ORIGINAL ARTICLE
Volume 46, Issue 5, September-October 2023
doi: 10.17711/SM.0185-3325.2023.030
Normality and mental health: The ethical dimension
Fernando Lolas Stepke1,2
1 Centro Interdisciplinario de Estudios
en Bioética, Universidad de Chile,
Santiago, Chile.
2 Instituto de Investigación, Facultad
de Ciencias de la Salud, Universidad Central de Chile, Santiago,
Chile.
Correspondence:
Fernando Lolas Stepke
Centro Interdisciplinario de Estudios
en Bioética, Universidad de Chile.
Diagonal Paraguay 265, Of. 806,
Santiago de Chile.
Phone: +56 9 9826-3393
Email:
[email protected] and fernando.
[email protected]
ABSTRACT
This article applies the concept of normality, in both its descriptive and normative connotations, to the field
of mental health, emphasizing its ethical undertones in different cultural and situational contexts. Ethics is
defined as the linguistic justification of morals, and bioethics is characterized by arguments based on dialogical, discursive, and deliberative processes. Bioethical decision-making influences human relationships and
has implications for diagnosis, prognosis, interventions, and evaluation of therapeutic results and outcomes.
Normality in mental health should be reformulated on bioethical principles to avoid being a source of stigma
and discrimination, at a time when human diversity and cultural change impose a redefinition of conceptual
boundaries and depathologization of different forms of behavior and experience.
Keywords: Normality, mental health, ethics, bioethics, discrimination, stigma.
Received: 16 March 2023
Accepted: 26 April 2023
RESUMEN
Citation:
Lolas Stepke, F., (2023). Normality
and mental health: The ethical dimension. Salud Mental, 46(5), 241-245.
Se aplica el concepto de normalidad en sus connotaciones descriptiva y normativa al campo de la salud mental, destacando su tonalidad ética en diferentes contextos culturales y situacionales. Se define la ética como
la justificación lingüística de la moral y se caracteriza a la bioética como fuente de argumentos basados en
procesos dialógicos, discursivos y deliberativos. La toma de decisiones en clave bioética influencia las relaciones humanas y posee implicaciones para el diagnóstico, el pronóstico, las intervenciones y la evaluación
de resultados y consecuencias. La normalidad en salud mental debiera ser reformulada sobre la base de
principios bioéticos a fin de impedir ser fuente de estigma y discriminación en una época en que la diversidad
y el cambio cultural imponen una redefinición de límites conceptuales y la despatologización de diferentes
formas de conducta y vivencia.
DOI: 10.17711/SM.0185-3325.2023.030
Palabras clave: Normalidad, salud mental, ética, bioética, discriminación, estigma.
Salud Mental | www.revistasaludmental.mx
241
Lolas Stepke
DIFFERENCES BETWEEN
INDIVIDUALS
Human behavior is characterized by its variability. Differences between individuals can be relatively permanent and
are conceptualized as personality traits. The personality
construct refers to the permanence of propensities and behaviors. It has the value of a predictive description. There
is also situational variability, which is alluded to in the concept of state. A person can feel anguish, fear, or joy, have
certain desires, and act unexpectedly. Such states, by definition transitory, are not used to characterize people but rather
to evaluate situations or capacities.
When traits or states cause impairment, disability, or
handicap, altering social relationships or causing suffering,
the result can be called a disorder. Disorders can be brief
and transitory or prolonged and permanent, configuring
psycho-pathological patterns. Persistent affectations are
usually classified as personality disorders and transitory
ones as symptoms of possible “diseases” that psychiatric
nosology distinguishes based on their intensity, frequency,
or degree of disturbance of habitual life.
Not all psychopathology requires specialized interventions. Depending on the culture and circumstance, manifestations that in one context may seem minor or that can
be remedied over time or through social support, in others
may be cause for concern and a cry for professional help.
A typical case is mourning the loss of a significant or loved
person, which begins to be considered pathological when
its duration or intensity exceeds the tacit frameworks established by a person's environment.
CONCEPTS OF NORMALITY
The concept of normality became culturally ubiquitous in
health in the mid-twentieth century. Previously it denoted a
statistical notion, meaning a distribution according to certain
quantitative parameters. Strictly speaking, it equated to a high
probability of an event or a high frequency of a characteristic.
The concept of normality has at least two connotations
(Rost, Favaretto, & De Clercq, 2022). It is a descriptive
notion, which indicates a state of affairs or belonging to a
group or habitual situation. It has also normative connotations, indicating what “should be” appropriate, correct, and
desirable according to accepted standards, either quantitative or qualitative. In physiological research, for example,
what the aggregation of process studies indicates as habitual for the human species becomes the norm. Thus, for example, a temperature higher than 37°C is both a description
and an indication of being outside the norm, in which case
one speaks of “fever” (Lolas, 2001).
In medicine, the notion of normality has different uses
open to criticism (Catita, Águas, & Morgado, 2020). The
242
first derives from statistics. A value or state found in most
measurement events or situations specified by theory is
normal. Most laboratory tests give results depending on the
conditions and methods of measurement. The accumulation
of measurements under standardized conditions allows for
the definition of a range of variation considered normal.
This is the case of glycemia, body temperature, blood electrolytes, hormonal assessments, heart or respiratory rate,
and a wide variety of parameters. Thus normality turns into
normativity (Lolas., 2001).
The second connotation of normality is associated with
a set of desirable or ideal attributes. The body accepted in a
culture without objection, or the manifestation of culturally
desirable attributes is normal. There is also a dynamic or
temporal consideration. Certain bodily processes that run
without alterations are normal, with their appropriate and
accepted rhythms and in the expected places in the body.
For the classical medical mentality, what makes a process
abnormal is heterochrony, going out of the expected rhythm,
or heterotopia, occurring in unusual places.
Normality is usually associated with adaptation to
changing environments and with the biological and social
advantage of existing without major modifications when
conditions change. Cannon's classical notion of homeostasis conceives of adaptability as part of biological normality,
and Claude Bernard suggested that the constancy of the internal environment is a condition for a free existence. Normality is adaptability, resistance, and resilience.
It is customary to consider normality as a component
of the complex concept of health, understood not only as
the absence of suffering, but as fullness and enjoyment of
capacities. To the consecrated definition of the WHO, a prospective factor of permanence and expectation must be added, which takes on importance when talking about mental
health.
“Mental health” is a pleonastic construction, that is, a
phrase or combination of words with excessive and redundant valence. There can be no health without mental health
in any animal species, especially human. What is insinuated
with the over-meaning added to the idea of health by the
adjective mental is both the self-perception of a satisfactory
and pleasant interiority and the ideas, projects, and perspectives that people harbor according to their knowledge and
beliefs. The mental is the conscious or the unconscious that
is accessible to the word, the relation of behavior to meaning, or behavior according to the social norm. When any of
these aspects of the mental show abnormality, the result is
called a mental disorder. Technically, it is unlikely or impossible that ideation or behavior does not have some form
of correlation with processes in the central nervous system.
However, debating dualism versus monism, determination,
or physiological modulation is not the objective of this text
(Armstrong, 2005).
Salud Mental, Vol. 46, Issue 5, September-October 2023
Normality and mental health
ETHICS AND MENTAL HEALTH
The concept of normality, which in physiological or physical medicine is assimilated, albeit with reservations, to average magnitudes of measurable parameters, is confusing
in the field of mental health (Jäger, 2018). Many variants
of behavior, self-perceptions of subjective interiority, and
sensibility are unequivocally incommunicable. The psychiatrist or psychologist has sources of information such as the
word (which roughly reflects interiority), manifest behavior
(motor behavior), and physiological signals (chemical or
electrical). This psychophysiological triad (Lolas, 1988b)
is expanded with the consideration of personal history as
biography (self or other), the material products of personal
activity (writings, drawings, objects), and family history as
suggesting abnormal predispositions or diathesis.
If morality can be considered the social behavior “accepted” by a society, ethics is the verbal justification of
what is correct and what it should be. It is not a question of
verifying only what is, or what nature can be. Ethics justifies what should be according to the ideals of a culture. It is
a philosophical discipline that uses language to support prescriptions and prohibitions. It requires a source of authority
that imperatively allows justification: a religious belief, a
philosophical conviction, the mandate of reason, the knowledge of nature, or any source recognized as an authority
worthy of compliance and respect. The variant known as
bioethics highlights the relational role of this “justificatory
language game,” by proposing that norms should come not
from the monological derivation of a system of thought, but
from the dialogical and participatory appropriation of conventions. In bioethics, dialogical or “multilogical” deliberation predominates, basing its acceptability on consensual
procedures rather than on the imposition of doctrines. Its
decisive cultural contribution has been the installation of
social institutions known as committees that combine different visions and interests to make decisions. There may
be tensions between the ethics of convictions and the ethics of responsibility (which considers the consequences of
actions). The bioethical discourse accepts the plurality of
rights and duties and combines perspectives and interests.
It is not surprising that ethical prescriptions and prohibitions can be read in a psychological key and that many
disorders today considered psychiatric (in medical psychiatry) have been attributed to “moral idiocy,” “perversion,”
or “demonic possession.” The abnormality is thus confused
with moral deviation and the disturbance is interpreted in an
ethical key. Remnants of such a position persist in the notions of deviation and degeneration, less useful today since
they have been associated with etiological considerations
that are no longer valid. The “causes” of so-called mental
disorders oscillate between physiological and anatomical
determinations, oppressive or limiting social contexts, and
genetic predispositions.
Salud Mental, Vol. 46, Issue 5, September-October 2023
DIMENSIONS OF BIOETHICS
IN PROFESSIONAL PRACTICE
When we address here the interface between ethics and
mental health, we do so from a special, limited perspective.
It is about elaborating on the form of ethics that can best
serve to help people who suffer from disorders, and the appropriate behavior of those who can and should help people
who need and require help. The appropriate practices in a
given context are defined by multiple interests: social, economic, cultural, and institutional. Thus, from a bioethical
point of view, it is a matter of specifying the ethical dimension that justifies individual or collective interventions to
alleviate disorders of ideation, emotion, or behavior (Lolas,
1988a).
The need for bioethical discourse begins with the adequate training of professionals, who must know how to
support their actions on a technical level, and also how to
justify them ethically. The perception of one's value architecture is possible with introspection and experience, which
can be exercised in teaching. It is part of the didactic analysis used in psychoanalytic training, but its principles should
be considered in any educational process.
In a professional relationship, there are a multiplicity of
planes. The people who meet—therapist-patient, doctor-patient—are just examples. However, each person entering
into the dialogue does so with a personal and cultural background, in addition to the presence of many relevant people,
who, although physically absent, never cease to influence
the relationship. There are “significant others” in the lives of
the interlocutors, authority figures, and the pervasive influence of law and custom. The relationship also includes what
in psychoanalysis is known as transference, sometimes with
vicariant identifications (the therapist replaces the father or
mother, and the patient can awaken associations with people from the therapist's biographical memory, for example).
In the dialogic situation, these various layers of meanings can be identified. It is not always easy. The medicalization of psychiatry reduces the interview to the search for
a diagnosis, a label that is reached inductively, depending
on the thoroughness of the examiner, the identification of
relevant signs and symptoms, and their division into significant groups (syndromes, clinical pictures, disease entities).
The idea of a patient in society is that of a “labeled person”
or “cataloged individual.” The power of professionals consists in giving names to what worries or torments people. It
is not always possible; many complaints and the feeling of
limitation or impairment sometimes do not fit with the categories in which “diseases” are coded. Feeling sick is not the
same as having a disease or being considered sick (illness,
disease, sickness). This discursive dissociation forces us to
consider different points of view in the construction of a
common concept (illness negotiation) based on the “offer”
of signs or symptoms that the expert can group into mean-
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Lolas Stepke
ingful categories and that can be labeled with a view to intervention. The psychiatric diagnosis is not only a description; it is also a prognosis and an indication to intervene.
However, there are also the perceptions of people who tend
not to communicate where there is no trust in professionals
or if communication implies unwanted stigmatization (Lolas, 2014).
Diagnosis, therefore, has an axiological dimension
(Lolas, 2009). Designations, and words, have effects on
people's lives and often initiate a “patient career,” since
with this labeling an identity element is added that can
cause stigmatization and discrimination. People labeled as
“carriers” of a condition assume an identity that modifies
their lives, induces concern or anguish, and determines
behaviors (Lolas, 1997). It also has legal and social consequences, since it can generate actions to repair damage
or limitations on interpersonal treatment. It is understandable to use diagnostic terms that avoid these consequences,
distorting statistics and leading to negative consequences
(although sometimes the diagnostic label is used to advantage). The psychological or psychiatric diagnosis requires
consideration of its consequences and is ethically relevant.
The relationship between professionals and applicants
for help is marked by prohibitions and limits that are part
of the ethical context of professional practice. In medicine,
most of the codes of behavior highlight the obligation to
keep secret what is exchanged in meetings and to practice
the trade following the ancestral precept of “do no harm,”
which also finds expression in prescriptions and interventions. Especially in the case of vulnerable people or those in
need of esteem and support, the relationship must be carefully elaborated in order not to generate harmful dependencies or affective transfers that alter the necessary “equanimity” that must prevail. Empathy and willingness to help, as
William Osler indicated, should not prevent the necessary
distance that avoids the clouding of clinical judgment and
distinguishes professional intervention from friendly comfort. People do not go to professionals just to be sympathized with. They also want expert knowledge, experience,
and accuracy.
There is a frequently highlighted tension here. The alleged dehumanization of medical practice and the reduction
of people to numbers or cases, the basis of some criticisms
of the medical model propagated by some sociological currents, is usually based on the convenience of not affecting
judgment based on feelings, the self-protection of professionals against the pain that is contagious and damaging,
or administrative reasons that simplify communication in
health institutions. The balance between understanding,
empathy, warmth, truthfulness, honesty, and technical competence is an achievement of correct professional training.
Therapeutic interventions are of many types. They begin with the word, and what Michael Balint has called the
“medical drug”: the mere presence of someone who knows
244
and has authority is a component of the healing or curative
action. Like any drug, it must be dosed and administered
at times and in ways appropriate to each subject. These
are semiotic and discursive technologies, part of the “hidden curriculum” of professional studies because they are
not always explicitly taught. Collecting data for a medical
history is not the same as reconstructing a biography. The
ethics of the verbal or pre-verbal intervention must be considered when defining the abnormality in conjunction with
those who want help. The ultimate foundation of the anthropological orientation of medicine, observed Viktor von
Weizsäcker, is the recognition of the Other as a person and
the reformulation of the interpersonal relationship as “communicative praxis.” In psychiatry, “encratic” technologies
(related to the management of professional power) have
historically played an important role, as noted by Foucault,
who observes how the prescriptions of the French alienists
of the eighteenth and nineteenth centuries explicitly highlighted manifest “psychiatric power” in the appearance, the
institutional design, and the hierarchies of “caretakers” that
the “moral treatment” then in place demanded (Foucault,
2007). It was a sign of abnormality not to abide by such
relationship designs. It is necessary to examine the historical changes in the ethics of professional practice leading to
more egalitarian forms of treatment and the abandonment
of old notions about the incapacity and incompetence of the
“mentally ill.”
Instrumental interventions, from the technification of
the diagnostic process to pharmacological, surgical, and
telematic treatments, are part of the ethics inherent in the
labeling of abnormality that precedes any non-verbal action in the technical process of “therapy” (which means
help). The complexity derives from the fact that it is never
a simple exchange or relationship between two people. The
significant others are present in the lives of therapists and
patients, the prejudices rooted in culture, the institutional
context in which the interaction takes place, and the omnipresent influence of economic factors. The latter involves
external actors, such as industry and social security systems. Factors and interests that affect the “quality” of care,
such as the prescription of novel drugs or sophisticated
techniques not available to all communities or individuals,
play a role. Not recognizing or ignoring these factors does
not nullify their influence on decisions, and requires, apart
from the usual regulations in professional behavior codes,
an acknowledgment of the conflicts of interests or loyalties
that their existence inevitably generates.
Finally, there is an ethical dimension (that is, morally expressible and in need of justification) in the analysis
of costs and benefits generated by professional work. It is
different to talk about “effects” as different from “results.”
Even perceptible curative interventions must be judged in
the context of the “satisfaction” that their final result generates in consultants and professionals. In the field of men-
Salud Mental, Vol. 46, Issue 5, September-October 2023
Normality and mental health
tal health, with its diffuse and incommunicable results, this
evaluation must incorporate not only the convictions of the
participants, but also the individual and collective effects
of the interventions. Evidence-based psychiatry cannot be
separated from value-based psychiatry. This second formulation, however, is ambiguous. It refers both to respect for
the values of patients and therapists and to the social and
economic cost of decisions. Not infrequently the normality
achieved for one group of people is unattainable for others,
and professionals are faced with working in the contexts
imposed by the resources and the possibilities of the populations to be cured and healed.
The normality predicated on the experiences and behaviors of people requiring help for disorders not exhibiting
a physically measurable substrate requires considering the
validity of this conceptual category. As medicine becomes
a search for normality through curative procedures, it condemns many individuals to exclusion and discrimination.
It dichotomizes a complex reality. The ethical challenge is
to distinguish abnormality from acceptable or condemnable
varieties of human beings. Historical evolution indicates
that many diagnostic labels of the past have been “depathologized” and have become acceptable variants of the human
condition (think, for example, of homosexuality, which
went through the stages of “egosyntonic” and “egodystonic” before becoming a socially and medically acceptable
variant of personal life). It is not about reducing psychiatry to a mere social control device or denying the existence
of pathological conditions, but about reformulating what is
normal and abnormal on a plane that is independent of what
is pathological. Canguilhem (1966) implicitly suggested the
need to deconstruct normality as normativity and not simply to oppose the terms normality and disease, especially if
the former is identified with “the average” or “the usual”.
What is pathic, what makes one suffer, is not necessarily
pathological, worthy of diagnostic labeling.
BIOETHICAL CONTEXTS
FOR A REDEFINITION OF NORMALITY
The redesign of a broad concept of normality requires considering the diversity of human existence and demands a
reformulation, at the level of what is loosely called “mental
health,” the changing boundaries of the pathological. It is a
challenge for a psychiatric and psychological metatheory
to rescue the original use of the idea of normal, which in
its statistical meaning is equivalent to “probable” or “frequent” (Rost, 2021). When adopted in the medicalizing (or
pathologizing) language game, it poses ethical dilemmas.
As a language game that reflects vital worlds, bioethics as
a deliberative and dialogical exercise reconsiders differences, deficiencies, and impairments as challenges. It invites
us to explore the “testimonial injustice” that makes social
Salud Mental, Vol. 46, Issue 5, September-October 2023
and physiological norms inflexible in pursuit of a desired
objectivity never reached by professional work in mental
health. It places importance on recognizing and celebrating
the perfections of imperfection, as well as understanding
the power of mental resilience. To reach normality is to embrace abnormality and accept the variability, inconsistencies, and discrepancies that are naturally part of all human
life. As a concept it demonstrates the importance of lifting
oneself up to build a brighter and more hopeful tomorrow,
and encourages individuals to make conscious and proactive efforts towards revitalizing their well-being.
The bioethical enterprise is in essence the discursive
reformulation of relational contexts through the deliberative
process embraced jointly by those who help and those who
seek help (Lolas, 2002). In this endeavor, bioethics goes
beyond the simple application of principles and calls for
pro-active thinking and a thorough examination of normality and normativity.
Funding
None.
Conflicts of interests
The author declared they have no conflicts of interest.
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