In many ways, the entire Western healthcare system is built around normalisation.
The fact that it is the job of ‘the system’, and all those that work within it, to identify those people who are ill, sick, or suffering, and to offer them a cure, is so deeply entrenched in the way health services work that it would be hard to imagine it otherwise. But imagine it otherwise we must, or else the more problematic aspects of the approach remain hidden.
Firstly, we should remember that normalisation is a social construct. What this means is that there is no object that you can point to to say “that is normalisation right there”. It is an idea; an invention, based on a set of principles that have their own history. Over time, people’s attitudes change and what was perhaps abnormal 100 years ago, might be perfectly normal today. Think of homosexuality and depression, for example.
Because it is a social construct, it is very much the product of the people and the times in which it was created and developed. For instance, normalisation could only become a ‘thing’ when we had enough epidemiological data on the population to know what the spread of human factors like height and weight were. The history of this is quite recent — dating back only to the 18th century — but, importantly, it is closely tied to government attempts to better know the population in order that we, its citizens, could be better managed.
Decisions about who and what constituted the norm, were essentially statistical assessments based on prevalence data. So the boundary between what is normal and what is abnormal is only a matter of degrees. Hence why it is so easy for these boundaries to change.
Where normalisation becomes really problematic though, is when we move beyond benign human features like height and weight, and start considering things like skin colour, gender, strength, reasoning, and intelligence, and the history of medicine’s normalisation of these things is really quite depressing.
The stigmatisation of people who have been labelled as deformed, deviant, disruptive, or difficult is now well known, as is the way these ‘traits’ gain official recognition through the process of medicalisation. But the catalogue of spurious medical labels that have been given to things that have no basis in medicine or healthcare and have, instead, entirely political motives, is extensive. The diagnosis of malingering being one prime example.
For decades, governments have sought medical advice on whether a person has an organic reason for their pain, and doctors, physiotherapists and others have been happy to oblige, not least because the failure on the part of medicine to locate the source of the person’s pain within their biological body might amount to a failure of medicine itself. So we invent endless tests, scales and scores to provide the answer, without ever questioning the normalising process going on in the background.
Some of the most powerful work on this was done by Erving Goffman in the 1960s. Goffman showed that there were significant negative consequences associated with being labelled as ‘abnormal’, not least being that it puts the person who is labelled in an almost impossible position: accept the label, and the person has to accept all of the social judgements that then get levelled at them (spastic, handicapped, ‘mental’, stupid, retarded, etc.); but resist the label and risk being labelled anew (as deviant, disruptive, in denial, mad, etc.), and forced into unwanted treatment, rehabilitation and remediation.
The history of normalisation in mental health is really problematic (remember One Flew Over the Cuckoo’s Nest, for example), but the history of normalisation close to physiotherapy is not much better, especially when we look at the way physiotherapists have contributed to the labelling and stigmatisation of physical disability over the last century.
Was there ever a more loaded term in the medical lexicon than ‘standard deviation’?