The insane are not ‘us’: on normality, psychiatric diagnoses and Norwegian terrorism

After the Oslo bomb and Utøya massacre there is a strong demand of declaring the perpetrator, Anders Behring Breivik, mentally disturbed. Yesterday, the swedish psychiatrist and profiler Ulf Åsgård claimed that Breivik suffers from several personality disorders, among them psychopathy, narcissism, borderline and, notably, obsessive–compulsive personality disorders. This was his judgement after having read a few pages in Breivik's ideological manifesto ‘2083: a european declaration of indepencence’.

The desire to declare Breivik mentally disturbed is quite understandable. He is a tall, blond scandinavian, just like me (well, I'm not that tall, and my hair colour is more like the brown rat, but that is beside the point), but he can't possibly be like me because I would never even think of killing a single person, less massacre young men and women at a youth camp. Following that logic, Breivik can't be normal, since normal people are not mass murderers. He can never be one of ‘us’; he must be insane. (If the perpetrator would have been a muslim, he or she would not have been one of ‘us’ anyway, and the desire to regard him or her as insane, I suspect, not that pressing.)

But what do we mean by ‘normal’? What we consider normal can be judged from at least four points of view. First, the statistical norm defines normality as an interval on a distribution of properties that, at least in theory, can be measured. For example, a person over 2 meters is considered unusually tall. Intelligence is another example: less than 70 points on the Wechler Adult Intelligence Scale (WAIS) is considered that far from the population average of 100 points that it is taken as a indication of mental retardation (in fact, this is the definition of mental retardation according to DSM-IV).

Second, social norms defines what is socially acceptable, and what is not. Social norms are contextual, culturally dependent and varies considerably over the world. Of course, no society allows killing people, at least not of their own kind. However, at war, things are different, and Breivik is at war, at least according to his manifesto.

Third, ideal norms are based on some idea of good health and psychological functioning, for example ‘a state of somplete physical, mental, and social well-being and not merely the absence of disease or infirmity’ (WHO, 1946).

Fourth, people that suddenly change in an unpredictable way, although still within statistic, social and ideal norms, are often considered abnormal or at least unusual. Even becoming ‘normal’ can be ‘abnormal’: consider, for example, the psychotic patient that suddenly behaves perfectly normal, or the Alzheimers patient that suddenly remembers everything. This marked change compared to his or her baseline of everyday functioning would certainly be considered abnormal.

Thus, what is ‘normal’ depends on how we see normality. In the case of Anders Behring Breivik, all and none of the above views applies. Of course, he can be a complete lunatic with a severely screwed worldview, emotionally disturbed and without ability of empathy, but he might as well be a consequent, determined man taking the necessary, rational consequences of his political convictions. He killed at least 68 people in cold blood, yes, but even ‘normal’ people do that in war. What is normal depends on the context.

So, is he a narcissistic, obsessive–compulsive psychopath with clear borderline tendencies (or, in other words, completely screwed up), as psychiatrist Ulf Åsgård claims? First, this judgement can not be based on a few pages from his manifesto. It requires meeting Breivik in person, interviewing and observing him. Second, psychiatric diagnoses, and particularly personality disorders, are pretty arbitrary labels of certain behaviour.

Since the 1970:s, when the dominating psychodynamic theories were challenged, psychiatry has worked hard to become a part of medicine and natural sciences. Among other things, this meant revising the diagnostic system (Diagnostic and Statistical Manual of Mental Disorders, DSM) so that it would resemble medical diagnoses. Consequently, all etiology (causes) were removed from the psychiatric diagnoses in the third revision of DSM, published in 1980. Psychiatric diagnoses are merely descriptive.

In this way, psychiatric diagnoses resembles medical diagnoses. A diagnose is a list of symptoms, which, when present, indicates some kind of underlying problem. An inflammation, for example, is a symptom of either an infection or a wound. After finding the correct diagnose, the physician treats the cause of the symptoms, in this case the infection or wound.

An important feature of medical diagnoses is that they are largely decontextualized. It doesn't matter if you broke your leg falling down the stairs or being hit by a car, the symptoms are the same, the leg is still broken and the treatment is the same in both cases.

However, this is hardly true for psychiatric diagnoses. First, since they are only descriptive, there can be no clear cause in a psychiatric diagnose. For example, the symptoms of depression has no equivalent known cause as the symptoms of a broken leg. On the contrary, several different causes can hide between a single diagnose, and the same cause can give rise to different diagnoses. Psychological distress is caracterized by equifinality (different etiologies behind same symptoms) and multifinality (same etiology behind different symptoms).

Even worse, expressions and conceptions of psychological distress differs between cultures. What we know as ‘depression’ in the western world is expressed in rather different ways in other parts of the world. For example, on Sri Lanka, depressed people often report bodily pain, particularly under their feet. This, of course, raises the question if people on Sri Lanka really are depressed? Or the other way round, how do we know that the conglomerate of symptoms we call ‘depression’ is nothing but a culturally dependent expression of psychological suffering?

Personality disorders are defined as ‘an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the culture of the individual who exhibits it’ (DSM-IV), but in reality they are even more fluid than ordinary (so called ‘axis I’) diagnoses. In the end, what qualifies as a personality disorders is what the working groups of the American Psychiatric Association considers being a personality disorder. Thus, the personality disorders have changed over time, with disorders like ‘sadistic personality disorder’ and ‘masochistic personality disorder’ being removed in DSM-IV (1994). It seems that personality disorders will be completely revised in DSM-V, including the very definition of ‘personality disorder’!

So, what can we gain from declaring the terrorist Anders Behring Breivik mentally disturbed or suffering from a severe personality disorders? Nothing much, I'd say. A psychiatric diagnose does not add anything to our understanding of why he did what he did, since psychiatric diagnoses are stripped of all etiology. However, a diagnose frees us of the need to understand; if he is insane, you can't understand anyway. Finally, and most important, if he is insane, he is certainly not one of ‘us’.

The 14th Biennial Conference of the International Society for Theoretical Psychology

Faculty of Education,
Aristotle University

Two weeks ago, I attended the 14th Biennial Conference of the International Society for Theoretical Psychology, a pretty small conference with some 160 participants from all over the world, held in Thessaloniki (Θεσσαλονίκη) during the greek financial crisis, with general strikes, protests, riots and police interventions. Although we did not experience much of that on the Aristotle University campus, i intend to comment on the greek situation at the end of this blog post.

This was my first academic conference. An academic conference, or symposium, is a conference where researches present and discuss their work, and this is usually done by presenting a ‘paper’ written for the conference. The first thing that struck me was how these papers were presented. With few exceptions, they were actually read out loud, word by word, with no or very few visual aids. Some presenters accompanied their reading with beamer presentations, sometimes with the actual text of the paper projected in a tiny, unreadable font.

Reciting the paper worked for some presenters, but for the most part, it didn't. As a pretty experienced lecturer, I tend to think that the aim of an oral presentation is to mediate my idéas and theories to the listener, that is, carefully guiding the audience into my world of terms and ways of thinking. Reading a paper out loud is not always the best way to do this. On the contrary, academic writing is often an exercise in complex formulations and precise nuances, something that is easily lost when reciting a text. It is very difficult to do justice to a text, particularly if English is not your native language.

Still, I get the idea that ‘presenting a paper’ at a conference means, litterary, to read the paper out loud. The paper is a work in progress to be discussed. However, since discussions constrain to a few minutes (at best) at the end of the presentation, reading a paper out loud seem like a waste of time. ‘Give me the text and I'll read it myself’, was something I thought more than once. Better consider the presentations a didactic situation, as any other lecture at a university (although that does not mean things necessarily get better).

The second thing that struck me was that the world ‘dialog’ is the current buzz-word in theoretical psychology circles. This was not only reflected in paper titles such as On dialogue in educational contexts, Rethinking dialogicality, The role of rhetoric in a dialogical approach to thinking, and Twelve sensitising questions for examining dialogicality, but also in the seemingly mandatory references to either Lev Vygotsky or Mikhail Bakhtin.

This is an aspect of what is sometimes refered to as ‘the sociocultural turn’ in psychology, or the view that culture, as a ‘web of meanings’, precedes psychology. Culture is not something that is added to the biological constitution of man, but the very foundation of mankind itself. All human understanding is rooted in culture, and thus social and interpersonal. All knowledge is socially constructed, a result of interpersonal processes, and ‘objective’ knowledge is simply a fallacy. I guess this is where the ‘dialogicality’ comes in, as a kind of umbrella term for all those interpersonal processes in which we construct our knowledge of ourselves, others and the world.

Manolis Dafermos (Μανόλης Δαφέρμος), assistant professor at the University of Crete (Πανεπιστήμιο Κρήτης), tried to put this ‘dialogicality’ in a historical context with his paper Greek philosophical dialogue and modern psychology, where he compared the ancient greek dialogue of Plato with its conteporary conception in psychology. I will return to his paper in future posts.

A large number of papers were presented at the conference, of which I could attend only a small fraction. To me, the most worthwile presenter was Stavroula Tsinorema (Σταυρούλα Τσινόρεμα), professor of contemporary philosophy at the University of Crete (Πανεπιστήμιο Κρήτης), who presented a paper titled The body-mind problem on the interface between psychology and epistemology: a philosopher's perspective. The body-mind problem and related questions of consciousness happen to be part of my greatest interest, and professor Tsinorema made a thorough review of the concept, from Aristoteles, over René Descartes, to modern neuroscience.

Though, the most rewarding aspect of the conference was not the presentations, but meeting and chatting with all those like-minded researchers, not to mention the celebrities within the field of theoretical psychology. I must admit that I felt pretty proud and respectful when professor Jeff Sugarman approached me, gave me his card and told me to get in touch if I had any questions (some half an hour before I had mentioned that I was reading his and Jack Martins work on hermeneutic psychology).

Of course, there were also some gossip, like who-has-said-and-done-what and who-sleeps-with-whom. I guess that is a part of all human activities, including academic conferences.

Finally, as I mentioned in the beginning of this post, this conference was held in Greece during the protests and riots regarding the austerity measures the greek government is forced to implement. On tuesday, there was a general strike among all government employees, and about one third of the conference participants did not make it to the keynote speaker from their hotels since all public transportations stopped. Athanasios Marvakis (Αθανάσιος Μαρβάκης), the conference general, informed us on the situation. There is a strong feeling among the greeks that the austerity measures are unjust, party because greeks in general can not see their part in the crisis, party because the austerity measures are unequally implemented. As the anonymous economist behind the blog Redesigning the foot writes:

Imagine a place where one person earns 91,000 euros and 9 others earn 1,000 euros. Now try and tell these people that, as their average wage is 10,000 euros, they are earning too much and so they must all accept a cut in their wages. How would you expect them to react?

This economist, who calles himself Albert John on twitter (I have tried to figure out who he, or she, is), claims that the Greek crisis actually is due to the structure of the Euro. In fact, he argues quite convincingly and I really recommend his blog, since even a non-economist like me can understand how things stick together. That said, I am thankful that Sweden chose to remain outside the Euro.

Theoretical psychology and the subject matter of psychology

This blog, named Theoretical Psychology, is the English counterpart of my swedish blog Psykologidoktoranden (“The Psychology PhD Student”). For quite a while I have felt the need to write in english, for two reasons. First, the academic language, at least in psychology, is English. I might as well get used to that reality. Second, my interest in theoretical psychology and philosophy is not shared by many within the discipline of psychology, certainly not in Sweden. Networking within the field of theoretical psychology, is probably best done on an international basis.

Scholars and laymen familiar with psychology probably recoqnize numerous subfields of psychology—developmental psychology, neuropsychology, personality psychology, social psychology, psychophysics, et cetera—but theoretical psychology is less known. I actually learned about it last year, after seven years as a scholar in psychology.

Theoretical psychology, at least according to Wikipedia, “is concerned with theoretical and philosophical aspects of the discipline of psychology”. It is often described as a interdisciplinary field that involves not only all fields of psychology, but also philosophy, history, sociology and antropology. However, I prefer to look at it as mainly meta-theoretical psychology, where the crucial question is what psychology really is about in the first place. Theoretical psychology is about the very foundations of disciplinary psychology itself.

What is psychology? This is a justified question since the subject matter of psychology is not so easily defined, particularly compared to disciplines like geology (rocks) or zoology (animals). Often psychology is defined by its methods (the psychological experiment and sophisticated statistical procedures) or simply—although seldom explicitly—defined as “what psychologists do”. Ever since William James and Wilhelm Wundt (the “fathers of psychology”) psychologists have argued over what psychologists should do, or not should do. Is psychology about experiences, consciousness, behaviour, mental processes, brain functioning, or something else?

The essential problem with any attempt to define the subject matter of psychology is the exclusion of all other views on psychology, which de facto is being practiced at universities all over the world. At the end of the day, defining psychology as “what psychologists do” might not be that bad after all. Unfortunately, this ends up in psychology being more of a tradition than a clearly demarcated discipline. Traditions tend to resist change.

Within the American Psychological Association, Division 24 is concerned with the theory and philosophy of psychology. The divisions of APA are numbered in sequential order, and the 24th division was formed in 1962. It has some 500 members, which should be compared to over 154,000 members of the APA. The International Society for Theoretical Psychology (ISTP) has some 200 members worldwide (that is, subscribers to the paper version of the journal Theory and Psychology). Psychologists, in general, do not trouble themselves with philosophical questions about psychology. Instead, implicit or explicit, they accept the basic assumptions of mainstream psychology: empirism, materialism and reductionism.