When I was just beginning my career as a therapist, I came across Allen Frances’ 2013 book, *Saving Normal. *Frances, who chaired the DSM-IV Task Force, argued that psychiatry was losing its grasp on the very notion of normality. During graduate school, the chair of our psychiatry department at the University of Pittsburgh happened to be leading the DSM-5 Task Force, so questions of diagnosis and classification were ubiquitous and captured my attention as well.
Frances’ central contention was that contemporary mental health pr…
When I was just beginning my career as a therapist, I came across Allen Frances’ 2013 book, *Saving Normal. *Frances, who chaired the DSM-IV Task Force, argued that psychiatry was losing its grasp on the very notion of normality. During graduate school, the chair of our psychiatry department at the University of Pittsburgh happened to be leading the DSM-5 Task Force, so questions of diagnosis and classification were ubiquitous and captured my attention as well.
Frances’ central contention was that contemporary mental health practice has pathologized ordinary human variation. In recent years, it seems that nearly everyone carries some form of diagnosis. The currently fashionable ones include adult ADHD, autism spectrum disorder, and complex trauma. Narcissism is commonly imputed to others but rarely to oneself. A decade or two ago, bipolar disorder dominated the diagnostic landscape; before that, it was multiple personality disorder, and so forth. As Joel Paris (2023) has observed, the history of psychiatry can be read as a history of diagnostic fads.
It appears, then, that the “normal” person has all but vanished. No one is simply normal anymore.
After graduate school, I developed an interest in psychoanalysis and undertook training in psychoanalytic approaches to psychotherapy. Psychoanalysis, it turns out, has a peculiar relationship to the idea of normality. While formal diagnosis occupies a relatively minor place in psychoanalytic thinking, with notable exceptions such as the work of Otto Kernberg, analysts are often among the first to discern pathology in others (and sometimes in themselves). The Harvard psychologist Henry Murray once remarked, “Were an analyst to be confronted by that much-heralded but still missing specimen—the normal man—he would be struck dumb, for once, through lack of appropriate ideas.” Merton Gill once told Robert Langs that he could “find an Oedipal conflict in a bowl of chopped liver.”
Indeed, when intellectual disagreement arises among analysts, diagnostic labels are often invoked as weapons rather than tools of understanding. Disputes over theory or technique easily become reframed as questions of pathology, with opponents subtly or overtly cast as disturbed, defensive, or regressed. This tendency, long remarked upon by observers of psychoanalytic institutions, reveals the enduring difficulty analysts have in distinguishing intellectual difference from psychological illness (Eisold, 1994).
If the concept of “abnormal” is to retain meaning, it must stand in contrast to something. And that something, psychiatry and psychoanalysis alike would do well to remember, is “normal.”
To define what is normal, we must first clarify what constitutes illness. Robins and Guze (1970) offered a scientific framework for doing so, proposing that mental disorders can be validated through a set of empirical criteria such as clinical description, laboratory studies, delimitation from other disorders, follow-up studies, and family studies. Implicit in this approach is that mental illness must be distinguished from normal variation by identifiable patterns of behavior that exhibit stability, course, and predictive value. Without a clear conception of what counts as illness, it becomes impossible to know where health begins.
In this sense, “normal” may best be understood as the absence of illness, a baseline state of psychological functioning not characterized by the symptom clusters, impairments, and maladaptive patterns that mark the 12 or so validated psychiatric conditions (Goodwin & Guze, 1989).
Kraepelin, whose work undergirds modern nosology, made a critical distinction between disease processes (Krankheitsprozessen), meaning endogenous, biologically rooted disturbances such as manic-depressive illness, and clinical pictures (Zustandsbilder), meaning constellations of symptoms arising from diverse causes but still recognizable as abnormal (Ghaemi, 2013). Both are departures from the norm, but each can be validated using the criteria later formalized by Robins and Guze. The Kraepelinian view implies that abnormality is not a matter of mere statistical deviation or subjective distress but of recognizable, recurrent forms of breakdown in the functions that normally sustain life and work.
Normal individuals, by contrast, demonstrate adaptability, emotional regulation, and the capacity for fulfilling relationships. They maintain employment, form attachments, and navigate social obligations without persistent dysfunction. It makes little sense to describe a person as mentally ill who enjoys stable social relations and professional success merely because he or she experiences occasional conflict, doubt, or ambivalence, which are hallmarks of ordinary human life. Indeed, such a person may need no treatment at all (Frances & Clarkin, 1981).
Yet within analytic circles, such distinctions are often blurred; “treatment” is offered to everyone. Psychoanalysis, at its best, helps people bear the inevitable conflicts of existence; at its worst, it can render all conflict suspect. To preserve the meaning of abnormality, we must allow space for the normal, i.e., the capacity to suffer, love, and work without disintegration.
Grinker & Grinker’s (1962) classic work on “homoclites,” those who cluster around the middle of the psychological distribution, offers a useful corrective. Grinker proposed that the vast majority of individuals are neither mentally ill nor exceptional but fall within a central range of adaptive functioning. The homoclite is neither a saint nor a sociopath, neither a hero nor a neurotic martyr, but an ordinary person whose personality is sufficiently flexible to meet life’s demands. The recognition of such individuals reminds us that the normal is not the absence of conflict or anxiety but the capacity to tolerate and integrate them without disorganization.
Psychiatry Essential Reads
To restore balance to the field, psychiatry and psychoanalysis must once again take seriously the study of normal psychological life. As Frances cautioned, the overextension of diagnostic boundaries threatens to erode our very conception of health. The task is not to deny the reality of mental illness but to define it rigorously, distinguishing it from the inevitable struggles of living with which each of us deals.
References
Eisold, K. (1994). The intolerance of diversity in psychoanalytic institutes. The International Journal of Psychoanalysis, 75(Pt 4), 785–800.
Frances, A. (2013). Saving normal: An insider’s revolt against out-of-control psychiatric diagnosis, DSM-5, Big Pharma, and the medicalization of ordinary life. HarperCollins.
Frances, A., & Clarkin, J. F. (1981). No treatment as the prescription of choice. Archives of General Psychiatry, 38(5), 542–545. https://doi.org/10.1001/archpsyc.1980.01780300054006
Ghaemi S. N. (2013). Taking disease seriously in DSM. World Psychiatry, 12(3), 210–212. https://doi.org/10.1002/wps.20082
Goodwin, D. W., & Guze, S. B. *Psychiatric diagnosis *(4th ed.). Oxford University Press.
Grinker, R. R., Sr, & Grinker, R. R., Jr (1962). “Mentally healthy” young males (homoclites). A study. Archives of General Psychiatry, 6, 405–453. https://doi.org/10.1001/archpsyc.1962.01710240001001
Paris, J. (2023). *Fads and fallacies in psychiatry *(2nd ed.). Cambridge University Press.
Robins, E., & Guze, S. B. (1970). Establishment of diagnostic validity in psychiatric illness: Its application to schizophrenia. American Journal of Psychiatry, 126(7), 983–987. https://doi.org/10.1176/ajp.126.7.983