What's Normal?

What’s Normal? is a collection of readings for a course in literature and medicine taught in the weekend college at Hiram College.  It focuses on mental and behavioral deviations from the norm, and is a complement to an earlier collection, The Tyranny of the Normal, designed for a course on physical abnormalities. 

            The book divided into seven sections:

1. Clinical and Bioethical Perspectives
2. Children and Adolescents with Mental Disorder
3. Mental Disability (Retardation)
4. Women’s Experiences with Mental Disorder
5. Men’s Experiences with War Trauma, Including PTSD
6. Men and Mental Disorder
7. Alzheimer’s and Dementia

This is a rather odd way to categorize readings about mental disorders, and this oddness is multiplied in the choices of readings.  This eccentric collection includes some excellent pieces, but I would not recommend it as a represented survey of narratives of mental and emotional disorders.

Of course, there are many possible ways to organize such a book, but one would expect any such book to include sections on depression, mania, anxiety and panic disorders, eating disorders and self-mutilation, addiction and substance abuse, schizophrenia and personality disorders.  One might also expect a major section on patients’ reactions to various treatments, especially the experiences of taking psychotropic medication and being in psychotherapy.  Unfortunately, What’s Normal? hardly covers these at all. 

Instead, the book provides a highly eclectic and rather critical collection of readings concerning psychological normality.  The first section, of clinical and bioethical perspectives, does not aim to provide a balanced selection of views, but rather sets the tone of the book with a selection of critical views.  Among the pieces is an extract from Seth Farber’s bizarre antipsychiatric book Madness, Heresy and the Rumor of Angels, in which he presents some thoroughly Szaszian cases of people diagnosed with serious mental illnesses such as manic depression or schizophrenia.  Farber claims that these people, who did not seem to benefit from psychiatric treatment, were not suffering from mental illness, but rather were experiencing spiritual crises or transformations.  Also included in this section is a selection from Ian Hacking’s book Rewriting the Soul, about multiple personality and the diagnosis of dissociative identity disorder.  Hacking, who takes a skeptical view of the diagnosis multiple personality, is a superb writer who documents his claims fairly carefully, but of course multiple personality remains an extremely rare diagnosis. 

The famous article by D.L. Rosenhan, “On Being Sane in Insane Places,” is another of the articles in this section.  Published in 1973, it recounts an experiment in which graduate students got admitted to psychiatric wards by going to emergency rooms and claiming that they had delusions, and then ceased to pretend any further that they had any psychiatric problems.  These “pseudopatients” were never detected by the psychiatrists, and all but one was discharged with a diagnosis of schizophrenia in remission.  It is a major piece of evidence for those who claim that the label of mental illness stays with people once attached, no matter how sane they are.  But it’s also a massively out-of-date article: the length of hospitalization of these pseudopatients was between 7 and 52 days, with an average of 19 days.  These days, unless patients are a danger to themselves or others, it is extremely unlikely that they will be admitted as inpatients at all, and it would be very unusual for them to be in hospitals for more than a few days. 

This is not to say Rosenhan’s article is not still relevant, but it is astonishing that this book makes no effort to reflect the current experience of patients dealing with managed care and the bureaucracy of health care, where often they or their families have to fight to get decent and consistent treatment.  The situation of the 1970s, when patients could be admitted to hospitals for several weeks if doctors thought it necessary, seems very attractive in many ways.  It’s a major deficit of the book that it does not reflect in the changes in the provision of health care over the last 30 years.  But rather than suggest that the book should include more modern discussion of the nature of health care by historians, sociologists or philosophers, it strikes me as a mistake to include a theoretical section in this book at all, because it is impossible to be at all inclusive.  The editors would have done better to stick to the central theme of the book, that of first-person and literary perspectives on the experience of emotional problems and mental disorders. 

Most of the other sections also fail to give a picture of the experience of mental illness in contemporary life.  For example, the most modern piece in the section on children and adolescents is by Susanna Kaysen, from her book Girl, Interrupted, which is a meditation on her hospitalization in the late 1960s, when she was given a diagnosis of borderline personality disorder.  This section also includes an extract from Peter Shaffer’s overwrought 1973 play Equus, Graham Greene’s short story “The End of the Party,” and Conrad Aiken’s story “Silent Snow, Secret Snow.”  These latter two are both from the early twentieth century, and are both unusual and interesting choices on the part of the editors.  However, for teachers who might be using this book in a course on the medical humanities (which is presumably what this book is mainly designed for), these are somewhat tricky stories to use as examples to educate students.  It’s far from clear how one might relate these stories to modern health care.  If teachers are comfortable explaining the background of writers such as Greene and Aiken, they may well have success in using these stories in class, but I know I’d be somewhat apprehensive in attempting it myself. 

I’d make similar observations about most of the other sections.  I found it hard to relate the writings in the section on mental disability – including Peter Nichols, Flannery O’Connor, John Steinbeck, Anne Tyler, and Eudora Welty – to contemporary issues in the diagnosis and social and medical treatment of the condition.  Why the editors include a whole section on war trauma is unclear to me, since war trauma is not a problem we have to face much today, even now that the US is engaged in a war on terror.  It would have made more sense to fold it into the section on men and mental disorders.

The most successful section, in my opinion, is the last on Alzheimer’s and dementia.  It includes an imaginative selection of authors, all of whom were new to me.  These pieces help convey the experience of the progressive dementia from a variety of perspectives, in works of great literary power.  They are the most successful in accomplishing what the book claims it sets out to do in its title, which is provide narratives of mental and emotional disorders.

My comments have been critical, but I should acknowledge that the task of this book is daunting.  To examine the themes of mental illness in literature requires a good knowledge of both the history of literature and of psychology, and anything approaching a satisfactory survey would require a massive collection of literature.  The collection of pieces in What’s Normal? is highly idiosyncratic, so other teachers considering it for use in their courses will find it hard to adapt to their needs.  I’d suggest that for the purpose of conveying ethical and humanistic issues in mental illness faced in contemporary life, it would be far more profitable to focus on the narratives found in the proliferation of memoirs of mental illness published in the last thirty years by patients and their family members.  (A fair number of these are reviewed in the Memoirs section of Metapsychology.)

© 2002 Christian Perring. First Serial Rights.