MENTAL HEALTH MUST BE BROADLY DEFINED IN TERMS THAT ARE CULTURALLY SENSITIVE AND INCLUSIVE. THE CRITERIA FOR MENTAL HEALTH MUST BE EMPIRICALLY AND LONGITUDINALLY VALIDATED. VALIDATION MEANS PAYING SPECIAL ATTENTION TO CROSS-CULTURAL STUDIES.

1. CONCEPTS OF NORMALITY
BY: DR. ROBIN VICTOR
PGT, DEPT. OF PSYCHIATRY
1

2. PLAN OF PRESENTATION
 DEFINING NORMALITY
 DEFINING MENTAL HEALTH
 HISTORICAL ASPECTS
 CONCEPTS OF NORMALITY
 MODELS OF MENTAL HEALTH
 CONCLUSION
 BIBLIOGRAPHY
2

3. DEFINING NORMALITY
 Normality is even more difficult to define than abnormality particularly in
rapidly changing & complex society such as ours.
 The WORLD HEALTH ORGANIZATION (WHO) considers normality to be a
state of complete physical, mental, and social well-being.
 Normality has been defined as patterns of behavior or personality traits
that are typical or that conform to some standard of proper and
acceptable ways of behaving and being.
 The use of terms such as typical or acceptable, however, has been
criticized because they are ambiguous, involve value judgments,
and vary from one culture to another.
3

4.  GEORGE MORA, devised a system to describe behavioral manifestations that are
normal in one context but not in another, depending on how the person is
viewed by the society.
Normality in Context
 LIMITATION- It give too much weight to peer group observations and
judgments.
TERM CONTEXT
Autonormal Person seen as normal by his or her own society
Autopathological Person seen as abnormal by his or her own society
Heteronormal Person seen as normal by members of another society
observing him or her
Heteropathological Person seen as unusual or pathological by members of
another society observing him or her
4

5.  THOMAS SZASZ in his book, The Myth of Mental Illness,
states that normality can be measured only in terms of
what persons do or do not do and that defining normality
is beyond the realm of psychiatry.
He claims that a belief in mental illness is asking to
believing in witchcraft or demonology.
 Psychiatry has been criticized over the years by certain
groups for its portrayal of normality.
The psychology of women, for example, has been criticized
as sexist because it was formulated initially by men
5

6. DEFINING MENTAL HEALTH
 Mental well-being presumes the absence of mental disorder defined in the
text revision of the fourth edition of Diagnostic and Statistical Manual of
Mental Disorders (DSM-IV-TR).
“A mental disorder is a behavioral or psychological syndrome or pattern
associated with distress (e.g., a painful symptom), or with a significantly
increased risk of suffering, death, pain, disability, or an important loss of
freedom. In addition, the syndrome or pattern must not be merely an expected
and culturally sanctioned response to a particular event”
6

7. DEFINING MENTAL HEALTH
 In Mental Health: A Report of the Surgeon General, mental health is defined
as “the successful performance of mental functions, in terms of thought,
mood, and behavior that results in productive activities, fulfilling
relationships with others, and the ability to adapt to change and to cope
with adversity.”
7

8.  CAUTIONARY STEPS NEED TO BE TAKEN WHILE DEFINING POSITIVE MENTAL
HEALTH
1. AVERAGE IS NOT HEALTHY- It always includes mixing in with the healthy the
prevalent amount of psychopathology in.
2. WHAT IS HEALTHY SOMETIMES DEPENDS ON GEOGRAPHY, CULTURE, AND
THE HISTORICAL MOMENT.
3. TO MAKE CLEAR WHETHER ONE IS DISCUSSING TRAIT OR STATE.
4. TO APPRECIATE THE TWOFOLD DANGER OF “CONTAMINATION BY VALUES.”
 The best way to enrich our understanding of what constitutes mental health is
to study a variety of healthy populations from different perspectives, in different
cultures, and for a long period of time.
8

9.  The commonly accepted and widely used definition of mental health adapted
from Campbell's Psychiatric Dictionary
 “Psychically normal persons are those who are in harmony with themselves and
with their environment. They conform with the cultural requirements or
injunctions of their community. They may possess medical deviation or disease,
but as long as this does not impair their reasoning, judgment, intellectual
capacity, and ability to make a harmonious personal and social adaptation, they
may be regarded as psychically sound or normal.”
9

10. HISTORICAL ASPECTS OF NORMALITY
 ADOLPHE QUETELET in 1835 published
the first important book on normality.
 Rather than focus on pathology, he
tried “to approach more closely to what
is good and beautiful,” and his goal was
the statistical analysis of healthy
humans.
 He challenged generations of future
investigators with his introductory
sentence: “Man is born, grows up, and
dies, according to certain laws which
have never been properly investigated.”
10

11.  After World War II,
 In1941 JOHN CLAUSEN and his coworkers were commissioned to assess
mental health for the draft board.As a way of assessing the mental health of
recruits they focused on the absence of psychosomatic symptoms.
 Questions about psychosomatic symptoms still form an important part of the
Hopkins Symptom Checklist (SCL-90).
 Other influential works on normal adaptive behaviour include—
 Roy Grinker and John Spiegel's - Men under Stress
 Robert White's - Lives in Progress
 Leo Sroles - Mental Health in the Metropolis
 Alexander and Dorothea Leightons' - Cove and Woodlot
11

12.  Many Postwar psychiatrists continued to agree with
Freud, who had dismissed mental health as “an ideal
fiction.”
 In the late 1950s two of the world's most
distinguished psychiatrists dismissed the term entirely:
 Sir Aubrey Lewis wrote in 1958, “Mental health is an
invincibly obscure concept.”
 1957 Fritz Redlich asserted, “We do not possess any
general definition of normality and mental health
from either a statistical or a clinical viewpoint.”
12

13. MARIE JAHODA suggested :
 (1) That mentally healthy individuals should be in touch with their identity and
their feelings.
 (2) They should be oriented toward the future, and over time they should
remain fruitfully invested in life.
 (3) Their psyches should be integrated and provide them resistance to stress.
 (4) They should possess autonomy and recognize what suits their needs.
 (5) They should perceive reality without distortion and yet possess empathy.
 (6) They should be masters of their environment—able to work, to love, and to
play and to be efficient in problem solving.
13

14. MENNINGER PSYCHOTHERAPY PROJECT
 Lester Luborsky devised a behavioral guide (Health-Sickness Rating
Scale [HSRS]) to assess psychological functioning on a scale of 0 to
100.
 In 1976 two of the architects of DSM-III developed a revision of the
HSRS called the Global Assessment Scale (GAS).
 A modified version of the GAS was introduced in DSM-III-R as the
Global Assessment of Functioning (GAF).
 On Luborsky's scale a score of 95 to 100 reflected “an ideal state of
complete functioning integration, of resiliency in the face of stress,
of happiness and social effectiveness.”
14

15.  On the GAF a score of 95 to 100 corresponded to “no symptoms, superior functioning
in a wide range of activities; life's problems never seem to get out of hand; patient is
sought out by others because of his warmth and integrity.” The words differ, but the
melody is the same.
 By 1978 The Report to the President by the President's Commission on Mental Health
forcefully introduced the importance of defining clearly what is meant by mental
health.
 It was 15 years later, evidence emerged to support the validity of Axis V of DSM-IV, did
psychiatry finally possess a metric for the measurement of “above-average” mental
health.
15

16. 16

17. CONCEPTS OF NORMALITY
 MAINLY TWO BROAD CATEGORIES:
 FUNCTIONAL PERSPECTIVES OF NORMALITY
 PSYCHOANALYTIC THEORIES OF NORMALITY
17

18. FUNCTIONAL PERSPECTIVES OF NORMALITY
 Described by Daniel Offer and Melvin Sabshin
 Four functional perspectives.
 Each perspective is unique and has its own definition and description.
 The perspectives complement each other.
 They represent the totality of the behavioral science and social science
approaches to the subject.
18

19. FUNCTIONAL PERSPECTIVES OF NORMALITY
NORMALITY AS HEALTH
 Most physicians equate normality with health and view health as an almost
universal phenomenon.
 Behavior is assumed to be within normal limits when no manifest
psychopathology is present.
 If all behavior were to be put on a scale, normality would encompass the
major portion of the continuum, and abnormality would be the small
remainder.
 John Romano – “healthy person as one who is reasonably free of undue
pain, discomfort, and disability.”
19

20. NORMALITY AS UTOPIA
 Conceives normality as that harmonious and optimal blending of the diverse
elements of the mental apparatus that culminates in optimal functioning.
 This approach can be traced back to Sigmund Freud, who when discussing
normality stated, “A normal ego is like normality in general, an ideal fiction.”
 Although this approach is characteristic of many psychoanalysts, it is by no
means unique to them.
 It can also be found among other psychotherapists in the field of psychiatry and
among psychologists of quite different persuasions.
20

21. NORMALITY AS AVERAGE
 Is based on a mathematical principle of the bell-shaped curve.
 This approach considers the middle range normal and both extremes deviant.
 The normative approach based on this statistical principle describes each
individual in terms of general assessment and total score.
 Variability is described only within the context of groups, not within the
context of the individual.
 This approach is more commonly used in psychology than in psychiatry
21

22. NORMALITY AS PROCESS
 States that normal behavior is the end result of interacting systems.
 Temporal changes are essential to a complete definition of normality. In other
words, the normality-as-process perspective stresses changes or processes
rather than a cross-sectional definition of normality.
 A typical example of the concepts in this perspective is Erik Erikson's
conceptualization of the epigenesis of personality development and the
developmental stages essential in the attainment of mature adult functioning.
22

23. PSYCHOANALYTIC THEORIES OF
NORMALITY
 Some psychoanalysts base their concepts of normality on the absence of
symptoms.
 Accordingly, most psychoanalysts view a capacity for work and enjoyment
as indicating normality or, as Freud put it, the ability “to love and to work.”
23

24. HEINZ HARTMANN
 Conceptualized normality by describing the “autonomous
functions of the ego”
 Autonomous functions of the ego is present since birth
that develop independently of intrapsychic conflict
between drives and defenses.
 These functions include perception, learning, intelligence,
intuition, language, thinking, comprehension, and motility.
 In the course of development, some of these conflict-free
aspects of the ego may eventually become involved in
conflict.
24

25. MELANIE KLEIN
 Normality is characterized by
strength of character, the capacity
to deal with conflicting emotions,
the ability to experience pleasure
without conflict, and the ability to
love.
25

26. KARL JASPERS
 KARL JASPERS, a German psychiatrist and philosopher,
described a “personal world”- the way a person thinks or
feels ”that could be either normal or abnormal”.
 The personal world is abnormal when:
1. It springs from a condition that is recognized universally as
abnormal, such as schizophrenia.
2. It separates the person from others emotionally.
3. It does not provide the person with a sense of “spiritual
and material” security.
26

27. ERIK ERIKSON
 Normality is the ability to master the periods of life.
 Trust vs. Mistrust(0- 18 m)
 Autonomy vs. Shame and doubt(18m-36m)
 Initiative vs. Guilt(3-5 years)
 Industry vs. Inferiority(5-13years)
 Identity vs. Role confusion(13-20 years)
 Intimacy vs. Isolation(20-40 years)
 Generativity vs. Stagnation(40-60 years)
 Ego integrity vs. Despair(> 60 years)
27

28. LAURENCE KUBIE
 Normality is the ability to learn by
experience, to be flexible, and to
adapt to a changing environment.
28

29. KARL MENNINGER
 Normality is the ability to adjust to the external
world with contentment and to master the task
of acculturation.
 Acculturation explains the process of cultural
change and psychological change that results
following meeting between cultures.
29

30. ALFRED ADLER
The person's capacity to develop social feeling and to
be productive is related to mental health; the ability to
work heightens self-esteem and makes one capable of
adaptation.
30

31. R. E. MONEY-KRYLE
Normality is the ability to achieve insight into
one's self, an ability that is never fully
accomplished.
31

32. OTTO RANK
 Normality is the capacity to live without
fear, guilt, or anxiety and to take
responsibility for one's own actions
32

33. W. SOMERSET MAUGHN
 The normal is an ideal.
 It is a picture that one fabricates---and
to find them all in a single man is hardly
to be expected.
33

34. MODELS OF MENTAL HEALTH
 Six different empirical approaches to mental health. It can be
conceptualized as :
1. Above normal and a mental state that is objectively desirable.
2. Maturity from the viewpoint of healthy adult development.
3. Positive psychology—as epitomized by the presence of multiple human
strengths.
4. Emotional intelligence and successful object relations.
5. Subjective well-being—a mental state that is subjectively experienced as
happy, contented, and desired.
6. Resilience, as the capacity for successful adaptation and homeostasis.
34

35. MODEL A: MENTAL HEALTH AS ABOVE
NORMAL
 It differs from the traditional medical approach to health and illness.
 If one were to put all individuals on a continuum, normality would
encompass the major portion of adults, and abnormality would be the
small remainder.
 Health refers to a reasonable, rather than an optimal, state of functioning.
 Mental health is not normal; it is above average.
 The absence of illness and the presence of health overlap but do not
always coincide.
35

36. MODEL B: MENTAL HEALTH AS MATURITY
 Unlike other organs of the body that are designed to stay the same, the brain
is designed to be plastic.
 Optimal brain development requires almost a lifetime, so does the
assessment of positive mental health.
 Statistically, physically healthy 70-year-olds are mentally healthier than they
were at 30 years in absence of any pathology .
 Erik Erikson in 1950 provided the first model of adult social development. He
viewed each of his well-known eight “stages” of human development as a
“criterion of mental health.”
 Jane Loevinger provided a model of adult ego development,
36

37.  Lawrence Kohlberg provided a model of adult moral development.
 James Fowler provided a model of spiritual development.
 Implicit in all of these models is the assumption that greater maturity
reflected greater mental health.
 The association of mental health to maturity is probably mediated not only by
progressive brain myelinization but also by the evolution of emotional and
social intelligence through experience.
 Erikson conceptualized that such development produced a “widening social
radius.”
 Life after age 50 years was no longer to be a staircase leading downward, but
a path leading outward.
37

38.  Erikson's model the adult social radius
expanded over time through the mastery of
the four tasks of:
 “Identity versus Identity Diffusion,”
 “Intimacy versus Isolation,”
 “Generativity versus Stagnation,”
 “Integrity versus Despair.”
 Vaillant added two more tasks—Career
Consolidation and Keeper of the Meaning—
to Erikson's four).
 The mastery of such tasks appears to be
relatively independent of education, gender,
social class, and probably culture.
38

39. MODEL C: MENTAL HEALTH AS POSITIVE OR
“SPIRITUAL” EMOTIONS
 In the 19th century came concepts like “moral insanity” and “good
character,” and mental health was deemed related to morality and
religious observance.
 There was relationship between morality and health.
 Model C is a reflection of positive (“spiritual”) emotions.
 Positive emotions arise from the inborn prosocial mammalian capacity for
unselfish parental love. Thus, they are grounded in our evolutionary
heritage.
 Limbic system is associated with generation of emotions.
39

40.  Love, hope, joy, forgiveness, compassion, faith,
awe, and gratitude comprise the important
positive and “moral” emotions included in this
model.
 All these emotions involve human connection.
None of the eight emotions listed is just about
the self.
 Five other positive emotions—excitement,
interest, contentment (happiness), humor, and
a sense of mastery limited to self for a person
can feel these latter five emotions alone on a
desert island.
40

41. POSITIVE EMOTIONS NEGATIVE EMOTIONS
Generated in the limbic system Generated in hypothalamus &
elaborated in the amygdala
Free the self from the self All about “me.”
More expansive and help us to broaden
and build. They widen one's tolerance
for strangers, expand one's moral
compass, and enhance one's creativity.
Crucial for survival in time.
Make thought patterns more flexible,
creative, integrative, and efficient.
Narrows attention
Activates parasympathetic nervous
system
Activates sympathetic autonomic
nervous system.
41

42. MODEL D: MENTAL HEALTH AS
SOCIOEMOTIONAL INTELLIGENCE
 High socioemotional intelligence reflects above-
average mental health in the same way that a
high intelligence quotient (IQ) reflects above-
average intellectual aptitude.
 Aristotle defined socioemotional intelligence as
follows:
“Anyone can become angry—that is easy. But to be
angry with the right person, to the right degree, at
the right time, for the right purpose, and in the
right way—that is not easy.”
42

43.  Suggests that instinct and object relations are equal partners.
 Primary emotions exist to assist basic survival. These include:
 Anger
 Fear
 Excitement
 Interest
 Surprise
 Disgust
 Sadness.
 The capacity to identify these different emotions in ourselves and in others
plays an important role in mental health.
43

44.  Empathic children, without being more intelligent,
do better in school and are more popular than their
peers.
 Early school success was achieved not by
intelligence but by knowing what kind of behavior is
expected, knowing how to rein in the impulse to
misbehave, being able to wait, and knowing how to
get on with other children.
 The more one is skilled in empathy, the more one
will be valued by others, and so the greater will be
social supports, self-esteem, and intimate
relationships.
44

45.  Social and emotional intelligence can be defined by the following criteria:
 Accurate conscious perception and monitoring of one's emotions.
 Modification of emotions so that their expression is appropriate. This involves
the capacity to self-soothe personal anxiety and to shake off hopelessness
and gloom.
 Accurate recognition of and response to emotions in others.
 Skill in negotiating close relationships with others.
 Capacity for focusing emotions (motivation) toward a desired goal. This
involves delayed gratification and adaptively displacing and channeling
impulse.
45

46.  ADVANCES IN STUDYING EMOTIONAL INTELLIGENCE
 Three important empirical steps to understand the relationship of socio-
emotional intelligence to positive mental health:
 First step-fMRI and ingenious neurophysiological experimentation have led
to advances in our understanding of the integration of prefrontal cortex
with the limbic system, especially with the amygdala and its connections.
 The second step forward has been our slow but steady progress in the
conceptualizing and even the measuring of “emotional intelligence.”
 The third advance is the use of videotape to chart emotional interaction.
Videos of sustained family interactions reveal that the most important
aspect of healthy infant development, of adolescent development, and of
marital harmony is how partners or parents respond to emotion in others.
46

47. MODEL E: MENTAL HEALTH AS SUBJECTIVE
WELL-BEING
 Positive mental health does not just involve being a joy to others; one
must also experience subjective well-being.
 Subjective well-being is never categorical.
 Subjective well-being is not just the absence misery, but the presence of
positive contentment.
 Happiness that comes from joy or from unselfish love, self-control and
self-efficacy, play and “flow” (deep but effortless involvement) reflects
health.
 Happiness that comes from spiritual discipline and concentration, humor,
or being relieved of narcissistic focus on shame, resentments, and the
“poor-me's” is a blessing.
47

48.  Subjective happiness can have maladaptive as well as adaptive facets.
 Pleasures can come easily and be soon gone.
 Illusory happiness is seen in the character structure associated with bipolar and
dissociative disorders.
 Such maladaptive happiness can bring temporary bliss but has no sticking
power.
 Examples of maladaptive “happiness” can be the excitement of risk taking,
from being “high” on drugs and from “turning-on” to any unmodulated but
gratifying primitive need like binge eating, tantrums, promiscuity, and revenge.
48

49. MODEL F: MENTAL HEALTH AS RESILIENCE
 In 1856, CLAUDE BERNARD, a French
physiologist imporved the understanding of
positive health when he wrote
“We shall never have a science of medicine as
long as we separate the explanation of the
pathological from the explanation of normal, vital
phenomena.”
 It is not stress that kills us, but healthy mastery
of stress that permits us to survive.
49

50.  In 1925, ADOLF MEYER, a founder of modern
American psychiatry, contributed to the
understanding of mental health when he
asserted that there were no mental diseases,
there were only characteristic reaction patterns
to stress.
 Meyer's point was that although adaptive mental
“reaction patterns” like denial, phobias, and even
projections can appear to reflect illness, they may
in fact be “normal, vital phenomena” related to
healing.
 Involuntary coping mechanisms heal by
distorting mental processes.
50

51.  Mental illness are the outward manifestations of homeostatic struggles to
adapt to life.
 Three broad classes of coping mechanisms that humans use to overcome
stressful situations:
 First, there is the way in which an individual elicits help from appropriate
others. Namely consciously seeking social support.
 Second, there are conscious cognitive strategies that individuals intentionally
use to master stress.
 Third, there are adaptive involuntary coping mechanisms (often called
“defense mechanisms”) that distort our perception of internal and external
reality in order to reduce subjective distress, anxiety, and depression.
51

52.  5 of the models described here are capable of being assessed
psychometrically—
 Above-average normality by the GAF (Axis V)
 Maturity by the presence or absence of Generativity,
 Positive emotions by the PANAS( Positive and Negative Affect schedule).
 Subjective well-being by scaled self-report
 Resilience by defense level on the optional DSM-IV axis.
 Measures to assess psychometrically socioemotional intelligence are under
development.
52

53. CONCLUSION
 MENTAL HEALTH MUST BE BROADLY DEFINED IN TERMS THAT ARE CULTURALLY
SENSITIVE AND INCLUSIVE.
 THE CRITERIA FOR MENTAL HEALTH MUST BE EMPIRICALLY AND LONGITUDINALLY
VALIDATED.
 VALIDATION MEANS PAYING SPECIAL ATTENTION TO CROSS-CULTURAL STUDIES.
 ALTHOUGH MENTAL HEALTH IS ONE OF HUMANITY'S IMPORTANT VALUES, IT
SHOULD NOT BE REGARDED AS AN ULTIMATE GOOD IN ITSELF.
 WE MUST REMEMBER THAT THERE ARE DIFFERENCES BETWEEN REAL MENTAL
HEALTH AND VALUE-RIDDEN MORALITY, BETWEEN HUMAN ADAPTATION AND
MERE PREOCCUPATION WITH DARWINIAN SURVIVAL OF THE FITTEST.
53

54. BIBLIOGRAPHY
1 SYNOPSIS OF PSYCHIATRY 10TH EDITION
KAPLAN & SADOCKS
2 COMPREHENSIVE TEXT BOOK OF PSYCHIATRY,
KAPLAN & SADOCKS 9TH EDITION
3 INTERNET SOURCES
54

55. 55