What is normalising?
Normalising is the art of reframing the problem from ‘weird’ and ‘alarming’ to ‘expectable’ and ‘soluble’. Expectable in terms of the cognitive and emotional characteristics of clients, the life problems that triggered the disorder, and the physical result (the anxious state). Soluble in terms of addressing, one by one, their thoughts and emotional judgments, physical state, and difficulties in life.
Underlying clients’ suffering is the belief that they are alone in their distress, and that what they have is a stigma. The attitude many people – including some medical professionals and psychologists – take towards mental health issues may reinforce this judgment. Namely, that they are in fact ‘abnormal’, even ‘pathological’. We see this in the elaborate classifications of DSM-V, the codebook used by psychiatrists all over the world to classify what the book calls ‘mental disorders’. To have one of those still implies shame and weakness in many quarters.
In fact, in any week in England one in four people will report a mental health issue. Approximately half the entire population will report an issue at least once in their lives. Of the rest, many will struggle with mental health but will not seek help. On that basis we might say that these ‘disorders’ are ‘normal’, while mental health is the exception. In explaining clients’ predicaments to them, we are helping them to grasp this fact.
Common mental health problems
One of the most frightening things about having a mental health problem is how crazy it can all seem. Panic attacks in which your body seizes up; depressed moods that make the world seem empty and meaningless; obsessions that keep you doing the same damned thing hour after hour. Too often, the client ends up worrying about where it is all going to end. The anxiety that results creates a spiral of worry that compounds the original issue. The burning question many clients have is: what the hell is happening to me? Why this? Why now? Clients naturally seek answers, and failure to address this may block people from taking that first step towards recovery.
Earning the client’s trust in therapy
Related to these questions is another concern: will a psychotherapist be able to help me? Do they know what they are doing? Can I trust them? This concern is especially salient if the visitor has never been inside a consultation room before. It’s even more pressing if she has, and been turned off by the vague, or disturbing, answers so far received from the professionals.
In framing the answer in terms of normalising problems the therapist is not simply offering re-assurance. She is also providing a route map. One that takes in the reasons for the problem, and shows what the solution might be. Along the way, she normalises the predicament the client is in.
Let us take a case of general anxiety, the most commonly reported mental health issue. Lisa is a woman in her mid-thirties, with a history of over-thinking and worry dating back to teenage years. Her father, let us say, has a similar history. Perfectionistic and self-doubting, Lisa has a demanding job in financial services in which faultless work is expected, and mistakes punished.
One day, in struggling to meet an unrealistic deadline, Lisa notices panicky sensations. Following that, she develops the thought that she is ‘cracking up’ and could lose her job. By degrees, the panicky feelings worsen and she worries she won’t be able to carry on. Unable to sleep, she goes to her GP who offers Citalopram, an SSRI drug commonly prescribed for anxiety and insomnia. Unfortunately, the drug makes things worse and her worries increase. Her line manager is unsympathetic when she phones in sick, and gives Lisa the impression that her job is on the line unless she sorts herself out quickly. Desperate, she attends for therapy.
After a brief survey of events over the past few months, the therapist might say something like this:
“There are several factors that go towards your problem. Firstly, that you have inherited a disposition towards anxiety. This may be genetic, or maybe as a child you modelled some of your father’s traits. Or it could be both. This is a common reason people fall into anxious habits – habits you have developed since your schooldays.
Fortunately, these habits can be changed. And one thing I would like to work with you on changing are your thoughts about yourself and about work – especially the thought that drives you towards perfectionism. Another thought I have been hearing about is your worry about the panicky feelings you’ve described. That is entirely normal, but counter-productive, as each time you have an anxious thought about your panicky feelings they will get worse.
We’ll do some work on breaking this loop. First, by showing you how you can defuse from anxiety, then by changing your thoughts about it, also by showing you ways that you can calm yourself. Finally, there is workplace stress. Your difficulty there is that your employers frequently present you with projects that can’t meet their deadlines. That is one trigger for your anxious thoughts at work, and I would like to work with you on how you can negotiate some realistic targets with your line manager. Is this a plan that would interest you?”
In providing answers to two questions: ‘What is wrong with me?’ and ‘How do I get out of this?’ the therapist has a window of opportunity, in which she explains how the problem came to appear, while also pointing to the achievable steps towards resolving it. Along the way normalising the problem by pointing to its common origins, what research has revealed about it, and the tried-and-tested procedures for addressing it.
Properly delivered these answers will provide the client with understanding, clarity of purpose, feelings of relief, as well as a motivation to start on the work of therapy. That way the path to change lies open.