Keith E Rice's Integrated SocioPsychology Blog & Pages

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What is Mental Illness? #2

Underpinning the attempts to categorise and classify mental illness are 4 broad approaches…

1.Deviation from statistical norms (statistical infrequency)
This is based on the notion that abnormal thought and behaviour are pretty rare in the general population.

The scores of most human characteristics and behaviours, when measured, tend to fall fairly evenly about the mean, giving the bell curve of normal distribution. Eg: there are a lot of people who are ‘averagely’ tall or aggressive whereas very few people are very small or highly aggressive. Thus, there are as many people/scores above the mean as below it in a normal distribution. The further you travel from the mean, the fewer  people/scores there are in the population.

Graphic copyright © 2018 Guang Jin/Illinois State University

In a normal distribution – see graphic above – the  majority of individuals are clustered  around the mean. In a normal distribution the scores of 95.5% of the population will fall within 2 standard deviations from the mean. Scores beyond 2 standard deviations are considered statistically infrequent and, therefore, abnormal. Thus, thoughts and behaviours which occur in 4.5% or less of the population can be considered abnormal.

As a way of defining what is meant by mental illness, this approach works well for some illnesses – eg: Schizophrenia at 1% in the general population and Bipolar Disorder at 2.8%. However, for Depression it doesn’t. In 1980 J Angst estimated that 1 in 20 Americans were severely depressed. 5% is just about within 2 standard deviations in a normal distribution and,  therefore, strictly speaking is not  statistically abnormal. Moreover Angst estimated that 1 in 10 Americans were at risk of having a serious depressive episode at least once in their  lifetime. 10% is well within 2 standard  deviations. According to the World Health Organisation (2018b), up to 25% of females will be diagnosed at some point in their life and up to 12% of men. At any one point in time it is estimated 9% of women are clinically depressed. Such figures are well within 2 standard deviations and thus are not statistically infrequent. Yet the WHO also says: “Depression is the leading cause of disability worldwide, and is a major contributor to the overall global burden of disease.” Clearly, most people would consider Clinical Depression a mental illness!

Gender differences, however, may not be reliable in statistical reporting on Depression. It is generally accepted that women are more likely to seek help for depressive symptoms while men are more likely to bottle up their problems or attempt to numb their feelings through alcohol and/or drugs. Thus, it is more than possible the level of male Depression in Western society is under-reported and, therefore, the statistical data is misleading.

While it is a one-time survey, Ronald Kessler found in 1994 that 48% of Americans across 48 states had suffered at least one psychological disorder at some point in their life. Such statistics seriously undermine the statistical infrequency concept.

There are also issues of desirability which confound this approach to mental illness. For example, as per the graph below, the mean for intelligence (in white Caucasians) is 100 (as measured on a Stanford-Binet IQ test). Someone 2 standard deviations below with a score of 70 is classified clinically as ‘retarded’. However, someone 2 standard deviations above the mean, with a score of 130, would be classified as ‘genius’ Many people would consider having ‘genius’ status as desirable while no one would consider ‘retard’ status as desirable.

Graph copyright © 2001 Psychology Press Ltd

The ‘desirability issue’ gets particularly complicated with homosexuality. There is an ‘urban myth’ that around 10% of the population are homosexuals, derived in large part from the 1948 report of Alfred Kinsey, Wardell Pomeroy & Clyde Martin, though their sample was largely drawn from male prostitutes and incarcerated prisoners. My own 2009 desktop literature review – see Just how many Homosexuals are there really? – found that most surveys showed around 3-6% declared homosexuals in Western countries. Those figures would most certainly be verging on the abnormal statistically; but the results of these surveys may not be accurate as any number of homosexuals may not have responded through fear of prejudice & discrimination. The number of homosexuals may be far higher – higher even than 10%! – but there is no way of knowing.

The statistical infrequency approach also ignores relativism. Eg: it is considered acceptable for children to be frightened of the dark; but not adults.

2.Deviation from social norms
Quite simply, this is deviating from – or not conforming to – social norms, the customs and behaviours the majority of people in a culture or sub-culture consider ‘normal’. Social norms form a major part of the value consensus – which Émile Durkheim (1893) referred to as the collective conscience. For example, wearing swimwear on the beach is considered perfectly normal but it would be considered inappropriate on the high street and totally unacceptable in an upmarket restaurant.

On the face of it – face validity – this definition appears to get around the desirability issue that the statistical infrequency approach fails to acknowledge. However, what is desirable can vary with time and culture. Eg: in World War II the Allies considered it desirable that ‘ordinary’ Germans opposed the regime. In contrast, the Nazis contended that people who opposed the regime were deviant and ‘sick’. Holocaust documenters have argued that the medicalisation of social problems and systematic euthanasia of people in German mental institutions in the 1930s provided the institutional, procedural and doctrinal origins of the mass murder of the 1940s. The Nuremberg Trials convicted a number of psychiatrists who held key positions in the Nazi authorities.

Because social norms  – especially morals – vary from culture to culture and over time within a culture – temporal bias – this undermines both the reliability and the validity of this approach. For example,  the acceptance or not of homosexuality has varied over time and from culture to culture, as discussed on the previous page.

With regard to this relativity, Jeanne Marecek & Rachel Hare-Mustin (2009):  “Ultimately, the decision to regard any set of behaviours or experiences as a psychological disorder – rather than an eccentricity, a criminal act or a response to oppressive and intolerable circumstance – is and cannot be a scientific one…. Judgements of normality and abnormality necessarily depend on cultural standards, social norms and local customs… Human behaviour always takes its meaning from its sociocultural surround.”

3.Failure to function adequately
The underpinning principle of this approach is that behaviour is abnormal if it is maladaptive – ie: it makes people unable to lead a ‘normal’ life and do the things most people want – eg: have sustainable relationships or hold down a job.

However, not all people with a mental illness are aware of their ‘failure to function’.

David Rosenhan & Martin E P Seligman (1989) enhanced understanding of this approach by stating 7 characteristics of failing to function adequately:-

  1. suffering – most abnormal individuals report that they are suffering
    “People do not come to clinics because they have met some abstract definition of abnormality. For the most part, they come because their feelings or behaviour cause them distress”Edgar Miller & Stephen Morley (1986).  David Sue, Derald Sue & Stanley Sue (1994) also contend that most people seeking psychiatric help are distressed
    However, not all psychological disorders involve obvious suffering – eg: bipolar patients in the manic phase and psychopaths
  2. maladaptiveness – behaviour which prevents people from achieving major life goals such as enjoying good relationships with other people or working effectively
  3. vivid/unconventional behaviour – ways in which abnormal individuals tend to behave often differs substantially from most people
    “Generally, people recognise as acceptable and conventional those actions that they themselves are willing to do…. If we do it, it’s conventional and normal. If we don’t, it stands out vividly as unconventional and abnormal” – Rosenhan & Seligman
  4. unpredictability/loss of control – the behaviour of abnormal people is often very variable and uncontrolled and inappropriate
    “We expect people to be consistent from time to time, from one occasion to the next, and very much in control of themselves” – Rosenhan & Seligman
  5. irrationality/incomprehensibility – others cannot understand why anyone would choose to behave in this way
  6. observer discomfort – observers to the behaviour are made uncomfortable by it
    This is, however, very subjective and may be more reflective of the observer’s mindset than the mental health of the person causing the discomfort
  7. violation of moral/ideal standards – behaviour may be judged ‘abnormal’ when it violates established moral standards
    In other words, deviation from social norms!

Rosenhan & Seligman argued that each characteristic might not be significant on its own but, when several are present, they are indicative of abnormality. Philip Zimbardo (1995) states that the more extreme the characteristics are, the greater the likelihood of the person having a psychological disorder.

4.Deviation from ideal mental health
The concept of ideal mental health was developed by Marie Jahoda (1958). She was heavily influenced by the leading Humanistic psychologists of the time, Abraham Maslow and Carl Rogers. ‘Normality’ and ‘abnormality’ were useless labels in Jahoda’s view. Instead, like Maslow and Rogers, she chose to focus on criteria for positive mental health.

Jahoda laid out 6 characteristics of ideal mental health:-

  1. self-attitudes – high self-esteem and a strong sense of identity are related to good mental health
    According to Jahoda, to be mentally healthy, someone must know who they are and like what they see
  2. personal growth – the extent of a person’s self-development or progress towards Self-Actualisation
  3. integration – the ‘synthesising psychological function’ integrating self-attitudes and personal growth
    Jahoda held that good integration created resistance to stress
  4. autonomy – the extent to which an individual is free of social influences and can rely on their own inner resources
  5. perception of reality – individuals don’t distort their perception of reality but instead demonstrate empathy and social sensitivity
  6. environmental mastery – the degree to which someone is successful and well-adapted, able to love, perform adequately in both work, play and interpersonal relations, be effective at problem-solving and adapting to meet situational requirements

Not having any of these characteristics would mean that the person didn’t have good mental health. Since most people don’t have these characteristics all the time, in the words of Dougal Mackay (1975): “…the majority of the population would have to be considered as maladjusted.”

Wade Nobles (1976) questions whether the concept is based on Western, individualistic values? In his writings about the extended concept of self amongst African peoples, Nobles claimed they have a sense of ‘we’ rather than the Western ‘me’. This means they value co-operation whereas Westerners focus on autonomy. This would mean the concept of individual personal development could be vulnerable to cultural bias.

There are also some problems with Jahoda’s use of Self-Actualisation in that she used Maslow’s (1943) conception – fulfilling one’s potential – rather than his 1956 revision which effectively redefined Self-Actualisation as a meta-level of thinking. However, even in his redefined version, Maslow saw Self-Actualisation as bringing in far more healthy thinking, with a loss of fear- as did Clare W Graves (1974) with his equivalent G-T (YELLOW) vMEME. Maslow would also agree that  anything that stops an individual progressing up the Hierarchy of Needs – thereby frustrating the actualising tendency – is likely to be injurious to mental health. According to Maslow’s biographer Edward Hoffman (1999, p206), ‘values pathology’ and ‘metapathologies’ are “the spiritual existential ailments that result from the persistent deprivation of ‘metaneeds’ [ie: the higher needs in Maslow’s hierarchy] – the lack of fulfilment of ‘metamotivations’. They include cynicism, apathy, boredom, loss of zest, despair, hopelessness, a sense of powerlessness, and nihilism”. Working from a partial Gravesian perspective, Ken Wilber (2003) has hypothesised that the mental health of 50 million Americans would benefit radically by a move from GREEN to YELLOW thinking.

The labelling of mental illness
The application of Labelling Theory to mental illness has its origins in the work of Thomas Scheff (1966). He argued that someone who acquires the stigma  of a psychiatric diagnosis will be treated as ‘mentally ill’ – and, as a result, is likely to become more mentally ill. Such a label creates expectations. These expectations can part of the labelled individual’s own selfplex. These expectations – memes – can influence others, altering their cognitive map (schemas) of the labelled individual. Thus, the individual may try to live up to the label. If they receive attention and sympathy – positive reinforcement – they are even more likely to live up to the label.

As Rosenhan’s classic 1973 study demonstrates only too clearly, people are influenced by labels of mental illness given to others. Rosenhan’s ‘schizophrenics’ pseudo-patients were ignored 88% of the time by nurses and 71% of the time by psychiatrists – a real sign of the schizophrenic’s low worth in the eyes of others. Such treatment could clearly increase the severity of the symptoms experienced by real schizophrenics.

Thomas Szasz (1974) was of the view that society uses stigmatising labels to exclude those whose behaviour doesn’t conform to its norms. Michael W Eysenck & Cara Flanagan (p602, 2001) elaborate: “Such labels include the following: criminal, prostitute, gypsy, foreigner. ‘Mental illness’ is simply a stigmatising label used to exclude non-conformists from society.”

Szasz notes the following examples of labelling used by the state to control/inhibit undesirable behaviour:-

  • It used to be considered deviant for a woman to have a child outside of marriage and some were locked up in psychiatric institutions. (Audits of patient records in the 1990s found that there were still women alive in psychiatric institutions who had been locked up decades previously for having a child out of wedlock!)
  • Middle-class women who were attracted to working-class men were ‘nymphomaniacs’
  • Women who inherited money and wished to keep it for themselves were diagnosed with ‘moral insanity’
  • Slaves who showed an ‘irrational’ desire to escape from their owners had ‘drapetomania’
  • In the Soviet Union in the early-mid-20th Century political opponents to the Communist government were labelled dissidents and locked up in psychiatric institutions

Erving Goffman, in his classic 1968 study of life in a mental institution, found much the same dismissive and dehumanising treatment of  patients as Rosenhan. However, he also documented ways in which the patients were controlled – eg:-

  • personal possessions taken away and obliged to wear the institution uniform
  • the day was tightly scheduled: when the patient got up, ate, bathed, took their medication and went to bed

Goffman notes that, if a patient resisted the label of mental illness, that was meta-stated by medical staff as another symptom of the illness. Consequently, the patient would be given further medication or subjected to another corrective measure such as electric shock treatment,

Of course, exposés such as those of Rosenhan and Goffman have contributed to reforms in the treatment of mental health patients and increasingly over the past 30 years there has been an emphasis on ‘care in the community’ for less serious/dangerous cases – eg: in ‘halfway houses’.

In spite of such progress, amongst the general public stigmas concerning the label of ‘mentally ill’ are proving difficult to shift. As late as 2000 Sue Baker & Julia MacPherson found that 60%  of young people admitted to using abusive and negative language to describe mentally-ill people. Such public perceptions are not helped by the media periodically creating moral panics about mentally ill people. For example, Greg Philo & Jenny Secker (1999) found that 2/3 of media organisations disproportionately focused on violence committed by the mentally ill and 40% of tabloid headlines used derogatory language to describe mental illness.

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