal affairs, those people cease any normal interaction or conversation with other people. Also, for these kinds of conditions, the use of medication is a very effective form of treatment, and can help us understand very clearly where the problem lay after all.

In contrast, less severe forms of mental illness, such as depression, often have a much more subtle and complicated background or origin. A lot of different illnesses can produce the symptoms common of depression. Using the standardized questioning method mentioned above, depression is commonly diagnosed, but, are all the diagnoses correct? Is there really a clear-cut way to determine what constitutes depression?

Diseases shape identity

Psychiatry has created many names for the illnesses it diagnoses. Before, people would say that these names were just a form of societal control, but, currently, there are many situations where people will actually accept these labels. The behaviour of some of these patients fits their diagnosis perfectly; their depression has even become a very important part of their identity.

Recently, in the psychiatric clinic, the amount of people with depression has been gradually increasing, and some of those people base some of their identity on the sentence “I am a depressive”. When they acknowledge this part of their identity as important, their identification as depressives will colour the way they view their own identity, their interactions with other people, and their roles within society. Some people with depression see it as an illness, and therefore consider that their moods should not be considered and cannot be dealt with in the same way as normal moods can, instead requiring professional help. They will require that they be treated as a special patient, and not as an ordinary person.

Achieving identity through illness is a very unusual phenomenon, and reflects the fact that the psychiatric vocabulary of the last 20 years has become more ingrained in Taiwanese society, and has become a part of some people’s identity, to the point where it has become a topic of discussion in everyday life. This is a process that has been given shape over a long period of time by many different factors. Some of the most important are the propagation by the media, the collapse of traditional social structure and institutions, and the increasing power of individualism, amongst others.

Irrationality in a rational system

How can we describe psychiatry’s role in society? Psychiatry is a space for irrationality within a rational system, which allows the mad individual to express their irrationality therein. This is not repression; it’s just a way of managing irrationality. As Michel Foucault wrote in “The History of Sexuality”, this really isn’t simply a power mechanism between the oppressor and the oppressed, but rather the mad part of you is dealt with by a relatively more tolerant rational mechanism.

There is a trend in our society in which only those who emphasize rationality and know how to suppress their emotional selves can be deemed normal and healthy. Over the last few years the words “mental health” have grown in popularity, but ultimately what is mental health? Mental health does not necessarily equate to happiness. In fact, there are two models for mental health. The first is the positive model, in which we pursue positive development, this kind of positive development can be reached through many different kinds of deep personal experiences; even short spells of depression can transform into positive energy, and lead to a more enriched and interesting mind. However, this aspect of mental health has little to do with treatment, and can probably be experienced in religious or social activities. The other model is the negative model, and is the way in which modern psychiatry treats irrational behaviour.

Function and position of psychiatric treatment

The welfare mechanisms in our society are very weak and offer very little support to the mentally ill; the resources dedicated to them are also limited. As a psychiatrist, it sometimes makes me feel utterly powerless. Because every patient a different story (maybe their husband died, or they got divorced, or became unemployed when they were middle-aged) at the root of their problems, even if I prescribe medicine for them, it does not guarantee that they will get better. If their personal environment and circumstances don’t change at all, it is not easy for their state of mind to take a turn for the better. Everybody has their own stories; some people are subjected to systematic domestic violence when they are growing up, or have many unbearable experiences, to the point where they can’t take it anymore and come to see a doctor. Only if the doctor can establish a long-term and deep psychotherapeutic connection, can he perhaps guide the person through growing up once more. If this connection cannot be established, in the brief period of time spent at the outpatient service, the help provided is often negligible.

Psychiatric treatment is one part of the societal mechanism for dealing with emotions. As psychiatrists, we come into contact with a lot of people’s emotions and innermost crazy conceptions, and these patients can only voice these in the presence of psychiatrists. Psychiatrists themselves are a part of the mechanism that manages and governs these irrational emotions. The knowledge that makes up this mechanism and its practical application may have some problems, but the problems it has have been balanced so far by the positive effects that it has brought about.

 

Interview with doctor Wu Yuquan.

Translated from the Chinese by Daniel Pagan Murphy.

 

 

Last modified on Wednesday, 08 January 2014 17:34
Raining (陳雨君)

人籟論辨月刊前編輯
Ex-editor of Renlai Monthly

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