In practice we do not know what normal is. In fact, it is not a question of knowing; the definition of normality is not something we can discover, we can only agree it amongst ourselves. It is more a question of deciding what we regard as normal. But who should decide and do the rest of us have to agree? Are we going to concede authority to anyone or more likely to any one body or institution? Which individuals or organisations would you trust with this responsibility?
Well we have already tacitly conceded this authority. There has never been any explicit granting of such authority; no process of informed public debate about how this could be undertaken. However, it has happened, and WE have for the most part gone along with it.
Not everyone is happy about this. Dr Allen Frances is one such. He has written a book called ‘Saving Normal’. The surprising thing is that he had a rather large hand in expanding our ideas about abnormality. He was the ultimate insider since he was the chair of the committee that wrote DSM-1V, (The Diagnostic and Statistical Manual of Mental Disorders).
He illustrates in detail with much data what he calls diagnostic inflation; the way in which increasing numbers of us now have a psychiatric diagnosis. He recognises that while many people want a diagnosis to ‘explain’ their difficulties this can change the way people feel about themselves in significantly negative ways. He illustrates this for many diagnoses including social phobia which has turned normal shyness into the third most frequent diagnosis.
He is particularly vehement about the way the pharmaceutical industry has taken advantage of the fuzziness of most diagnostic criteria to sell their wares. While pharmaceutical companies justify the high prices they charge due to the cost of researching new drugs, he points out that they spend twice as much on advertising as they do on research. This is especially the case in the US where they can advertise directly to the public.
Dr Frances is also critical of the fact that most diagnoses are undertaken in general practice. He does not blame his fellow doctors for this as he argues they do not have the training or enough time.
He saves some ire for the media who like to focus on and dramatise the suffering of individuals and seem uncritically fascinated by the various new diagnostic categories that are being constantly proposed.
Lastly, he is critical of patient lobby groups which push for ‘better recognition’ of particular diagnoses and the treatment services and benefits that follow.
He does admit some errors on the part of the DSM-1V committee. These he regards as due to a lack of foresight as to how DSM would be abused by big Pharma, time-pressured GPs and lobby groups.
The book may appear to be in part a ‘mea culpa’ but is as much a ‘not me guv’. What he really seems to want to do is to Save Psychiatry rather than Save Normal. He wants psychiatry to become what it was, in his terms, a highly specialised group of professionals who alone have the skills to detect ‘true mental disorder’. As such he is claiming which professional group should have the authority to decide who amongst us is normal/abnormal. At the same time his book is critical of how psychiatry has done this in the past.
In spite of DSM’s many attempts to define different diagnostic categories the criteria remain essentially fuzzy. This inevitably leaves the door open for diagnostic inflation. But more importantly the criteria always focus on elements of a person’s experience and regards these as symptoms. These symptoms are seen as things we suffer from; things that happen to us. This narrative is so much a part of our cultural landscape that the alternative of understanding the connection between what we are doing and thinking and these ‘symptoms’ is mostly invisible to us.
Dr Frances’ book is an intelligent, data-rich argument about diagnostic inflation and its dangers. While his voice is an important one it is unlikely to be heard against the voices coming from the many vested interests on the other side. Can anything slow the momentum of diagnostic inflation? It seems unstoppable at present.
Is there anything individuals can do to stop diagnostic inflation and save normal?
In effect as a culture we have unwittingly conceded authority to the definitions of abnormality as exemplified in the DSM. We do this in the way we think about disorders and conditions and how this is reflected in our everyday conversations with each other. We could be more aware of doing this and how it adds our tacit support to diagnostic inflation. This is a parallel to how we are struggling to change our conversations over issues of sexism and racism.
But to really save normal we need to go further. We need to recognise the ordinary psychological processes that lie behind the nature and quality of our experiences. For example, when we feel sad, we are thinking and acting in a particular way. To not recognise this is to rob us of our agency and real self-understanding. When we do not recognise our agency, we can do very little about our suffering except seek help from the system that has persuaded us we can do nothing for ourselves.
As another example, anxiety problems should not be hard to understand since they flow from the very ordinary and necessary psychological processes by which we attempt to deal with the risks we face. In my book The Origin of Anxieties I describe the key processes and show how easy it is for ordinary sensible people to develop anxiety problems because they have been misled by the way our culture encourages us to understand anxiety.