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The role of diagnosis in counselling and psychotherapy
The role of diagnosis in counselling and psychotherapy

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3.2 Normality and abnormality

The division between normality and abnormality is highlighted when we consider ‘common mental health problems’. For example, we are all frightened of something and most of us worry about lots of things. These worries are not the same for everyone and differ over time. For example, the worries of the adolescent may not be the same as those they experience later in life when they become the parent of an adolescent. Also, most of us become sad when someone we know dies or we lose control in our lives. Moreover, when we lose control and become sad this also worries us. Misery becomes a ball of wax, which picks up distressing signals from our outer lived context and spirals of distress, insecurity and self-doubt from our inner life. Fear and sadness coexist and reinforce one another. Making distinctions between them in practice becomes difficult.

Misery thus comes in all sorts of shapes and sizes, depending on the person and their context. In the light of these regular shifts in our emotional life, what sense does it make to turn sadness and fear into medical diagnoses? What if people are oblivious to problems that ought to worry them? Hence the comic variation on Kipling’s verse found in graffiti: ‘If you alone can keep your head when all around are losing theirs, then you clearly do not understand the situation!’ After all, fear is a normal physiological response to threat. Similarly, sadness is a normal response to loss.

Thus life should frighten us sometimes, just as it should depress us. Why are anxiety and depression medical conditions to be diagnosed and split off from ordinary life? Why should recurrent ordinary human suffering, which simply comes with living and dying, turn as all into patients? For example, the capacity to be sad reflects a form of mature human development; a point emphasised by the psychoanalyst, Donald Winnicott:

The capacity to become depressed, to have a reactive depression, to mourn loss, is something that is not inborn nor is it an illness; it comes as an achievement of healthy emotional growth … the fact is that life itself is difficult … probably the greatest suffering in the human world is the suffering of normal or healthy or mature persons … this is not generally recognised.

(1988, p. 149, emphasis added)

Winnicott’s final lament is interesting, because he does not explain what he means precisely (‘generally recognised’ by whom?), but we could surmise that he is complaining of an increasing assumption in the late twentieth century (and still with us) that misery is pathological and should be treated. For him, in a sense, we are all ill (thus making it normal not abnormal) and the question is an existential one: how should we make sense of, deal with or endure misery in our lives?

‘Neurosis’ can be thought of as blocked creativity when it dominates the person’s consciousness, takes on a life of its own of self-absorbed, socially disabling ‘psychopathology’ and diverts them from addressing the existential challenges noted above. ‘Mild to moderate depression’, ‘phobic anxiety’ or ‘agoraphobia’ can be treated as illnesses by doctors and psychologists or they can be addressed as provocations about the patient’s life and invitations to him or her to be more productive. If these symptoms of ‘illness’ were suddenly removed, where would the person be in their life? What tough aspects of their life might they need to face up to? What opportunities could be taken or what choices might need to be made?

Pause for reflection

Think about your own life experience in the light of these questions. Consider a time in your life when you experienced fear or sadness. In your view was Winnicott saying something important or do you disagree with his conclusions? If you agree or disagree (or a bit of both), consider why.