Developing a Substantive Understanding of the Concepts of Normality and Pathology
by David Gard, Psychology

There is no dearth of student interest in the Introduction to Clinical Psychology course. This course focuses on adult mental illness, covering everything from depression to antisocial personality disorder. Many students dive right into the material, developing a penchant for diagnosis--e.g., their roommate clearly meets criteria for Obsessive-Compulsive Disorder or their ex-boyfriend has a severe case of Narcissistic Personality Disorder. Others come down with "Medical Student's Disease" where upon reading about a specific disorder, the afflicted student becomes certain he or she has that disease. It is therefore important in teaching this course to elucidate the basic concepts of normality and pathology.

In the past, a failure to spend adequate time on these concepts has produced dreadful results. Typically the rest of the semester is spent with students speaking of people with mental illness as "them"--members of a category wholly unrelated to our own "normal" group. Diagnosis is mistakenly perceived as a tool to separate our (normal) behavior from their (abnormal) behavior. Thus, without careful consideration of how diagnostic categories help and hinder our understanding of being human, it is easy to slip into a tautological position: a behavior is abnormal if it falls within a mental disorder diagnostic category.

I tried a number of strategies to underscore the fuzzy boundaries between normalcy and abnormality, but did not see marked change in understanding of this issue until I implemented the following series of individual and group activities. First, students spent the week after the first class writing down examples of when and why they concluded that a particular behavior they observed in someone else was "abnormal." Further, they devised the best way to decide (in general) if a behavior was normal or not. The next week, using student responses regarding their distinctions between normal and abnormal behavior, we brainstormed as a class on the numerous (often conflicting) ways of determining normality: statistical normality, the presence or absence of overt symptoms, cultural and societal norms, developmental norms, optimal functioning, and whether the individual feels there is a problem (to name a few). This sparked a lively debate about both the pros and cons of each method, as well as the inherent issues of socioeconomic, ethnic and cultural differences of "normality." In doing so, we ultimately were able to see the problem with using the term 'normal' to categorize behavior, given how contingent "normalcy" is on other variables. Instead, it becomes crucially important to specify how a behavior is pathological.

In the second part of the assignment, students formed groups of three or four, chose a particular diagnosis and read about the symptoms. Each group then met and discussed similar non-pathological manifestations of the symptoms found in everyday life (e.g., one symptom of depression is "severe depressed mood for two weeks in a row," while an everyday example would be feeling sad after a breakup). The next week each group presented the diagnoses to the class and also discussed everyday life examples of experiences that resembled the symptoms for that diagnosis. Interestingly, every group had several examples from their own lives that were quite common but did not necessarily cause them problems. For example, the ritualistic counting, which is seen in extreme form in Obsessive-Compulsive Disorder, and which causes a great deal of misery for those with the disorder, was present in a milder form in several students' everyday lives (e.g., not stopping a workout on the 13th repetition) without the distress or problems in their functioning. Overall, this part of the assignment allowed people to see that the symptoms that exist in all mental illness categories are in fact just severe versions of experiences that are common occurrences in the human condition. These experiences could only be called pathological if there was additional harm or clear dysfunction in their everyday life.

After implementing these two assignments at the beginning of the course I definitely noticed a change from previous years. First, there was a marked decrease in the frequency with which students referred to people with mental illness as "those people" or implied second-class citizens. Further, upon discussing individual cases, students were much more likely to question the reasoning for a particular diagnosis and whether giving such a diagnosis was beneficial for that person. Finally, at the end of the year each student wrote a summary of a case including a diagnosis. In addition to more students being thoughtful about the diagnostic process, for the first time in teaching this course, several students wrote about their rationale for the diagnosis given, not just the list of symptoms the individual presented with. Clearly, making these concepts more applicable to students' everyday lives was what was necessary to make concepts of normality and pathology central to their understanding of behavior and mental illness.