H567/03 Section A - Historical views, abnormality and classification

Changing explanations and care

An explanation of mental illness influences both how a person is treated and who is considered responsible for helping them.

In some historical communities, unusual experiences were interpreted through supernatural or spiritual accounts, such as possession. Responses could involve religious rituals or punishment. Such accounts were never the only views: ancient bodily explanations, including the idea that an imbalance of humours affected mood, also existed. Neither a single supernatural belief nor one continuous story of progress describes every society or period. Evidence of a hole in an ancient skull does not, by itself, establish that its maker intended to release a demon.

In parts of early modern Europe, confinement in institutions placed emphasis on custody and control. Overcrowding, restraint and exclusion could remove people from ordinary social life. This reflected social judgements about order and danger as well as attempts to provide care. Conditions varied; it would be inaccurate to claim that every institution treated every resident identically.

Humane reform offered another view. The York Retreat opened in 1796 and became associated with moral treatment: a supportive routine, personal relationships and milder methods of care. Here “moral” refers to a psychosocial approach to the person, rather than simply blaming them for being immoral. Humane aims did not make all later institutional care humane, and support and control could coexist.

The medical model locates mental disorder in illness processes and encourages clinical classification, investigation and treatment. Twentieth-century developments included biological treatments and psychological therapies, followed in many settings by greater emphasis on community care. These approaches can coexist. A modern biopsychosocial explanation considers biological vulnerability, thinking and learning, relationships and living conditions together.

Changes also involve values: whose experiences count, whether care is voluntary, and how dignity and autonomy are protected. Spiritual meaning may be important to a person even when they receive clinical care. Respecting that meaning does not require treating a spiritual belief as a proven biological cause, or dismissing suffering as a moral failure.

Four ways of defining abnormality

Abnormality can be defined in several ways, each drawing attention to something different.

For statistical infrequency, define the population and measure before deciding what is rare. A score rare in one age group may be ordinary in another. A cut-off converts a continuous distribution into a category; changing the cut-off changes who is classified.

For failure to function, consider the person's situation rather than assuming inability is wholly internal. Someone unable to attend work because transport is unavailable differs from someone whose persistent distress prevents attendance despite access. Functioning also involves the person's own needs and goals, rather than only an employer's judgement of productivity.

Distress, dysfunction, duration and context help distinguish a disorder from an unusual preference or temporary reaction. Distress alone is insufficient: grief can be painful without automatically indicating a disorder. Conversely, some people experiencing a disorder do not recognise it as distressing. Definitions are tools for reasoning, rather than four interchangeable diagnostic tests.