Posts Tagged parenting
Sexual Disorders are Not Illnesses (Part 2)
Posted by Phil in A Behavioral Approach to Mental Disorders on July 21st, 2010
In my last post I described frotteurism, which the APA lists as one of their mental disorders/illnesses. The central theme of this blog is that there are no mental illnesses – that mental illnesses are essentially psychiatrists’ ways of conceptualizing ordinary human problems for the purposes of consolidating turf and legitimizing the use of drugs to alter people’s behavior and mood.
This is not to say that the behaviors in question are not problems. They certainly are. Frotteurism is a case in point. A man who uses the crowd cover of trains and buses to press his genitals against non-consenting females clearly has a problem. The question is: how can we explain this behavior? Why does he do it?
Socialization is the process by which we acquire the skills necessary to function in society. The newborn has no sense of the needs/rights of others. He is a bundle of pure and utter selfishness. During childhood his parents and other significant adult figures instill in him an appropriate measure of regard for other people’s rights and needs. They also help him acquire an appropriate level of personal control. During his formative years he acquires the ability to control his immediate needs, to respect the rights of others, and to pursue the attainment of long-term goals. This is a complex process, but it is generally achieved through the long-established practices of consistently applying appropriate rewards and punishments and through the process of good example (role modeling).
Now it’s a fairly obvious fact of life that this socialization process isn’t always entirely successful. We have all encountered adults who are “spoilt brats” or who routinely afford more priority to short-term than to long-term goals, or who blatantly disregard the rights of others.
The reasons for these failures in socialization are as varied as the population. Sometimes the parents simply didn’t know what they should have been doing. Other times they were drinking and drugging and just didn’t care. Other times there was conflict and tension between the parents, and the child “slipped through the cracks.” Other times the parents themselves weren’t adequately socialized and so the role modeling was inadequate. And so on.
In order to understand why an individual is deficient in these areas, one needs to examine the individual case closely. So in the case of frotteurism, we have an individual who routinely disregards the rights of females (i.e. the right to be free from molestation) and who probably lacks the social skills necessary for normal heterosexual interactions.
The explanation of his behavior is:
1. Like almost all men he has an internal drive to make genital contact with women.
2. He has not acquired the skill/habit of controlling and channeling this drive in socially appropriate ways.
Note that this is not a complete explanation of the behavior in question. If we wish to understand why an individual behaves in a certain way, we must devote a good deal of time and energy to studying and examining the individual case. There are no shortcuts in behavioral analysis.
This is in marked contrast to the APA’s implied position, i.e., that he engages in this behavior because he has a mental illness called frotteurism. The facile nature of this explanation is seldom articulated, but this kind of simplistic thinking underlies the response of the mental health system (and frequently of the judicial authorities) to these individuals.
Next Post: More on sexual disorders.
Conduct Disorder and Oppositional Defiant Disorder
Posted by Phil in A Behavioral Approach to Mental Disorders on April 17th, 2009
CONDUCT DISORDER
The essential feature of Conduct Disorder, according to the APA, is a “repetitive and persistent pattern” of rule breaking or activity which violates other people’s basic rights. The manual identifies four broad categories of behavior under this heading: aggression; destruction of property; theft or deceitfulness; and serious violation of rules.
DSM goes on to state that individuals with this disorder display little concern for the feelings or welfare of others, are frequently callous and indifferent to other people’s pain and loss, and show little in the way of feelings of guilt or remorse. Poor frustration tolerance, irritability, temper tantrums, and recklessness are cited as frequently associated features.
Diagnostic Criteria for Conduct Disorder
The notion that the kinds of serious misbehaviors described above are caused by a mental disorder represents an enormous departure from common sense and conventional wisdom. For this reason, the complete list of DSM criteria are set out below, to enable the reader to clearly assess the APA’s position on this matter. The manual lists the following fifteen items, three of which must have been present in the previous twelve months:
Aggression to people and animals:
(1) often bullies, threatens, or intimidates others
(2) often initiates physical fights
(3) has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)
(4) has been physically cruel to people
(5) has been physically cruel to animals
(6) has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery)
(7) has forced someone into sexual activity
Destruction of property
(8) has deliberately engaged in fire setting with the intention of causing serious damage
(9) has deliberately destroyed others’ property (other than by fire setting)
Deceitfulness or theft
(10) has broken into someone else’s house, building, or car
(11) often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others)
(12) has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery)
Serious violations of rules
(13) often stays out at night despite parental prohibitions, beginning before age 13 years
(14) has run away from home at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period)
(15) is often truant from school, beginning before age 13 years
(DSM-IV, 90)
It is clear from these criteria that what is being described here is plain old-fashioned criminality. A serial rapist, for instance, who threatens his victims with a weapon meets criteria 1, 3, and 7, and is therefore suffering from a mental illness. A person who smashes car windows to steal from the glove compartment, who steals from stores, and who bullies and intimidates his family meets criteria 1, 11, and 12, and is also suffering from a mental illness. Just about any kind of criminality you care to imagine is covered by these criteria. In other words, a “diagnosis” of Conduct Disorder means habitual criminality. The APA is not saying that some habitual criminals have a mental illness. Rather, they are saying that habitual criminality in and of itself constitutes a mental illness.
Prevalence
APA’s estimates of prevalence rates are high: 6 to 16% for males, and 2 to 9% for females. DSM goes on to state that Conduct Disorder is “one of the most frequently diagnosed conditions in outpatient and inpatient mental health facilities for children.” The so-called disorder is not confined to children, however, and the manual makes it clear that the diagnosis can be assigned to adults if they meet the criteria.
Former Times
As with most mental health diagnoses, the critical issue is not whether the misbehaviors in question represent serious problems. Clearly they do. Rather, the issue is whether or not they should be conceptualized as mental disorders. Former generations would have used more conventional terms, such as delinquency, villainy, vandalism, crime, brutality, etc., to describe these kinds of activities, and as with ADHD, would for the most part have identified lax or inconsistent parental discipline as the proximate cause. By calling these misbehaviors a mental disorder, the APA is promoting an entirely different way of conceptualizing these problems, and in particular is promoting the notion that these kinds of problems need to be treated by psychiatrists and other mental health workers. The assignment of the diagnosis also implies that the problem is something inherent to the child, and downplays the role of the parents, or indeed of other factors.
The high prevalence rates cited earlier make it clear that the individuals diagnosed with Conduct Disorder represent a sizable proportion of the government statistics mentioned in an earlier post. It is tempting to wonder if politicians and other interested parties who endorse these statistics realize that many of the “afflicted” individuals whose cause they champion are included purely on the basis of a persistent pattern of serious misbehavior and delinquency.
One noteworthy feature of Conduct Disorder is that it has not garnered as much public acceptance as ADHD, even though conceptually there are multiple parallels. The likely reason for this is a recognition on the part of the APA that ascribing such serious misbehavior to a mental disorder would not be palatable to the general public, and that a more lengthy “softening-up” period may be necessary before such a concept would be widely accepted.
OPPOSITIONAL DEFIANT DISORDER
DSM-IV-TR defines Oppositional Defiant Disorder as a “recurrent pattern of negativistic, defiant, disobedient and hostile behavior towards authority figures…” (100), characterized by temper tantrums, arguing with parents and other adults, defiance, refusal to comply with requests and directives, deliberately annoying other people, blaming others for his/her own errors, and being spiteful and vindictive.
The manual lists eight specific criteria, four of which must be present for the diagnosis to be assigned. The eight criteria items are listed below:
(1) often loses temper
(2) often argues with adults
(3) often actively defies or refuses to comply with adults’ requests or rules
(4) often deliberately annoys people
(5) often blames others for his or her mistakes or misbehavior
(6) is often touchy or easily annoyed by others
(7) is often angry and resentful
(8) is often spiteful and vindictive.
There is little to be said about this so-called mental disorder that has not already been addressed with regards to ADHD and Conduct Disorder. The fundamental question is why this kind of misbehavior, which former generations would have characterized as “being a spoiled brat” should now be considered a mental disorder.
And as with the other so-called mental disorders, the answer is because the APA say so. This is in marked contrast with general medicine, where the identification of a disease usually represents an enormous breakthrough in terms of understanding and treatment. The idea of conventional medical researchers sitting in committees and inventing illnesses by voting and consensus would be considered laughable. Yet that is exactly what the APA has been doing for the past half century with successive revisions of the DSM.
As with other so-called disorders discussed earlier, the diagnosis clearly implies that the problem is something inherent in the child. This effectively lets the parents off the hook, reduces expectations, and in practice encourages a kind of self-centered egotism on the part of the child which usually persists into adulthood. The “disorder” also serves as a portal diagnosis, and typically other mental disorders (e.g., depression, ADHD) are “uncovered” as the child receives “treatment”.
In this context it is worth noting a major weakness of the entire DSM system i.e. the “all or nothing” nature of the so-called diagnoses. In conventional medicine, the all or nothing framework is generally valid. You’ve either got meningitis or you haven’t. There are, of course, degrees to which the infection may have developed, but even a mild case of meningitis is a serious condition, and a dichotomous approach is warranted – not only for treatment/administrative reasons, but also because it accurately reflects the objective reality.
The behaviors outlined above, however, as diagnostic of Oppositional Defiant Disorder are emphatically not dichotomous. Each item very clearly admits of degrees. Consider the first item on the list: “often loses temper”. This could mean anything from a few irate foot-stampings, to wholesale mayhem. Additionally, the word “often” is subject to quantification. Does often mean daily? weekly? monthly? Similar considerations apply to the other items on the list, and to the APA’s requirement of four or more items to make a diagnosis. Why not three, or five?
The fact is that childhood defiance is not a simple unified construct, and is emphatically not dichotomous. It contains multiple components, each of which admits of degrees and could be quantified. In their drive to “medicalize” all human problems, the APA shoehorned this phenomenon into a simplistic yes or no format to facilitate the process of “diagnosis.” The result is not a genuine understanding of the child’s/family’s problem, but a travesty that serves only the interests of the psychiatrists and the pharmaceutical companies. The same criticism can be leveled at almost all the so-called diagnoses in DSM.
Next Post: Anxiety Disorders
How Can They Just Invent Illnesses?
Posted by Phil in A Behavioral Approach to Mental Disorders on March 25th, 2009
The notion of a professional group such as the APA sitting in their councils and committees inventing illnesses for themselves to treat seems so preposterous that a measure of disbelief on the part of the reader is understandable. In its historical context, however, the development is not so surprising. The original 1952 DSM was very simple and unpretentious, and whilst part of the APA’s motivation in drafting the document was undoubtedly to draw some credibility and respectability to their profession, there is at the same time nothing to suggest any great drive at that time towards aggrandizement or service expansion. However, having agreed in 1952 that neurosis was a form of mental disorder, it was inevitable that subsequent revisions of the manual would attempt to define this feature further and look for subdivisions of the general category. This, of course, is exactly what has happened, and the current version of DSM lists literally dozens of disorders of this sort, although the general term neurosis is no longer used. (For an interesting discussion of this matter, see Karen Franklin’s post at In The News.)
Trichotillomania is a case in point. DSM-IV describes trichotillomania as a mental disorder in which the victim, usually a female child, twists, tangles, and pulls out her hair in a compulsive, habitual manner.
The reality is that children play with their hair, and children also frequently develop dysfunctional and counterproductive habits, such as picking their noses, putting their fingers in their mouths, etc.. It is likely that children have displayed hair-tangling and hair-pulling tendencies since before people lived in caves. Parents from generation to generation have dealt with these kinds of problems as a matter of course, as an integral part of the normal parental responsibilities.
Functional, effective parents intuitively use the normal systems of coaching, teaching, rewards, punishments, etc., in a more or less systematic attempt to instill productive habits in their children and eliminate dysfunctional ones. This includes hair-pulling. Certainly up till a generation or so ago, no parents would have conceptualized this as anything other than a habit, and the matter would have been resolved promptly within the family using natural methods of coaching, encouraging, etc..
Today, however, thanks to the widespread “consciousness raising” of the APA and the pharmaceutical companies, a growing number of parents have accepted the notion that a child displaying this kind of behavior has a mental disorder and needs immediate professional attention. Newspaper ads and free screenings, both paid for by pharmaceutical companies, promote these ideas and frequently suggest that failure to seek prompt treatment may result in matters becoming a good deal worse.
The treatment usually involves a psychotropic prescription, the side effects of which frequently are far more destructive to the child’s health than the original problem. The child is also “enrolled” in the ranks of the mentally disordered, and is given the false notion that it is impossible to deal with life’s normal problems without the assistance of professionals and pills. He or she is well on the road to customer-for-life status, which of course benefits the practitioners and the pharmaceutical companies.
In this context it is important to note that the question “is trichotillomania a mental disorder or not?” becomes meaningless, because there is no definition of a mental disorder other than the one the APA provides. If the APA says something is a mental disorder, then it is, otherwise it is not. There is no external reality to which their findings must conform. By contrast, a geologist, for instance, who asserted that wood is a form of rock would be rebutted on the grounds that wood simply does not have the objective qualities and characteristics of rock, and no amount of discussion or consensus can alter that reality. A psychiatrist, on the other hand, who suggests that road rage, for instance, is a mental disorder, merely has to persuade enough of his colleagues that this is the case, and it will become so by being included in the next edition of DSM. It is the psychiatrists who decide what is a mental disorder, and their general philosophy in this regard for the past fifty years has been “the more the merrier.” A recent editorial in the American Journal of Psychiatry, for instance, asserts that Internet addiction is a mental disorder and should be included in the next edition of DSM.
In general, business has been good for psychiatrists in recent decades. Clients are indeed seeking their help for an increasingly wide range of problems, and it is likely that DSM-V, when it emerges, will list even more mental disorders than the current edition.
Calling a problem a mental disorder obviously does not change the nature of the problem, nor does it provide any special insight into the matter. The fact is that most children play with their hair. For a very small number the habit becomes strong, and they actually tear hair out in significant quantities. When psychiatrists say, “This is a mental disorder,” essentially what they are saying to the parent is, “You can’t take care of this. You must bring this child in for treatment.” The disempowering aspect of the message is not usually articulated, but parents who succumb to these kinds of pressures do in fact become disempowered and ineffective, and usually relegate an increasing measure of their parental responsibilities to the professionals. This, of course, is good for business, but the results in terms of the child’s general development are often far from satisfactory. Furthermore, by defining the problem as something inherent to the child, the system is ignoring the role the parents may have played in the creation and maintenance of the problem, and in general, little or no attempt is made to empower or coach them towards more effective parenting. (For an interesting perspective on this, see codeblog’s post about a day in the children’s psych ward.)
In the context of diagnostic proliferation, it needs to be recognized that psychiatry is a profession, and that the APA’s primary agenda – rhetoric notwithstanding – is to promote the welfare and interests of their members. That’s why the individual psychiatrists join and pay their dues (currently $540 a year). Like other professional groups, they window-dress their documents and their press releases with public welfare platitudes, but also like other professional groups, they protect their own interests and fight tenaciously for their turf.
It should also be acknowledged that in the turf protection area, psychiatrists have enjoyed a great deal of success and have become extraordinarily adept at lobbying legislators and other decision-making bodies in matters that affect psychiatry’s financial interests. In this regard they have had the wholehearted assistance of the pharmaceutical companies, who have used their formidable advertising and lobbying power to full advantage in the drive to develop the mental disorder framework and to promote its acceptance by the American people. Pharmaceutical companies routinely fund most of the “free screenings” for depression and other so-called mental disorders that one sees advertised in the newspapers and on TV. Their funding sources are seldom acknowledged in the ads, but can usually be verified by calling the 800 number and asking where the funding comes from. In addition the pharmaceutical companies donate large quantities of money to organizations sympathetic to their cause, for instance, the National Alliance for the Mentally Ill (NAMI), and have in recent years begun targeting ads for psychotropic drugs directly towards potential patients.
The central theme of this website is that the APA’s framework, in which an increasingly wide number of human problems are conceptualized as mental illnesses and best treated by psychotropic drugs, is spurious and counterproductive. It is a disempowering philosophy that undermines not only the value and integrity of the individual affected, but also saps the strength, vitality, and creativity of our families and communities. In the following posts I will discuss some of these so-called diagnoses in more detail.
Next post: Attention Deficit and Disruptive Behavior Disorders
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