Is Me cRaZie!? - Blog#22 - 9 August 2019
This is a loaded question if there ever was one. It is the provocative version of the question, “What is normal?” No one wants to be “crazy,” and most of us would prefer to be considered normal. On the other hand, most people want to be “unique,” not a cookie-cutter clone of some middle-gray cardboard portrait of normalcy. We all want to be competent, yet special and one of a kind, capable of managing our thoughts, feelings, behaviors, and relationships, but not so common or standardized that we are boring and b-flat. But how do we determine what is psychologically normal? What is mental health? We can approach these questions from a variety of angles, some of which are quite subjective, involving obvious or subtle value judgments.
For starters, we can distinguish between statistical normal and healthy normal. Statistical normalcy requires a mathematical comparison between you and the masses. Healthy normalcy requires a judgment based on some criterion of mental health/illness, but how do we decide on these criteria? Statistically, do you do what other people do? If most Nazi soldiers followed orders and marched the Jews to the gas chambers, did that make it normal? What percentage of people are depressed? What about depression after the death of one of your parents? Is it normal then? How depressed? How commonly do people hear voices? Voices telling them to kill others, the voice of their recently deceased mother saying she's okay, or the soothing voice of God answering a prayer? Do most people have panic attacks? How about anxiety in a dark parking lot late at night? How about such anxiety in the aftermath of a parking lot assault last week? Is this statistically common? Is it healthy? As you can see, discussions of normalcy can quickly degenerate into controversy, whether we are comparing people statistically with each other, or deciding what is healthy. In a roughly sketched cultural portrait, we tend to share a notion as to what is psychologically healthy. However, both the statistical and the psychologically healthy criteria for normalcy can be criticized as being somewhat dependent upon subjective values, cultural and religious norms, and a relatively ordinary, nontraumatic set of childhood and adult experiences. Statistical comparisons simply tell us what is common, but we must decide what is psychologically healthy.
The Diagnostic and Statistical Manual (DSM, current version DSM 5) of the American Psychiatric Association (2013) is the professional standard for classification of mental illnesses, and is used by clinicians, insurance companies, and researchers. By this standard, you are mentally ill if you have any of the disorders listed in this compendium of psychopathology. From this perspective, your odds of being crazy are increasing, as the number of mental disorders in DSM increased from 106 to 297 between 1952 and 1994, raising the dark specter that our great grandchildren will all be crazy! That march toward madness was dialed back in DSM 5, but the previous steady increase in diagnoses says more about our perspective on mental illness than it does about the true statistical frequency of psychopathology. Critics have insisted that our concepts of psychological normalcy and abnormality, and our diagnostic labels, are less facts about people than social fabrications, with DSM being more a social than a scientific document. From this angle, mental illnesses are not discovered, but invented. They are social artifacts that serve the value system of those in power, designed to maintain the social order. Back in 1961, in The Myth of Mental Illness, Thomas Szasz shook up the psychiatric world with scathing criticism of such psychiatric bias, and controlling psychiatric interventions (e.g., involuntary hospitalization, lobotomies) based on such diagnostic inventions. Comparing modern day psychiatry to the Inquisition, he provocatively asserted, “In the past, men created witches: now they create mental patients.”
The most glaring example of a socially-biased mental “disorder” is homosexuality, which was deemed a psychiatric disorder by DSM in 1952, but then depathologized in 1973. In the same sexual vein, we might note Szasz’s criticism of psychiatry for its campaign against masturbation during the late 19th century, after centuries of religious condemnation of this common sexual behavior. But there are many examples outside of the sexual arena as well. Take antisocial personality disorder as another example. Many of the DSM 5 characteristics of APD, reflecting “a pervasive disregard for and violation of the rights of others,” particularly criterion #A1, “failure to conform to societal norms with respect to lawful behaviors …” are based on social values. But the antisocial individual may view these same behaviors as clever and effective strategies that provide a competitive advantage in the social jungle. APD is clearly a social construct, reflecting prevailing social values, norms, and rules, rather than a mere set of facts about individuals. It has social utility, but should not be seen as a solely internal condition, existing independently of its social context and prevailing social values. Furthermore, descriptions of behavior can be elevated, via circular reasoning, into causes for that behavior. Thus, “antisocial” describes antagonistic, exploitive, or selfish social behavior, but then a diagnosis of APD is used to explain the cause of that behavior.
Similar issues involving the psychiatric imposition of societal values arise for conditions such as schizoid personality disorder. If you have no interest in people, but are not bothered by this, are you abnormal? Yes, most people who consistently go against or away from other people are more distressed than people who successfully go toward and attach to other people. But not all of them. Some people are comfortable in the jungle or in their cave. To be fair, DSM does require “clinically significant distress” for most diagnoses. If you yourself are disturbed by a certain set of your thoughts, feelings, or behaviors, we are clearly on more solid ground when talking about a mental illness. But then again, some of us are so far into denial that the man in the moon knows we’re sick more than the man in the mirror. So are there any rough guidelines or criteria for mental health/illness that we can fairly apply?
One criterion for mental illness is loss of control. If I have lost control of my perceptual apparatus and hear voices or see people that no one else hears or sees, I am likely to be diagnosed as psychotic, which is large “C” crazy. Likewise, if my beliefs are out of control and I spout delusions (e.g., the rabid dogs that I hallucinate were sent by the CIA because my brilliance is a threat to national security), we can talk of a psychotic loss of control. And if my behavior is out of control, not just in your opinion, but in my own opinion, and I’m upset about it (e.g., I start fistfights during arguments, or get so drunk that I drive dangerously), we can diagnose a mental illness - crazy with a small “c” (out of control but not psychotic). So loss of control over perceptions, beliefs, and behavior, or even memory (dementia), or any function of the mind, is one yardstick for mental illness.
Emotions are another such element of the mind that requires control. Thus, one angle on what is psychologically healthy or normal is whether you experience primarily positive or negative emotions (the clinically significant distress noted above). Do you frequently experience sadness, guilt, anxiety, frustration, anger, etc., without much pleasure, joy, love, gratitude, etc.? This criterion of mental health is commonly applied, simply because feeling good, and not bad, at least most of the time, is important to all of us and drives much of our behavior. And it is not only the degree of positive versus negative emotion that is at issue here, but also our control over those emotions. Uncontrolled crying, severe panic attacks, and unbridled anger are problematic for most people who experience them. But if I am overwhelmed with grief and unrelenting tears when my beloved spouse suddenly dies, am I temporarily mentally ill, or crazy? What if I am emotionally numbed in the same tragic circumstance, and experience no negative emotions at all? Does this make me more normal or healthy? The context always matters.
A rather different, integrative view on normalcy is the notion that mental health involves combinations of opposites, and requires the ability to shift up and down any given dimension to find the behavior that is most adaptive to your situation. If we look at self-esteem as an initial example, healthy self-esteem involves a combination of opposites, specifically, valuing oneself coupled with humility. We are each unique and special, yet mere specks of dust in the vast universe. Without humility, we become narcissistic and self-aggrandizing, though if we cannot value ourselves, our low self-esteem may form the bedrock of a persistent depressive state. To be healthy, we need simultaneous complementary talents, in this case, self-esteem tempered by humility. Most of us have well developed skills on one end of any given dimension, but how are your skills on the opposite end of that dimension?
From yet another angle, normalcy may involve connectedness. Human beings are a very dependent species. We raise our young until age 18 or later, which is rare in the animal world. We are quite dependent upon our connections with others. Thus, our degree of romantic, social, and family connectedness, or our degree of satisfaction with such relationships, could be one criterion of mental health or normalcy. Spiritual connectedness, feeling connected with God, or a more secular connection with the universe as a whole, is important to most of us as well. Without it, we feel lacking. And then there is internal connectedness. Self-esteem is a crucial building block of personality. Liking oneself, i.e., being connected to oneself in a positive way, is essential to happiness. Thus, our ability to be positively connected both internally, to ourselves, and externally (romantically, socially and spiritually), might be considered an important criterion of psychological health. But who gets to decide? If I’m a schizoid hermit or an antisocial hellion, and I’m okay with that, despite a lack of spirituality or close relationships, am I abnormal?
Just feeling crazy can make you crazier. Crazy carries a stigma. Mental illness and sexual difficulties, that is, insanity and impotence, give rise to far more shame than most other problems. A broken mind, a limp penis, or a missing breast is far more disturbing than a broken arm or a gallbladder stone. Such shame can be poisonous to our self-esteem and identity, which each need to be solid for good mental health.
As a psychologist conducting psychotherapy, the context and origins of your negative feelings, behavior, and relationships is very important to me. Many clients feel “crazy” in the street sense of the term, and indeed, they are quite abnormal, both statistically, and in terms of most criteria of mental health, if you compare them to the general population. But if you compare such clients to other people who have been through a similar degree of trauma (e.g., growing up with alcoholic, violent, or sexually abusive parents), their level of emotional distress, relationship difficulties, and behavioral disturbance suddenly looks quite “normal,” at least statistically. An early part of recovery involves acceptance that such difficulties are “normal” consequences of such an abnormal or unfortunate past, thereby improving self-esteem by depathologizing behavior. By accepting such behaviors as normal consequences of abnormal environments, while working on altering these same behaviors, we become more normal. Our past trauma hopefully becomes something that happened to us, rather than something that defines us. Additionally, we need to support and nurture our core identity, even if we reject some of our behaviors.
Finally, there is the well-known lay definition of craziness, that is, repeatedly engaging in the same behavior despite the same old negative consequences. Or, perhaps you’d prefer to simply apply U.S. Supreme Court Justice Potter Stewart’s threshold for obscenity (“I know it when I see it”) to mental illness. For practical purposes, most of us do have an internal sense of psychological health. But all of this is subjective, and what makes me feel crazy may be entirely different from your craziness. Thus, we might hesitate before we judge others as crazy. The stigma of mental illness itself is crazy-making, and can be counteracted by compassionate tolerance. Ultimately, we are remarkably fragile as human beings, and could benefit from more support and understanding from each other when we are troubled. If you haven’t personally experienced such fragility, you might take a moment to count your blessings.
For more on the criteria for mental health and illness, the complementary angle of positive psychology, and other topics in psychology, coping, and recovery check out Ed Chandler’s Psychomechanics – Tools for Self-Regulation of Emotions, now available in Print and E-Book on Amazon. Or, if you are interested in secular approaches to spirituality, the chapters of Psychomechanics are also included as the final section of Beyond Atheism – A Secular Approach to Spiritual, Moral, and Psychological Practices, also available in Print and e-Book on Amazon. Or explore this website (edchandlerandbeyond.com) to see Ed’s photography and stained glass, in addition to his writings on psychology, spirituality, anthropocentrism and prejudice. Thanks for listening.