The concept of physical illness is readily understood: the body becomes infected or inflamed, or grows abnormally, or is affected in any number of ways, all of which can be studied conventionally with laboratory tests or under a microscope. But a mental illness is something else altogether. Mental illnesses, or emotional illnesses, are disturbances of behavior and of feeling and thought. They are disorders of function that do not correspond readily to precise physical impairments and that seem, therefore, intangible--vague, aberrant expressions of the mind. At the same time, they are elusive, because they seem to be only exaggerations of the way ordinary people think and behave. And so they are.
Every person is distinctive, a particular individual with his own ideas and his own ways of doing things. The mentally ill seem special only in that they are more distinctive. They are idiosyncratic or eccentric, even peculiar; yet in their strangeness there is nothing unrecognizable. They experience no impulse nor longing that is foreign to a normal person, and they suffer no illusion that a normal person has not known. The symptoms of mental illness are embedded in, and grow out of, the normal personality. Since life is varied and complex anyway, it is hard to determine where normal behavior leaves off and abnormal behavior begins. In retreat from this tantalizing ambiguity, some psychiatrists have chosen to take the position that there is no such thing as mental illness. In similar argument, one might contend that since orange blends closely into red, there is no such thing as orange.
A medical student assigned to a psychiatric ward evaluated his first patient, an eighteen-year-old girl who had been admitted to the hospital because her mother had complained that there was something the matter with her. Following an argument with a teacher, the girl had become withdrawn and preoccupied with religion. She began eating poorly and leaving her room in a mess, which was out of character, for she was usually very neat. Then on the day before her admission she was found sitting on a subway platform, dangling her feet over the edge.
The medical student, after speaking to her on a few occasions, told the director of the ward that in his opinion she was not really ill. All he noticed about her was a kind of flightiness of thought and a somewhat depressed mood, which he thought was not out of keeping with the unpleasant circumstances of being on a psychiatric ward, especially for a sensitive young girl. Although his patient had little to say about the episode in the subway station, he explained it as an adolescent prank. Adolescence is a time when one is given to silly and impulsive behavior, he said, and to preoccupations with religion, for that matter. He went on to say that there was a time during his own adolescence when he himself was concerned with religious questions. And as for messiness, his room was even now, a mess. He said in conclusion that if she was emotionally sick, he thought that perhaps he himself, and certainly some of his classmates, were sick also.
This medical student felt a rapport with his patient which allowed him to see the world through her eyes. Nevertheless, he was wrong about her. She was psychotic. He could not yet tell where normal behavior came to an end and something else began. He had not seen orange and red set up against each other often enough to tell one from the other. As for his classmates—it is likely that he was right and that among them there were a few who were indeed mentally ill, for emotional disturbances are common, and no one is immune.
If the manifestations of mental illness can only be seen in relief against normal behavior, what then, after all, is normal behavior? What sort of person is a normal person? He is someone, first of all, who feels happy a considerable part of the time. Not all the time, of course. He is angry when he is frustrated, disappointed when he fails. He grieves when he has lost someone. Sometimes he is frightened. But he is not characteristically in any single mood, for there is an aptness to his feelings, a fit between them and the circumstances of his life. Since the circumstances of every person’s life are varied, so are his feelings. Still, in general he thinks of himself as being happy. He can relate to other people, being assertive when appropriate and conciliatory at other times. He may not feel comfortable with everyone, but he does feel secure within his family and among his friends.
And there are groups --religious, perhaps, or social-with whose members he feels an identity. And he can love, which means he can be trusting and affectionate. And he can make love without feeling oppressed or uncomfortable. Such a person often finds himself committed to other people, or even to an idea, to a degree where he loses himself in a larger purpose. Consequently when he has children, he becomes part of them and continues on in their lives, so that personal death becomes less real and less frightening.
A normal person can work with satisfaction, if it is decent work; and he can relax when he is not working. He enjoys play. In fact he enjoys himself much of the time, even if he is only talking to a friend or watching television. But probably the defining quality of a normal person is a kind of flexibility that allows him to adapt to the different demands and stresses that life imposes upon him. He can tolerate conflict and frustration and loneliness-to some extent. And he is able to seize upon life, too. He is successful at work and with people and within his family-to some extent. Probably it is possible to go on endlessly sketching the form of an ideal human being, but as he is drawn more and more precisely, he less and less resembles anyone in the real world. And yet there are normal people.
Perhaps it is easier to say what is not meant by normal than what is. Normal is not average. If someone could be average in every conceivable way, he could still be disturbed, although a perfectly average man is no more real than someone who is perfectly normal. Conversely, being atypical does not mean someone is sick. A man may still be normal who every day sleeps only five hours, works an extra full-time job, and takes three showers. But knowing just how someone deviates from the average is important in understanding him, for three reasons:
1. Although a particular behavior may not be in itself abnormal, it may be part of a pattern that reflects an abnormal process. Sleeping less than average, for instance, is sometimes associated with severe depressions and other psychoses. Also, if someone is extremely far from average in some respect of behavior or attitude, it is likely he will turn out to be emotionally ill by some other criteria.
2. Someone who is significantly different from other people may be under special strain as a result, for in order to be with people, it is necessary to do pretty much the things other people do. A man who works two full-time jobs, for instance, is not likely to be at home when his family is. If he is away from the important people in his life most of the time, to some extent, inevitably, he will be emotionally deprived.
3. But most important, an individual is most himself at just those points where he is different from others. Consequently these are points of departure for a search into an understanding of him. Human behavior is always hard to understand, for it is an expression for the most part of unconscious wishes and conflicts; nevertheless, personality becomes tangible in these out-of-the-ordinary habits and attitudes. One may ask why, for instance, a man would take three showers every day. It may be because he thinks of himself or his body as being unclean; or he might find a sensual pleasure in rubbing himself; or there might be countless other reasons, any of which may illuminate a facet of his personality. Knowing what is special about someone is knowing, at least, what is worth paying attention to for a therapist and what to ask about.
Normal also does not mean adjusted, if that word is used to refer to someone who accepts the dominant ethic of a particular society. For one thing, that ethic is frequently not what it pretends to be. The unwritten rules that govern sexual behavior in this country, for example, are scarcely those that issue from the pulpit. Even such a fundament of civilization as the law, which is spoken of invariably with esteem, is treated actually with bland disregard. People are not really expected to strictly obey the law, any more than they are expected to work a full day or to keep every promise they make.
But even were society more consistent, there would still be room for an unconventional person. At every extreme of social custom, there are normal people, and creative valuable people. Normal does not refer to a state of being at all, but rather a process, the process of growing up and into life. Adolescence has been described as a continual adjustment to the business of growing up, but that adjustment goes on at every age. Somewhere along the way, if a person is healthy, he learns to be himself and fulfill himself, but the process is never complete. He may know himself, but never altogether, for he is always changing. If he is unable to change enough to compensate for new circumstances in this life, then he will develop an emotional disorder. For that reason emotional illness may always be regarded as a failure of adaptation.
So if mental health is a process of growth, mental illness is an inhibition of that process. If being normal is to work and love and feel happy—relatively—being disturbed emotionally is to suffer relative impairment in these capacities. There is not yet a better distinction between health and illness, or between an ordinary person and someone who has become ill. (This passage is excerpted from “Caring: Home Treatment for the Emotionally Disturbed.”) © Fredric Neuman Follow Dr. Neuman's blog at fredricneumanmd.com/blog