Being Labeled “Abnormal” Is Ignorant, Wrong, and Unfair

Often “crazy” behavior is adaptive, and a coping response a dimension of resilience, and sometimes not.

Source: Creative Commons Pxfuel

There is great debate as to the validity of the psychiatric diagnosis. David Rosenhan, in a classic study, was admitted to St. Elizabeth's Hospital. Only the Chief Administrator knew about the ruse.

Once there, the clinical staff filtered all his behavior through "insane" versus normal.

He took notes. The nurse entered into his charts, "Obsessive note-taking." All normal behavior suddenly became odd and abnormal.

In 1972, homosexuality was abnormal in the mental health diagnostic manual. It is now unethical to treat a client for being gay since science suggests nothing is wrong with them. So-called "conversion therapy" is unethical. Yet some people (and some theologies) still consider homosexuality "abnormal," which leads people to offer and even seek such therapy. To label, a person "abnormal" often says more about you than it does the person being so labeled.

You can't prove normality, and its definitions are constantly updated

The problem in mental health is you can’t prove you are normal, but for some reason, many seek to prove you are abnormal as a good excuse for odd behavior. Insanity is a legal term: not knowing the difference between right and wrong.

At UVA law school, I participated in a law and mental health weekly seminar. A brother shot his other brother while on LSD. Is he insane for a criminal, or abnormal, or all three? He was convicted and went to jail.

Psychopathology, more often than not, despite advances in psychological science, is a subjective social construct. The DSM-V Diagnostic Manual is five times thicker than 50 years ago.

Are we sicker or simply more aware, using valid measurements of psychopathology? When does odd bleed into abnormal? In formal diagnosis, one considers chronicity, base rates, and cultural norms.

Classical definitions of psychopathology

The "4Ds" of psychopathology are defined as deviance, dysfunction, distress, and danger. The problem is some of these factors are social constructs, and other factors are cultural or sub-cultural.

There are also definitions of what constitutes abnormal behavior based on statistical frequency. This interpretive inference is unfair to the individual based on a biased random sample or casual observation, as the below parable explores. In addition, often, “crazy-like” behavior is adaptive and a coping response as a dimension of resilience.

As we go about our day, we all see odd behavior never fully explained, but that oddity is not necessarily due to psychopathology, but personality style or individual differences.

Fast and quick decision-making is often misleading if behavior is just odd or abnormal

In everyday life, we all make instant casual observations, so-called "fast thinking," and jump to conclusions in a second: average or abnormal; like or dislikel odd, or okay. I do the same with a new client, but the rules of engagement are different.

I am allowed to ask personal, probing questions in oder to make better sense of what may seem odd and may, in fact, be abnormal or not.

Therapy facilitates making this professional opinion

Therapy often determines if strange or deviant behavior is a product of self, place, or both. My bias is "both." We all do certain things triggered by specific events.

Often treatment is as simple as the sound advice, "Avoid person X or never enter place B." Society monetizes places to be odd, like painting your face in your team's colors at a college football game. The same painted face in a chemistry class may well be classified as abnormal.

People act oddly coping with stressors and can easily be mislabeled as deviant

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We are all psychologically vulnerable to a worst-case scenario. If a tragedy happens, a person might act oddly to others who lack insight into the details, but once the facts are known, the same person is normal.

The best way to explain this is through a parable (not from a real case) where, for example, a woman (who is grieving, but the observer lacks this knowledge) seems to act oddly, but once you know, the motivating factor(s) she is not so odd at all.

There is a woman in a hurry. She is redecorating her house and does not have a lot of time. She picks the first painter that bids and asks him when he can start. He says, “Right away.” He rushes to the paint supply store and buys plenty of paint; he rushes back and begins painting.

She views his work and inquires if he thinks there will be enough paint. He replies, “Plenty.” She asks him to buy more paint, just in case. By now, the original room has been painted with hundreds of coats. The room has become smaller and smaller with every passing coat.

She is pleased with the results. However, the painter believes the woman is off her rocker, but a job is a job, and he is making a fortune. Who coats a room with thousands of coats of paint? She views his work. She is pleased with the results. The painter is scratching his head, thinking, "This woman needs help."

The grieving woman opens the door to the bedroom. She slides the interned ashes of her stillborn baby inside a dollhouse crib coffin into the painted room made into a mausoleum.

The painter had no idea. What seems abnormal is now simply odd since most mothers do not do this, a very low-frequency event. It's the “kid’s room” she always wanted but could not have, so she imagined and created it.

Many casual opinions about an observation are misattributions

Another typical example of a "misattribution" or falsely assigning one reason when the actual reason has nothing to do with it. Your teenage son slams his hand hard down onto the kitchen table. Boom! The table reverberates. The dishes clatter. The boy’s father interrupts, “What are you so mad about?” The son raises his palm. There is a dead bug on the table. The father apologizes.

The father’s misattribution is more about the father thinking his son has a reason to be upset because he grounded him for coming home late last week. Their relationship is fine, but a casual observer might label the son's loud bang odd, seemingly out of the blue.

If the same father came into my office the next day and said, “My son is crazy. He hit the kitchen table hard last night," I would make all kinds of false inferences about the son's mental health and stability.

We tend to rush to judgment based on base rates. If I am a primary care physician, it is flu season, and a patient presents with these symptoms, the diagnosis is not a broken leg, but usually the flu. However, in mental health, most behavior is overdetermined for more than one reason.

This misattribution (really a confusion) happened to to me once during a neuropsychological testing session. As one measure of long-term memory, I asked, "What were you doing on this date last year?" The client, with a Cheshire cat grin, said, "Nothing. I did not exist on this date last year."

That answer was odd and abnormal. I forgot that the current testing was on February 29, a Leap Year. There was no 2/29 the previous year. I was like the painter. I ignored or was unaware of other vital information that distinguished odd versus abnormal. After all, not existing last year is a psychotic response, like "note-taking" as an inpatient.

What is a therapeutic breakthrough?

Therapy seeks to distinguish odd versus abnormal. A “therapeutic breakthrough” happens when a clinician knows the true roots of a choice or behavior. If sometimes you observe something really odd, you have plenty of company, but be careful labeling it as abnormal.