What is Normal versus Natural when it comes diagnosing?
Assignment – Discussion – Psychopathology and Diagnosis: Alan Frances proposes (pp19-21) that psychiatric diagnosis is analog to “Umpire 2” who states, “There are balls and there are strikes, and I call ’em as I sees ’em”. What do you see are the implications of this approach to identifying and classifying psychiatric problems and disorders? Where does this heuristic hold merit and where does it break down in considering understanding human problems and providing treatment? Do you agree with this position or would you find yourself aligning more so with umpire one or umpire three?
What is Normal versus Natural when it comes Diagnosing?
According to Frances (2013), when diagnosing patients, “we lack a general definition of mental disorder to help us decide whether he is normal or a patient, mad or bad” (p. 25-26). Since there is no useful definition of mental disorders, Frances continues, it is not only more difficult to decide which mental disorders to include in diagnostic manuals, but also to determine whether a person actually has a mental disorder. Frances explains that even though we know considerably more about the nature of reality than we did hundreds of years ago, there is still a big disparity between how we perceive our daily reality and how it appears to be constructed. As an example, although most people use electricity daily, it is still very difficult for scientists to explain how electricity truly works. The same is true when attempting to comprehend the human mind, which, interestingly enough, actually runs on electricity. Thus, while it is relatively simple to observe what a person does or says, it is extremely difficult to fully comprehend the epistemology of human behavior, meaning the nature, origin, and limits of what we do and why.
To depict different ways of relating to this elusive reality, Frances divides how mental health clinicians react or respond to a lack of sufficient knowledge about the true nature of our reality into three distinct approaches. While the first approach, also referred to by Frances as Umpire One, holds that mental disorders are actual “diseases” and that it is possible to “produce convincing evidence that any mental disorder is a discrete disease entity with a unitary cause” (p. 27), which numerous scientific studies over the past fifteen years appear to disprove, the third approach, or Umpire Three, argues, contrary to the first approach, that mental disorders are mere “myths” that all fit within a broad definition of a normal that excludes mental disorders. In the second approach, Umpire Two, these two opposing viewpoints are expressed in a more nuanced manner as something in between, taking into account our limited understanding of the nature of reality and, by extension, the underlying nature of mental disorders. Consequently, mental health clinicians adhering to the second approach, which I personally most strongly identify with, appear to accept a more modest and inquisitive method of diagnosing and treating their clients, at least according to myself.
This discussion of potential limitations in the application of psychology leads to the heuristic approach, which holds that in situations of uncertainty and incomplete information, research indicates that heuristic-based judgments and decisions can be sufficient to arrive at an adequate practical solution (Scholz, 1983). Since a heuristic approach to understanding mental disorders, to the best of my knowledge, employs a method that is not guaranteed to be optimal, perfect, or rational, but may still be useful for achieving an immediate, short-term goal or approximation, it is likely used to some extent by the majority of mental health practitioners, whether or not they are willing to admit it.
Thus, a realization that occurs while writing this is that could it be possible that one difference between adhering to Umpires One and Three as opposed to Two is that people in the latter group are more or less aware and acknowledge that they are trained to use a heuristic approach when diagnosing and treating clients, whereas those adhering to Umpires One and Three believe or, maybe, hope this is not the case, indicating that their confidence in the accuracy and depth of the current scientific understanding of psychology may be greater than it really is? Although this is an intriguing question, in all modesty, I recognize that I do not yet fully comprehend the subject’s complexity and may therefore be a little off in my observation and conclusion. Nonetheless, as the course progresses, I hope to learn more and gain a deeper understanding of the subject and, consequently, the significance of this idea.
A final reflection after reading portions of Frances (2013), Frances and Widiger (2012), Beidel and Frueh (2018), and Masel et al. (2009) and having worked in the field of psychology for the past twenty years, I wonder what would happen if the word normal was replaced with the word natural when diagnosing, treating, and conducting research in the field of psychology? While normal is “characterized by that which is considered usual, typical, or routine” (Merriam-Webster, 2022a), natural signifies “being in accordance with or determined by nature” (Merriam-Webster, 2022b). In today’s society, where most people are experiencing stressors that the human nervous system was not exposed to thousands of years ago, and since it takes evolution a long time to adapt to these changes in stressors, many things that were once considered normal may no longer be considered natural. Consequently, I believe it would be most beneficial to examine the degree to which a person with a mental disorder is out of sync with what is truly considered natural, which would not only be consistent with the humanistic approach but also represent a paradigm shift in understanding and assisting those in need, all per novelist Pearl Buck’s writings in which he states, “The test of a civilization is the way that it cares for its helpless members” (Atkins, 2018, para. 2).
Atkins, A. (2018, February 21). Famous misquotations: A civilization is measured by how it treats its weakest members. Atkinsbookshelf.wordpress.com. https://atkinsbookshelf.wordpress.com/2018/02/21/famous-misquotations-a-civilization-is-measured-by-how-it-treats-its-weakest-members/ Links to an external site.
Biedel, D. C., & Frueh, B. C. (2018). Adult psychopathology and diagnosis. John Wiley & Sons, Inc.
Frances, A. (2013). Saving normal: An insider’s revolt against out-of-control psychiatric diagnosis, DSM-5, big pharma, and the medicalization of ordinary life. HarperCollins Publishers.
Frances, A. J., & Widiger, T. (2012). Psychiatric diagnosis: lessons from the DSM-IV past and cautions for the DSM-5 future. Annual review of clinical psychology, 8, 109-130. http://psych.colorado.edu/~willcutt/pdfs/frances_2012.pdf (Links to an external site.)
Maser, Norman, S. B., Zisook, S., Everall, I. P., Stein, M. B., Schettler, P. J., & Judd, L. L. (2009). Psychiatric Nosology Is Ready for a Paradigm Shift in DSM-V. Clinical Psychology (New York, N.Y.), 16(1), 24–40. https://doi.org/10.1111/j.1468-2850.2009.01140.x (Links to an external site.)
Merriam-Webster (2022a). Merriam-Webster Online Dictionary. Retrieved May 3, 2022, from
https://www.merriam-webster.com/dictionary/normal Links to an external site.
Merriam-Webster (2022b). Merriam-Webster Online Dictionary. Retrieved May 3, 2022, from
https://www.merriam-webster.com/dictionary/naturalLinks to an external site.
Scholz, R. W. (1983). Decision making under uncertainty: Cognitive decision research, social interaction, development and epistemology. Elsevier.