The concept of normality after 100 years of IPA

What we understand by the concepts of ‘mental health’ and ‘normality’ will vary considerably, depending on whether we approach the question from the perspective of medicine, psychiatry or psychoanalysis. As psychoanalysis is not a special branch of medicine it is able to respond to this difficult question in a way that is in keeping with its own theories. However, in doing so it must again face a series of taxing questions: after 100 years of psychoanalytic theory and practice, what concept of mental health do we analysts use? When and under what circumstances can a person be said to be in good mental health? What is our position, as psychoanalysts, regarding the question of ‘normality’ in the human mind?

Sigmund Freud responded many years ago in (1930) by saying that when a person could work productively, laugh freely and engage in sexual love without anxiety, then that person could be said to show good mental health. Some years earlier he had already stated that his work as a psychoanalyst served only to transform hysterical misery into common, everyday unhappiness (Freud, 1895). This was the same Freud who, in his 1917 work on mourning and melancholia, said that it was the mind’s ability to tolerate pain and hate, together with the ego’s capacity for discrimination, which enabled the work of mourning to take place by withdrawing cathexis from the lost object and investing it in a new one. In the absence of such a process, mourning would become pathological. So there would appear to be a difference between normal and pathological mourning. Here, Freud is referring indirectly to what is normal in mental functioning. Therefore, one might say that ‘pathology’ is determined by the ‘type of mental mechanism’ which is used by the individual in question.

Regarding this same problem of mental health, Melanie Klein said that it depended on a particular strength of character which enabled painful emotions (such as sadness and anxiety) to be tolerated and managed without recourse to symptoms. She went on to say that mental health was not compatible with superficiality, or with the denial of the problems or difficulties that we may face in life. Indeed, the presence of mental health requires an inner strength that enables us to acknowledge, face and deal with painful feelings, seeking solutions to our everyday problems (Klein, 1975 [1960]).

Psychoanalysis promotes mental health through ‘unconscious work’, which gives people the opportunity to know themselves and accept themselves as they are. This ‘work’ is achieved by a person becoming more conscious, more aware, alongside an inner emotional experience that one could call ‘becoming responsible’. All this leads the individual to modify the harshness of his or her own infantile superego, and it is this that gives him or her the strength to bear painful feelings and face the problems of everyday life. One could say that this is what psychoanalysis offers.

At all events, deciding what is meant by ‘mental health’ is no simple matter. Unlike other animals (who do not share a common language with us), human beings are subjected to what is called a ‘process of civilization’, one in which our drives are tamed. As psychoanalysts we know that when a human being is born, he or she is going to face inevitable demands. We know that his or her parents belong to a particular culture, whose values and customs the child will be required to accept. Therefore, the child will be pressed to renounce, above all, his or her incestuous and patricidal desires so as to become a civilized being. These two desires are profoundly human and universal. In renouncing and repressing something that is inextricably linked with the life and death instincts, the child will have to find partial solutions to the satisfaction of these prohibited desires. Inevitably, he or she will find some kind of solution which, in turn, will produce a particular kind of behaviour, thereby shaping the child’s future personality.

Now, psychiatry may classify this host of behaviours in various ways and regard some of them as psychiatric symptoms. However, we as psychoanalysts are more likely to think of them as variations or variants on how to live (i.e. diversity). We do not label symptoms or make diagnoses, nor do we consider behaviour as illness. Obviously, each child, and every resulting adult, will have his or her own way of living life (the worldview) and a particular way of managing his or her drives, i.e. imperious sexuality and murderous desires. Yet this does not have to be regarded as pathological or indicative of illness.

I am fully aware that this proposal is rather audacious and highly controversial. Clearly, it is a psychoanalytic way of thinking about the delicate problem of normality and mental health in today’s society. From an institutional (non-psychoanalytic) point of view the concepts of ‘mental health’ and ‘normality’ are defined by the World Health Organization (WHO) in its latest International Classification of Diseases (ICD-10), where normality and health are presented in generic and universal terms. Here, everyone starts on an even footing from the point of view of the symptom list, since these symptoms are seen from an epidemiological perspective based on statistics. However, what interests me more is how, when it comes to the concept of ‘mental health’, the terms ‘illness’ and ‘abnormal’ are applied to all those behaviours and ways of living that fall outside the statistical distribution of the Gaussian bell curve.

We know, of course, that these psychiatric or medical diagnoses (classifications) based on symptoms, which in turn are defined according to statistical criteria, are no more than a general guide for psychiatrists, as well as for psychiatric statistics. One must admit that these diagnostic guides are useful as regards the commercial decisions that have to be made by health services, or the investment strategies that multinational pharmaceutical companies decide to follow. However, they are clearly of little use for understanding what is particular in our patients, and even less so when it comes to managing the analytic process. For the latter require a dynamic form of understanding that includes working with the unconscious and with all that is particular to the individual, not least the specific story of his or her childhood experience. Thus, these concepts of ‘mental health’ and ‘normality’ are based on what is general, rather than on what is particular to each of us as individuals.

The ‘bell curve or ‘Gaussian distribution’ was named after the German mathematician Carl Friedrich Gauss, who first described it. It refers to the mean distribution of the characteristics of a given set of data, whose graphical representation takes the form of a bell curve. At all events, things are even more complicated, because pregnancy, birth and the baby’s feeding regime can all vary widely. Some babies suffer more than others during these sensitive periods at the start of life. Inevitably, the amount of satisfaction which a baby experiences while feeding will vary according to how much frustration that same baby experiences, and we know that an excess of frustration during feeding will increase the amount of envy, which in itself is an inevitable part of human life. Therefore, the amount of envy varies from one individual to another and according to how an individual responds to the death anxiety that is produced by the inevitable hunger which arises from having to wait for food (the breast). Envy is a powerful feeling and a mental mechanism that produces hate and the desire for destruction in the individual. This early envy is the basis of resentment in humans. Yet all of this falls within the diversity of life, since we have all, at the outset, suffered a degree of hunger, a degree of envy. What makes the difference is the amount of envy experienced, for it signals the particular amount of resentment that each one of use feels.

These involuntary infantile experiences can lead to a range of behaviours, and from a psychiatric point of view these may be regarded as symptoms or as signs of a certain disorder. Psychoanalysis, however, would regard these behaviours as ‘character formations’ rather than ‘symptom formations’. None of these various forms of development in human life need be considered pathological or a sign of illness simply because a given behaviour falls outside the statistical distribution of the Gaussian bell curve, i.e. outside normality. It is worth stating that there are some brain disorders (with an organic origin), which can and do produce symptoms in a person’s mental functioning. In other words, there are psychiatric disorders that have an organic cause. However, these cases of organic aetiology are not what I am referring to here. Indeed, psychoanalysis generally (although not always) theorizes about and works with people who are not suffering from any organic brain disorder.

Of course, a person without any kind of pathology may nonetheless seek professional help from a psychoanalyst or psychotherapist, doing so in order to gain greater self-awareness and selfacceptance, to achieve a more harmonious inner life. In my view, this illustrates that what we as psychoanalysts do is see people, and in doing so we do not consider them as mentally ill. This leads us to the conclusion that for psychoanalysis, ‘mental health’ is not defined by the presence or absence of symptoms, but rather by an individual’s acceptabce of him of herself.

Naturally, certain strange and bizarre behaviours (referred to as psychotic) may violate existing social codes and become regarded as unacceptable for society as a whole. Societies tend to be clear about their codes of conduct, just as they are when it comes to religious standards. If an individual’s behaviour violates the expectations of his or her own family, the norms of social behaviour established by the community, the standards set for religious behaviour or the code of conduct laid down by a political regime, then the problem is with the family, with society, with the religious institution or with the political regime, but this in no way means that the individual concerned is mentally ill. It is simply that this individual does not wish or is unable to follow the codes of conduct that have been pre-established according to the culture, religion or politics of the community, and instead decides to abide by his or her own standards (or, one could say, ideology). I am aware that such a decision by this individual inevitably places him or her in the position of being a social outcast, but this does not mean that he or she is somehow lacking in mental health.

Long before our time, at the end of the 18th century, those who behaved bizarrely and who violated the codes of social conduct Philippe Pinel, a French physician working in Paris, was the first to ‘identify’ and then ‘free’ the ‘mentally ill’ by distinguishing them from ‘common criminals’ (around 1776). This social movement led to the development of asylums and the alienists (psychiatrists of the day). Were locked away in the prisons of Europe. However, the new notion of ‘insanity’ led to some of them being released and taken to hospices known as ‘asylums’. This gave rise to the study of mental pathology and saw the birth of psychiatry. As a result, those physicians of the day who were interested in mental phenomena had to find a way of formalizing the diagnosis of the newly discovered mental illnesses, and thus it was that psychiatry became linked to medicine and the biological sciences. By the time that psychoanalysis made its entrance, which was broadly speaking around 100 years later (in 1895), psychiatry was forcefully proposing (and demanding of itself) that the study of humankind should be based on the difference between mental health and mental illness. This was the era of the great European psychiatrists, of Esquirol, Kraepelin, Bleuler, Kretschmer, Ellis, Babinski, Binet, Charcot, Liebault and Bernheim, etc., all of whom were seeking to draw the map of mental illness based on the study of mental symptoms.

This interest in mental health led several psychoanalysts at the beginning of the 20th century to develop theories of normality, linking it to the functioning of the mind. Thus, by 1931 Ernest Jones was expressing his interest in the difficult question of what should be regarded as normal mental functioning (Jones, 1931). However, his proposal (suggested by the presence of symptoms) led to a rather absurd notion, since the mind is not an organ, whereas the brain is. Psychoanalysis proposes that the mind is a virtual apparatus, known as the ‘mental apparatus’.

I realize that when, in psychiatry, we speak of the ‘mental examination’ we are referring to the examination of certain aspects that are founded on brain functioning, such as spatial-temporal orientation, the characteristics of memory, attention and concentration, thought processes, sensory and perceptual functions, and the capacity for synthesis and critical judgement, etc. As with other functions, such as those of the sense organs, the motor and balance systems, or proprioceptive awareness, etc., the logic of statistical distribution (the Gaussian bell curve) can be applied to the above-mentioned characteristics based on brain functioning. By taking such an approach we can identify the average response within this distribution, which in the mental examination will represent the norm. In biology all this is perfectly acceptable, the mental examination is the examination of biological organ, the brain functions.

Up to this point, one can speak of normality based on the mean of the statistical responses which represent these cerebral functions. However, any attempt to apply these statistical criteria of normality to the functioning of the mind (which is not the same as the brain) proves to be an uphill struggle. Indeed, we will be swimming against the tide if we believe that Gaussian logic is applicable in this case. For there is no way of evaluating normality (the average response) when, for example, we are dealing with the dialectic of human desire or the ambivalence of love and hate toward the object. In that same 1931 paper Ernest Jones concluded that the normal mind was a utopian idea, in other words, that it didn’t exist. In doing so he anticipated the opinion expressed in 1937 by Freud himself, who said that ‘a normal ego of this sort is, like normality in general, an ideal fiction’.

Now, in the year 2010, one might say that the normality of something is clearly defined by statistics and refers to all those responses which fall within the distribution of the Gaussian bell curve. Everything that lies outside the curve is simply not normal. In other words, the ‘abnormal’ is that which is outside the norm. It’s as simple as that. As we have seen, this may be applied to the functioning of specific bodily organs, such as the brain and its functions, anatomy and biochemistry. For example, one could determine the statistical mean and distribution for the weight of the human brain at different ages, and then regard as abnormal any brains whose weight placed them outside the Gaussian curve. However, the mind is a virtual phenomenon to which, as we have seen, statistical logic is not applicable. Therefore, every individual in his or her enormous diversity is a ‘natural being’. By ‘natural’ I mean that an individual is a normal being in relation to him or herself, even if he or she is unique within the infinite diversity of humankind and behaves in a way that is strange and bizarre, i.e. removed from ordinary reality (as in the case of psychotic behaviour).

In conclusion:
Whether or not an individual is regarded as presenting a ‘mental disorder’ or what might be called ‘mental abnormality’ depends on his or her degree of selfacceptance . If people cannot accept themselves, in all their diversity, then something is not quite right and they will most likely seek help. In this case, one may speak, of some kind of ‘mental disorder’. But if an individual does accept himself, then we may say that he is in ‘good mental health’. Should his or her bizarre behavior cause social, religious or political disruption, then the problem belongs to the community and its corresponding social, religious and political norms, but it does not constitute ‘mental illness’.

Freud, S. (1895) Studies on Hysteria. SE vol. 2. Freud, S. (1917) Mourning and melancholia. SE vol. 15, pp. 237–58.
Freud, S. (1930) Civilization and Its Discontents. SE vol. 21, pp. 57–146.
Freud, S. (1937) Analysis terminable and interminable. SE vol. 23, pp. 209–54.
Freud, S. (1940) An Outline of Psycho-Analysis. SE vol. 23, pp. 139–208.
Jones, E. (1931) The concept of the normal mind. Int J Psychoanal 23: 1–8.
Klein, M. (1960): On mental health. In Envy and Gratitude and Other Works, 1946–63, edited by Masud Khan. London: Hogarth Press. 1975