Learner therapist (32)…… What’s psychologically normal, or Am I crazy now (draft)
May 6, 2013
Is normal good enough??
A potential handout for patients, or outlines of various ‘inputs’ to be made by therapists, as part of patient education about what’s psychologically ‘normal’
Before you start reading this please do the following:
Write down one thing you think is abnormal about you. Then identify one patient who is troubling for you.
Now consider that a role of psychology in contemporary life is as a well-being improvement service for the ills our parents would barely conceive treating. We are the “worried well” from that viewpoint. Determining what’s normal provides fences around what’s good-enough, the moral self-evaluation (and social evaluations) of wellness.
In psychology (and health services generally) a patient life is composed minimally of biopsychosocialspiritual /cultural components. These 4-5 factors, in principle, equate to the presumptive ‘normal’ which is intrinsically good-enough for living well. We inherit certain biological features and a society and a social status. Hence family, school and culture of origin are critical factors in establishing our growth, but not well-being, capability. We are not responsible for our inheritances. They are fated, but we are responsible for what we do with them. For some, fate is almost destiny – e.g. being born into a constantly marginal care (material and /or psychosocial) environment can almost permanently damage capability.
A general fact about anyone appearing as a patient in therapy is that they will report a range of symptoms for their appearance, often the most important not first. Among them will be little things like:
…disordered sleep, binge-like consumption of food and /or drink, failure to exercise regularly and adequately, rumination about certain events or prospective events, occasional periods of mildly self-harming or suicidal thinking and, more visibly, self-destructive consumption behaviours, differing degrees of present relationship disturbance, conflict or breakdown, some degree of perceptible anxiety like mild panics or phobias, negative self-appraisals like ‘I’m just not good enough’ or ‘I’m worthless’ and a history of inadequate family of origin early in life, with continuing
These are known in the psych trade as “comorbidities”. They are what make “mental health” issues so resilient. They spread into many aspects of patients’ lives, usually with one symptom dominant and thereby attracting the diagnosis of Disorder X or Y, whatever it may be. These lesser symptoms also present a variety of treatment opportunities which can provide easily achieved small steps of recovery.
I‘m going to focus on patients on the borderline of mental illness – long term trauma victims who provide the deep end of the anxiety-depression ranges.
1) A suite of bad normals which normally occur for people assailed by multiple morbidities: these are common and also not good for people. Therapy should challenge these directly as and when appropriate. Trouble is, they are the outer expressions of the defenses you needed to survive the trauma, so they have natural resistance to being disclosed and even more to changing. So, many victims of long term trauma:
· blame themselves for their trauma and feel guilty for being injured
· feel it is unethical to put themselves first
· self-medicate with alcohol and/or drugs, or self-distract with compulsive behaviours like gambling, sex, etc.
· deny their traumatic experiences (I was never mistreated by my parent(s), school master(s), and anyway I don’t remember anything, even if someone else – a sibling – reminds me, etc.)
· have things they’ve never told anyone, and never will…
· just don’t feel much of anything…like pleasure or pain or anger or…
· life feels conflicted much of the time
A look back over this suite will show a bunch of interactions among the items which tend to keep you stuck in your defenses, even after the immediate threat has passed. These are normal in varying degrees and configurations. (Effective) defenses are normal, until they become dysfunctional. Some, like aggressive behaviour, are so close to normal that they are mistaken for being so, as when they appear in the hands and mouths of leaders.
2) Underlying patient trauma is ‘right’ normal life…that of eating, playing, loving, achieving, learning, creating, sustaining, believing…but what is a normal life? After thinking all around this topic for weeks (years actually, as I’ve responded to patient needs for normalising of their experiences as much as they can be normalized, which is almost always a great deal more than they expect) I realized that the question is: where are the boundaries of normality which we can lay clear and reliable claim to for ourselves and others??
Well, they seem to be expanding / fracturing / evanescing at an increasing rate. There’s a website for every imaginable (to this point) way to vary our look to others and ourselves, to vary our duration in this life, to vary our creativity, to vary our speed, mass, agility….on it goes to validate any variation. Enhancement is the objective of our times, bringing to reality the fears once held for eugenics in a positive psychology, moving forward form. The new black is grey.
This expanding universe of human aspiration leaves in its wake the detritus of previous generations’ norms, which cling as do broken limbs and dropped leaves to the ground on which they fall but without the fertilizing effects. People miss their norms and flail in the breeze of the as yet thinly shaped successors. What’s a real relationship? How would you know when you have one? ...or have the right body? … or the right sex. Equally, determining the boundaries between normally occurring psychological distress and pathological is not at all easy for two reasons: one, what pathological distress is is unclear (its defining characteristics) and, two, how much of it someone has to have to have it is uncertain. Depression is a good example of this difficulty, recently getting print and digital media airtime as the DSM’s latest version struggles into the light of publication.
So in what follows I will lay claim to some boundaries which seem to be viable now and have some prospects for imaginable futures. My main resource in this pretense will be ideas about human needs and well-being (cultures and values) and some structural features (aspects of brains and bodies) and some contextual features (socioeconomic and cultural/historical played out in family and community life) which seem relatively reliable. In all cases, a recurrent question to patients will be: “How does it work for you?” Is your life effective for you?
Am I nuts, or on the way to it?
3) A very common concern of patients who appear with relatively acute anxiety or depression is their sanity. Anxiety produces moments of intense disorientation in its panicky forms and depression feels like death and grows thoughts of dying. Because patients know a little about psychology from the public press, health adverts and friends / family with mental health experiences (or opinions about what the experiences of others should or should not be), they default to assumptions that they’ve caught a special kind of cancerous disease and they may be scarred for life, especially if others know about it. ‘I can’t tell X… they would not listen, they would reject me, would tell me what to do’ (order from bad to worse option).
Most of what we treat is not life threatening. It is however, life distorting. And if it goes on long enough, the distortions harden, building defending and compensating behaviours around them. When these become ineffective, taking them apart can take almost as much time as initially required to build them. The same is the case for physical injuries, which can take months of daily exercises of appropriate sorts to return a patient to ‘normal’ functioning, and often they never return to completely ‘normal’, though they may be good enough!
So, you are not crazy, so far. To be crazy you have to pass a CAT exam for hospital admission, and then you are only crazy for that moment. Long term craziness is attested by recurrent incarcerations, especially if they are against your will. Some long term meds may be a good introductory step, but are not conclusively correlated with future pathological outcomes.
I’m just confused, muddled, can’t keep my mind on anything
4) Another concern is how to make sense of the morass you may feel you are in, at least on arrival. Having an idea of what’s a normal mind may be a helpful response to this concern. Much of the early stages of therapy are ventilation, dumping, letting it all hang out, etc. Letting it out gives our mind air and allows a self-organising process to occur…stuff is gathered up in chunks and bunches and families and domains…a natural storage and retrieval system. We vary in our facility and style of remembering – variations which can be very irritating or blocking under pressure. Some prefer pictorial approaches, others verbal and others physical, etc. All are normal and we all have some capacity in each remembering style, but may be more gifted in one.
There are unavoidable complexities to the memory tasks – for example, family is a multi-generational, multi-contextual entity complicated by gender (cultural) and sex (biological) and mediated by ethnicity, religion, etc. This is the biopsychosocialspiritual /cultural perspective mentioned above. A little recording of brain dumps is often helpful. It gets the stuff outside and into an examinable position. Normally, there’s relief in just unburdening.
Dilemmas along the way
However, there are unavoidable dilemmas along the way: e.g. –
· we are all the same (human) and all different (individuals);
· we are subject to unequal workload distributions and/or unequal affection distributions – one loves more than the other;
· what’s good for one is sometimes bad for the other;
· work-life imbalances drain our energies and contest with other values for attention;
· we are subject to conflict / interdependence between our needs and those of family, team and other groups;
· we are whole (one consciousness / awareness) and broken (incomplete, in process never to be completed); and,
· we think we should choose but discover we are repeating habits.
These are all presented digitally, as either/or constructs, when most are continuous ranges. Only the life and death dilemma is either /or, though it is also one of the domains which is continuously being enlarged (some would say deformed) by science jet-propelled with wealth – e.g. surrogacies of various kinds (children, body parts, etc.), life-support systems of increasing power, procreation choice tools (ultra-sound, day after drugs, surgical abortion, in-utero pre-natal surgery, etc.).
So, conflict is unavoidable in life!! There are some other reasons, too, but these are systematic…and actually so are the others like the emerging nature of our needs, the impact of unpredictable forces on our normal progress in life…
Will I ever get over this? I just want to move on…
5) And yet another concern – will I ever get over this? Will it be gone forever? This is about memory – its roles and characteristics (e.g. feeling based, unreliable…etc.) and especially about how we come to maturity…by handling challenges, creating new approaches, trying new behaviours, etc. So, implicitly, we will be changed by the pains we carry and our efforts to manage them. And like the activities which please us, all experiences contribute to who/what we are as long as we remember them. Peak experiences tend to get remembered, especially painful peaks repeated systemically.
We are creatures of habit, who develop over time thru relatively predictable life events (both inner e.g. puberty, ageing and outer e.g. transition from school to work, becoming competent, shifting careers/workplaces, becoming coupled, etc.). Our potential for habit formation is leveraged by our capacity for communication, which comes laden with pre-formed (“hard-wired” as the neuro’s, and just about everyone, now say) potential.
The nature of consciousness: we are that being which can observe itself and reflect on what it sees – that is, evaluate itself; much of the processing of experience is below the level of daily awareness and the outcomes are usually intuitive; that is, they seem to emerge whole out of nowhere, and especially without trying (in fact, you can’t get there from here by trying too hard!).
Awareness, which is conscious presence, is a key tool for learning of all kinds. Awareness works mostly by focusing on parts of the total potential experience at any one time; high focus is very like obsessiveness, as skilled action is like compulsiveness (that is automatic in large parts)…It can be developed by working on mastery of any kind of activity. We can choose some things to some extent some of the time.
The body is the main instrument of awareness, and the vehicle of consciousness (think of a brain without a body; it’s easier to think of a body without a brain). Awareness grows by small steps and so does therapeutic effectiveness, one of the on-going learning activities that humans can engage ‘til death!
There are natural life stages, through which we are able to develop to varying degrees, so learning (and unlearning or change) is always present, driven by naturally occurring challenges; but, natural learning is only assured by necessary natural conditions – e.g. nutrition, care, experience
Freud was right – family is central and essential because it is the place for all learning for 5-6 years for most people in most cultures…and that learning is always likely to contain distorting elements to the congenital needs and capacities we start with…there is no perfect family. The claim daily seen in the news that so and so, now dead, had a loving family, was a loving parent, etc. is the signal of its untruth. Why would anyone bother saying this? May be they think it will make dead turn into passed?
There are normal feelings, esp. including the so-called “negative” ones – anger, sadness, despair, fear. These feelings occur in graded levels of intensity. But what terrifies me may only slightly disturb you. We can learn to deal with things through experience, training, watching others deal and so on. There are natural functions – for example, our in-built threat detection system, the FreezeFlightFight response it triggers, the body readiness processes (muscle tensing, etc.) etc.; organic needs and self-regulation; stress management in the face of cumulative stressors.
Who / What can I trust?
6) Another concern is to interpret the myriad of commercial and “evidence-based” claims about what’s normal in life and effective in treatment. A few trust indicators:
· How does the product offer feel to you?
· What market recognition does it already have?
· Google the product and find professional reviews of it by accredited members of recognized professional associations.
· If the product has recognition then it will have user blogs providing client /customer experience reports
· Check out CHOICE for product danger warnings.
· Ask your treating therapist, GP or experienced friends
The “K 10” test you took at the GP’s to get your Mental Health Care Plan is based on the assumption that perceptions of feeling are individual and that certain levels of perception are potentially toxic for anyone.
What’s a good person?
7) A related concern is how to know if they are good enough human beings. This may not be the same as ‘normal’, but includes normal as a foundation. There is no single right way of living, believing, etc., demonstrated by the endless struggle between even very similar religions (e.g. the Abrahamic trio) for dominance of the god space. Diversity in sameness is the rule…and the foundation of species survival in short and long term. An unchanging species is a dead one…in the long term. There seem to be some basic conditions of life which, if transgressed or disregarded, lead to less fulfilling or early terminating lives. Among them are adequate food, cover, care, exercise …etc.
There are natural human values – e.g. fairness, balance, wholeness – and virtues: persistence, integrity, etc., which seem to be present across all cultures. The values come into play automatically under the appropriate conditions. For example, we sense when we are being unjustly treated. That sense is a reliable capacity, except where it has been distorted by punishments directed at it by the more powerful in life. Even then, in therapy the sense can be exhumed from its socially induced grave (or rehabilitated from its weakened state). It appears in patient observations of their world which retain sensitivity to truth, which reflect other perspectives on that world than the ones approved by the powerful. We can see the truth sense operating at the broad cultural level in all (not only the repressive) societies in the socio-culturally appropriate forms of whistle-blowers.
Another source of truth is what I call our gifts. These are the natively occurring interests and dispositions towards the world which shape our preferred occupations or vocations. We are not all equally gifted, but almost no one is ungifted in this sense. Everyone has capacity for taking an interest in life’s opportunities; a few have huge capacities in specific areas – the arts are the most glaring example of this, along with certain technical proclivities (the nerd-doms).
There are some whole constructs of what human being is. Draw on Maslow, AQAL (Wilber), Spiral Dynamics, etc. The religions offer worked-through answers to this question, too, though lumbered with some empirical historical falsehoods of major orders. Seligman’s wellbeing theory; the needs construct of
Primacy of the non-verbal / feeling in expression and perception – that is, the body is the instrument of the mind and shapes it to its needs!! A pain in the foot is in the foot, etc. Eg. The brain doesn’t sense, the body does; brain interprets sensation in habitual (schematizing) and hard-wired ways and mind interprets it above the FFF level. This could go on but much of the detail of ‘normal’ should be found in an introduction to psychology textbook, failing which reverse engineering the prescriptions of abnormal psych may provide backup through implicit definition of the terrain of normal…
Interpretation – a recursive step.
Go back to the beginning. Look at what you wrote and ask: Is this normal? How normal is it (a little, not at all, fairly, quite, completely)? Could you easily share it with someone you know? Who?..... If not, why not? This last query reveals the true normal you are working with; the definition you practice for yourself now. There’s no reason to hide the normal, is there?