BEHAVIOURAL ABNORMALITY, AND IT AFFECT UPON OUR SOCIETY.

Men will always be mad, and those who think they can cure them are the maddest of all.

Voltaire. (1694-1778) Letter 1762.

In our western culture, we take the behaviour of the largest cross-section of our population, assess their behaviour, and accept it as our cultural norm. We allow some deviation from this norm if it is firstly, non threatening, and secondly, if it generally benefits our society. (i.e. we accept artists, performers, entrepreneurs, and controlled risk takers, but we refute dictators, megalomaniacs, drug takers, and drunken drivers.) Thus we use the numbers of ‘norm’ to repress all others. However many researchers take the view that the so called ‘Statistical Criterion’ is a poor way of assessing the baseline of normality.

To emphasise this fact Gross (1984) points out that this ‘Statistical Criterion’ is not a good way to set the ‘norm’ standard, as it does not allow us to accept the problems that people have in coping with 20th century stress. Many of these so called problems such as depression and anxiety are really part of daily living but are often seen as deviations. It also carries some degree of stigmatisation, even though it may be transient and non threatening. We even go so far as to label it as an ‘Abnormality’.

In some cultures abnormality is much more acceptable. i.e. Cochrane (1985) writes that “Although depression is the commonest psychological disorder found in the UK, its occurrence in many other cultures is less well established”. and that “Schizophrenia is seen as a life long disability in the UK, whilst in Mauritius, it is viewed rather like a physical infection which can be cured”. It could be rather risky to set a standard of normality which could create a barrier between groups of people, although Johada (1958) does this when he proposes a table of ‘normality’ (and therefore any deviation could be regarded as an abnormality).

a) Absence of mental illness. (clearly a negative definition).

b) Being introspect about ourselves, and aware of what we are doing and why.

c) Growth, development, and self actualisation.

d) Integration of all processes and attributes.

e) The ability to cope with stress.

f) Concept of autonomy.

g) Seeing the world as it really is.

h) Environmental mastery, ability to love, work and play.

If we had used Maslow’s “Hierarchy of Needs” triangle as a standard of norm, then, as Mackay (1975) points out “Most of us would not achieve self-actualisation and so there will be a fundamental discrepancy between the realistic criterion and the so called Statistical Criterion”. However, having set out a table of normality, it follows that we must therefore have a table of abnormality. as seen by other researchers in this field. Therefore Abnormality is defined by Stratton & Hayes (1993) as:-

1)Behaviour which is different from the norm.

2) Behaviour which does not conform to social demands.

3) Statistically uncommon behaviour.

4) Behaviour which is maladaptive or painful for the individual.

5) Failure to achieve self-actualisation.

The above puts abnormality as a deviation of behaviour, from the perceived or accepted norm. We shall see later on that these rigid guidelines do nothing to help us understand or accept people with behavioural problems. In western cultures we used to see all abnormality as a mental illness, and as such we have in the past embraced the ‘Biomedical’ model of abnormality.

Probably the first clinical description that abnormality had a definitive cause was Silverberg (1872) who called the 3rd stage of Syphilis “General Paralysis of the Insane”. Since then, whether the causative factor was physiological or psychological we have used the term ‘mental illness’ if the persons behaviour breached our collective norms. We have also advocated that people with abnormality be incarcerated into specialised hospitals, and that active treatment be given, (i.e. medication, psychosurgery, E.C.T. etc.). A whole new branch of medicine became self-perpetuating and the medically minded psychiatrist was created. The medical model by its complexity, and lack of ethical morals soon became corrupted. The system even perceived ‘socially defective people’ i.e. single pregnant women, as abnormal and they where admitted into psychiatric hospitals. Finally people who where Typhoid carriers where certified to prevent spread (Birmingham Medical Officers Report on ‘Rubery Hill Asylum’ 1901). Furthermore in the Soviet Union, abnormality was diagnosed in Russian dissidents to remove them from society.

Critics of the medical model such as Rosenhan (1973) looked at abnormality in psychiatric hospitals, and in his unethical ‘Stooges’ experiment proved the inadequacy, or uncertainty of psychiatrists in diagnosing some perceived abnormalities such as Schizophrenia.. Maher (1966) points out that “When a persons deviant behaviour (abnormality) ceases we regard them as ‘cured’ and discharge them back into society”. Thus the medical model of abnormality depends entirely on the behaviour presented at any one time, and does not look beyond that time scale. Any re-occurrence of problems is seen as a failure of the patient and never the system, therefore never the fault of the psychiatrist or his medical regime. Heather (1976) saw psychiatry as a “Quasi-medical illusion” In our 20th century world, most of like to attach labels to things and put then away tidily. The medical model follows this human trait very well. Scheff (1966) highlighted this trait when he looked at patients in an institution, and says on the problem of abnormality and mental illness “The ‘mentally ill’ are seen as breaking a set of ‘residual rules’ of society which are rather vague and unspecified, having to do with ‘decency and ‘reality’. As the breaking of these rules can be strange and frightening for those observing it, the fear can be reduced by labelling such unintelligible behaviour as ‘mental illness’. Thus the labelling reinforces the role of being ‘mentally ill”.

The most damming evidence of the treatment of abnormality in a medical model is given by Goffman (1968) who “Sees the mental patient as being involved in a ‘career’ where they go through a series of rituals, starting with diagnosis, hospitalisation, and the ‘mortification of self’. In this latter ‘ritual’ the patient may have personal clothing and belongings removed and their private life becomes public. Goffman feels that patients respond to this attack on their identity by becoming institutionalised. They become passive and apathetic to all around them. The institution then, rather than improving the quality of a persons life may be seen as having the opposite effect”.

The fact that some patients would benefit from hospital admission is emphasised by Blaney (1975) who legitimised admission for abnormalities “As a humane action to enable the psychologically disturbed person to be considered ‘sick’ rather than morally defective i.e. ‘bad’. Therefore when we label someone as ‘sick’ we remove all responsibility from them for their behaviour, and that doctors and nurses will take over responsibility. Furthermore no blame will be attached to the patient”. This opinion however, is now rather suspect in so far that current trends are to close the huge monolithic institutions, and replace them with day attendance hospital units, Furthermore researchers have moved away from the medical model of treating abnormality, towards a more holistic approach in which, personal behavioural deviation is seen collectively as a non-physiological syndrome.

This trend away from hospitalisation has led us to criticise our preconception as to whether behavioural problems are indeed a medical condition at all. Heather (1976) believes that the criteria used by psychiatry to judge abnormality must be seen in a moral context and not a medical one. Furthermore he argues “The fact of cultural relativity makes psychiatry an entirely different kind of enterprise from legitimate medicine”. and that “A psychiatrists claim to be a part of medical science rests upon the concept of ‘mental illness’, and far from being another medical speciality, psychiatry is a quasi-medical illusion”.

When looking at the effect of behavioural abnormality as a form of personal distress, (Which is the physical reason for most medical admissions, as this distress is the observable symptom that affects others around the patient), researchers do not appear to agree as to whether this personal distress is actually present, or whether this distress itself is abnormal or not. Smith et al (1986) says “That people with behavioural disorders are unable to modify their behaviour in response to changing environmental requirements. Thus, their behaviour is maladaptive because it is inflexible and unrealistic. It is also likely to be statistically uncommon and socially deviant, although neither of these characteristics is always present. People whose behaviour is abnormal may or may not seem unhappy about their failure to adapt” Although others such as Atkinson et al (1990) propose “That subjective feelings of personal distress may sometimes be the only symptom of abnormality”, and that “As far as their personal behaviour is concerned they may be perfectly normal. (although the converse may occur)”. Thus one can draw from this, the inference that whether personal distress is present or not, the problem can well be a behavioural syndrome, rather than a ‘mental illness’.

Some researchers have taken a new , if astonishing view on mental illness. They have proposed a new viewpoint which belies all that has gone before. Szasz (1962) authored two books called ‘The Myth of Mental Illness (1962)’ and ‘The Manufacture of Madness and Insanity (1974)’. The titles give us advance warning of his beliefs on abnormality. He advocated “That if the abnormality was not caused by a neurophysical disorder, (as might be the case with traumatic or acute viral disorders we should separate it from the medical model of abnormality, and look at this new separation as a .’problem of living’ . This abnormality deviation should be seen in an ‘ethical and social context”. This is now called ‘Holisticism’ whereby we look at the moral and social content of a persons lifestyle. We therefore do not accept someone’s behavioural problems in isolation, and then call it a mental illness. Szasz goes on to say “That a vast majority of cases of mental illness fall into the criteria of ‘Problems of Living’. This somewhat startling viewpoint has found many adherents. One such as Bailey (1979) reinforces Szasz by confirming that “Non-organic psychosis, is now known as functional psychosis whereby the ‘functional’ part indicates no physical brain damage. and that the basis for the abnormality is that something has gone wrong with the way that the person functions in the network of relationships which make up their world”.

Looking at the above has led Gross (1984) to asks, that if it is not the brain itself which is diseased , then surely we are left asking in what sense can we think of the mind as being diseased. Szasz answers this by saying that “Only metaphorically can we attribute disease to the mind”. Bailey (1979) maintains “That an organic mental illnesses are not mental illnesses at all but physical illnesses in which mental symptoms are manifest. Also that functional mental illnesses are not illnesses but disorders of psycho-social or interpersonal functioning”, (Szasz’s ‘problems of living’) in which mental symptoms are important in deciding the type of therapy the patient requires.

The use of many therapies other than the medical one has been looked at by Smith & Glass (1977) who analysed the results of 25,000 experimental and 25,000 control clients for over eight hundred different effects, and concluded that the average psychotherapy client was better off 75% of the time. (using therapies, rather then medical intervention). Shapiro (1980) says that: “The effectiveness of a therapy (for abnormality) is due partly to the inherent characteristics of the therapy itself, the quality of the therapy and the qualities of the therapists, plus the clients expectations regarding outcome”

Critics of Szasz and others, such as Heather (1976) criticised behavioural techniques in treating abnormality as ‘dehumanising and mechanistic’. However Cardwell (1984) disagrees with this when he says “That if the object of behavioural intervention is to rehabilitate clients, then it appears more humanising than dehumanising. Similarly, if the processes of learning are mechanistic in the first place, then it makes sense that the unlearning process is likewise mechanistic”. Another critic of the holistic approach to non-physiological abnormality was Eysenck (1952) reviewing outcomes for neurotic patients said that “The outcome for treated and untreated patients was about the same i.e. two-thirds recovered within two years . Although Bergin (1971) found that only 30% of untreated patients recovered.

In conclusion I must admit to a personal bias. I was a ‘Community Nurse’ for many, many years, and for some of this time in the 70s I was a ‘Certifying Officer’. I have in conduction with a doctor certified a number of people, and as a result of this, they have been forcibly removed (if required) to a psychiatric hospital. (This function is now carried out by a Social Worker).

If given the same patients to-day, there is no way that many of them would have been certified. We have moved away from the medical model, and the so called ‘Statistical Criterion’ due to our better knowledge that people who do not quite fit in with our perceptions of ‘norm’ still have a valuable role to play in our now multi-cultural, and not so western hide-bound civilisation. In fact, we now welcome ‘Individualistically’ minded people.

My final conclusion is, that the work of Szasz (1962), Bailey (1979) and other researchers has steered us towards a more holistic look at abnormality. Their separation of the physiological symptom from the psychological symptom, has been a vital reference, from which modern non-medical theories of treatment have been proposed. These have been developed for behavioural modification with excellent results. We now accept depression and some degrees of hyper-mania as a 20th century manifestation, which, if it becomes severe will be amenable to simple one to one therapies without medical intervention. It was almost prophetic that psychologists would look at abnormality in a different way to psychiatrists. Nowadays psychologists have been able to decry the old methods of care, and propose (backed up with research) a much more realistic and humane method of treating the basic abnormalities that beset a modern civilisation.

Almost as a footnote one must add that, we must still be able to care for people who are inclined to injure themselves or others. Therefore there is still a need for supervised in-patient nursing care, providing that care is only transient, Then we must release them into the one-to-one therapies, whether they be analytical, behavioural, or cognitive therapy depending on the problem.

REFERENCES.

Cardwell. M. (1994). A-Level Psychology. Longmans. London.

ibid., Cochrane (1985)

ibid., Eysenck (1952)

ibid., Goffman (1968)

ibid., Maher (1966)

ibid., Rosehan (1973)

ibid., Scheff (1966)

ibid., Shapiro (1980)

ibid., Smith & Glass (1977)

Gross.R. (1992) Psychology 2nd edition. Hodder & Stoughton. London.

ibid., Atkinson et al (1990)

ibid., Bailey (1979).

ibid., Blaney (1975).

ibid., Heather (1976).

ibid., Johada (1958).

ibid., Mackay (1975).

ibid., Szasz (1962).

Silverberg.P. (1872) Welcom Foundation Abstracts. Welcom Medical Found.

BIBLIOGRAPHY.

Argyle.M. (1990). Behaviour. Penguin Press. London.

Cardwell.M. (1994). A-Level Psychology. Longmans Press. London.

Gross.R. (1992) Psychology. Hodder & Stoughton. London.