Questioning Healthy Normality

Is it normal to be healthy? Intuitively, it seems like it is. It seems like healthy is the ‘default’ and we’re only sick when something goes ‘wrong.’  But I want to suggest that this very common belief – this assumption of healthy normality - is not only wrong, its damaging. Let’s walk through it…

The mental health community has witnessed and generated the ‘biomedicalization’ of human living. This means that Western people prize freedom from physical or mental distress to the point where distressing thoughts, feelings, memories have come to be viewed as ‘symptoms’ and having a certain number of these means that you have some type of abnormality or ‘disease.’

Part of the problem has come about because of the term ‘mental health’. This phrase, designed to draw a parallel or an analogy between mental health and physical health or mental illness and physical illness does has some merit to it. There is a parallel. But not a perfect one. And here is the problem. Medicine (bodily/physical medicine) is different to psychology/psychiatry/mental health work in a key way: There is a very high level of agreement about what medicine should be aiming for because there is very high levels of agreement about what ‘health’ and subsequently ‘disease’ mean when it come to a person’s body. For example, most people agree that a heart that pumps blood is better than one that doesn’t. And most people agree that eyes that can see are better than eyes that don’t. Legs that move are better than one’s that can’t. Nerves that feel pain are better than one’s that can’t and so on. People basically agree on the purpose and function of the human body and the organs therein.  But when we move to the brain things get a lot fuzzier because the brain doesn’t have a simple task like the lungs, eyes or legs. We know very clearly what the job of lungs, eyes and legs is.  But what is the job of the brain exactly (particularly the cerebral cortex; the cerebellum and the older brain parts are obvious in what they are for in that they keep us alive in a very simple and straightforward sense)? What does a 'healthy' mind look like? This is a much thornier question.

But because this analogy between mental health and physical health has been so widely adopted as to have become ubiquitous, we now have a serious problem. It is my contention that we have stretched this metaphor too far and/or have adopted it uncritically, resulting in – ironically - serious mental health issues. For all the good that has come from this metaphor there is a dark side that needs to be talked about - the ‘assumption of healthy normality.’ Because it is normal to be healthy in physical medicine (ie. if you’re in pain or feel sick we call it an ‘illness’ or ‘disease’ or ‘disorder’ etc), many people now think it’s normal to be healthy psychologically where ‘normal’ is assumed to mean ‘happy’ or ‘free from distress.’ This is a serious problem. Is it always a ‘disorder’ to feel sad? Has something gone ‘wrong’ if you feel anxious?  Are you really mentally ill if you’re still grieving the death of your spouse 12 months on? This mindset is what has spawned syndromal thinking and our myriad and ever-expanding catalogue of mental health labels (Generalised Anxiety Disorder, MDD, Adjustment Disorder, BPD, ADHD, Histrionic Personality Disorder, Autism Spectrum Disorder, Conduct Disorder, Paedophilic Disorder, etc.).

This syndrome focus has led us to develop treatment approaches that overemphasize symptom reduction and downplay functional and positive markers of psychological health. What is amazing is even the progenitors of psychiatric nosology (the branch of medical science dealing with the classification of diseases) are questioning the syndromal approach (their own approach!). Have a read of these stunning excerpts from the report of the American Psychiatric Association planning committee for the DSM-5 (Kupfer et al., 2002):

The goal of validating these syndromes and discovering common etiologies has remained elusive. Despite many proposed candidates, not one laboratory marker has been found in identifying any of the DSM-defined syndromes. (p. xviii)

Reification of DSM-IV entities, to the point that they are considered to be equivalent to diseases, is more likely to obscure than to elucidate research findings. (p. xix).

Many, if not most, conditions and symptoms represent a somewhat arbitrarily defined pathological excess of normal behaviours and cognitive processes.  This problem has led to the criticism that the system pathologizes ordinary experiences of the human condition. (p. 2)

Despite the honesty of the workgroup report, the release of DSM-5 in 2013 showed that those controlling our psychiatric nosology have not solved these problems.

Enter…Acceptance and Commitment Therapy (ACT).

ACT starts from the belief that human suffering, far from being ‘abnormal’ or ‘pathological’, predominately emerges from normal psychological processes, particularly those involving human language.

There is no more dramatic example of this than the phenomenon of human suicide. Suicide from a (basic) evolutionary perspective makes no sense. Why on earth would evolution produce an organism that wants to die and does indeed kill itself? Nothing would appear more counter to survival and reproduction than suicide. And yet we know that suicide is ubiquitous in all human societies (Hayes, Strosahl & Wilson, 2012). Moreover, suicide is essentially, if not completely, absent in all other animals (Norwegian lemmings were thought to be an exception but this turned out to be false/complicated).  Why do humans kill themselves? The standard answer, the biomedical answer, is that people kill themselves because they are mentally ill. Perhaps they had schizophrenia or they were depressed or they had bipolar disorder, etc. But an examination of suicide reasons, by looking for example at suicide notes, shows that stated purposes are usually drawn from the everyday lexicon of emotion, memory, and thought. For example, people will talk about the immense burdens of living, the loss of a loved one, of loneliness, the meaninglessness of life or hopelessness about the future. The phenomenon of suicide demonstrates the limits and flaws of the purely syndrome-approach to human suffering. Suicide is not a syndrome, and many people who kill themselves cannot be neatly categorized under any well-defined syndromal label (Chiles & Stosahl, 2004).

From this we have to conclude that there must be something unique about being a human. That humans are in some sense ‘good at suffering.’ This is the core idea behind the assumption of destructive normality, the idea that ordinary and even helpful human psychological processes can themselves lead to destructive and dysfunctional results, amplifying or exacerbating whatever abnormal physiological and psychological conditions may exist.

In other words, our amazing brains are a double-edged sword. They give us the power to solve problems to a degree that other species can only dream of (or can't dream of!). Harnessing the power of language we can solve incredibly complex problems, have complex thoughts, and build wonderful, rich relationships.  But ‘with great power comes great responsibility’ (Voltaire or was that Spider Man?) and the human mind is capable of causing tremendous suffering, not only to other people, but to its host.

Consider that a human being can sit in a nice room, warm, clothed, comfortable, with a delicious meal set before them, and be utterly miserable. How is that possible? Its possible because the human mind can be somewhere else.  The human mind can be sitting a room but thinking about the past (ruminating, regretting, reliving…) or the future (worrying, panicking…).  The human mind has the ability due to language (or ‘symbolic activity’) to draw connections between things, carry forward aversive events, form relationships between historical events and current events, create predictions about the future and so on.  This superpower is again, what makes us great, and makes us the top of the food chain.  But the dark side is that suffering is almost as natural to us as breathing. Being sad is natural and normal. Being anxious is natural and normal. You are not necessarily ‘sick’ if you feel depressed or anxious.  

So what’s the solution? Is there a way out of this evolutionary bind? ACT (Acceptance and Commitment Therapy) thinks there is. We can't solve the problem of human pain, that's built in to life, but we can solve the problem - to some extent at least - of human suffering. ACT is a trans-diagnostic mindfulness-based form of psychotherapy that targets this problem by teaching skills in unhooking from language. Rather than seeking to fight with our thoughts or control them it seeks to build psychological flexibility by accepting thoughts and feelings.  ACT also challenges the assumption that achieving normality is necessary for leading a fulfilling life. Instead, it proposes that psychological flexibility – the ability to adapt to changing circumstances while staying true to one's values – is a more meaningful and sustainable goal.  I’ll write more about ACT in upcoming blogs…