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Are Relationship Problems Disorders: Harmful Dysfunction versus Pragmatism

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Title: Are Relationship Problems Disorders: Harmful Dysfunction versus Pragmatism


1
Are Relationship Problems Disorders? Harmful
Dysfunction versus Pragmatism
  • Christian Perring, Ph.D.
  • Associate Professor of Philosophy
  • Dowling College, NY

2
Main Claims
  • Psychiatric Classification is essentially a
    pragmatic issue based on the state of science,
    current values, and the structure of society.
  • Psychiatric Classification cannot be purely
    scientific.
  • Thus, the decision whether to include relational
    disorders in DSM-V is essentially pragmatic.

3
Wakefield HD Theory
  • Can Relational Problems be Genuine Medical
    Disorders? A Harmful Dysfunction Perspective.
    (2006)
  • Dysfunction failure of evolutionarily designed
    mechanism
  • Harmful pain or disability

4
Wakefield (ctd)
  • "It is true, as Perring (2005) emphasized, that
    in my writing about disorder I have claimed that
    dysfunctions must be failures of mechanisms
    internal to individuals. But that was in the
    context of addressing DSM Axis I and II disorders
    that are by definition disorders of individuals
    in such cases of individual disorder, there must
    indeed be an internal dysfunction within the
    individual, according to the HD analysis."

5
Wakefield (ctd)
  • " However, there is nothing inherent to the logic
    of the HD analysis of disorder as a harmful
    failure of biologically defined function that
    restricts it to individuals. It can apply to any
    level of organization that is biologically
    designed and so has parts with biological
    functions. The essential idea is that disorder in
    the medical sense is a harmful failure of
    biologically designed functioning."

6
Wakefield (ctd)
  • In a relational disorder, "no single mechanism is
    dysfunctional, yet an evolutionary dysfunction
    exists nonetheless due to the interaction of the
    two normal mechanisms and the relationship
    between the levels of their activity."
  • Parallel example Pregnant woman with normal but
    narrow birth canal and baby with normal but large
    head.

7
Wakefields Psychological Example
  • For example, the infant may have relatively low
    frustration tolerance, and the mother may have
    relatively high latency for response to infant
    crying, so that the mothers response, although
    not pathologically delayed or withholding, allows
    for severe anxiety to be experienced by the
    infant. In such a case, there need be no
    individual disorder in either mother or infant,
    at least not yet. Nonetheless, their relationship
    fails to fulfill what is plausibly part of the
    effects for which the mother-infant bond was
    naturally selected, namely, an adequately speedy
    and reassuring response by the mother to infant
    crying. If such a relational function goes awry,
    it seems that there is a dysfunction in the
    strict, literal, evolutionary sense. And, it is
    certainly harmful.

8
Criticisms of the use of evolutionary psychology
  • Many have argued that it is far too speculative a
    theory on which to base our current needs in
    classifying mental disorders.
  • Many have also suggested that evolutionary
    psychology will never receive adequate
    verification for us to know which mental
    functions are evolutionarily designed.
  • There's also been suggestion that the notion of
    "design" in evolutionary theory is at best a
    metaphor, and to put heavy weight on it for our
    classificatory purposes is to fundamentally
    misunderstand the theory of evolution.
  • Furthermore, there are have many concerns that
    evolutionary psychology, like its forebears
    sociobiology and Social Darwinism, is often
    driven more by ideological conviction than
    scientific promise, and can very easily be
    co-opted for political aims.

9
Evolutionary psychology of problems in
mother-infant relationships
  • Wakefield gives little explanation
  • He does refer to Zero to Three. (1994).
    Diagnostic classification of mental health and
    developmental disorders of infancy and early
    childhood.
  • This includes overinvolved, underinvolved,
    anxious/tense, angry/hostile, mixed, abusive,
    verbally abusive, physically abusive, and
    sexually abusive relationships.
  • However, it is not clear why this should lend
    support to EP.

10
Attachment theory EP
  • Bowlby (1969) integrated psychoanalytic and
    ethological approaches to attachment.
  • One recent survey of evolutionary developmental
    psychology says that "the attachment process is
    biologically driven, but the nuances of the
    relationship--the measurable phenotype--are
    shaped by the nature of the parent child
    relationship. (Greary Bjorklund, 2000).
  • Possible link between insecure attachment and
    later marital instability not proven.

11
Central Example Underinvolved Mothers
  • Bowlby's original idea was that when the mother
    is underinvolved, the infant will form
    anxious-avoidant attachment.
  • Problem if the mother is underinvolved, then the
    infant will be damaged. So the infant will
    already have an individual attachment disorder.
    Not a relational disorder.
  • Such an infant would presumably already not
    demonstrate secure attachment in Ainsworth's
    Strange Situation experiment, but would
    demonstrate anxious-avoidant attachment.
    (Ainsworth et al, 1978)

12
Individual or Relational
  • other Zero-to-Three relational disorders that
    Wakefield lists -- overinvolved, anxious/tense,
    angry/hostile, mixed, abusive, verbally abusive,
    physically abusive, and sexually abusive
    relationship
  • All of these would lead to disorders of the
    individual infant, which then means that there
    would not be a disorder of the relationship

13
More problems for attachment theory and EP
  • Anthropologists Robert LeVine and Karin Norman
    (2001) consider out research done in Bielefeld,
    Germany, and East Berlin, among others

14
Robert LeVine and Karin Norman (2001)
  • While Ainsworth and her attachment theory
    colleagues took the relationship they labeled as
    secure attachment to be a requirement for mental
    health, there is strong evidence that different
    attitudes towards childrearing practices in
    Germany give very different results.
  • They suggest that at least in some parts of
    Germany, parents believe that it is important not
    to spoil the child and to let it cry for much
    longer than most American parents would. This
    helps to instill more independence in the child,
    they believe.
  • Yet there is little evidence that these
    practices, which would by American standards be
    tantamount to child abuse, do actually cause
    damage.

15
Controversy over Mother-Infant Bonding
  • 1970s Kennell and Klaus published Maternal
    Infant Bonding The Impact of Early Separation or
    Loss on Family Development
  • They postulated the existence of a sensitive
    period in the first few minutes or hours of life
    for both mother and father to have contact with
    the baby in order for future development to be
    optimal. This enhanced attachment in both
    directions.
  • This biologically based argument came under
    significant critical scrutiny from many authors.
    While the debate may still be somewhat
    unresolved, there has certainly been a great deal
    of doubt cast on the claims for the importance of
    bonding (Eyer, 1992)

16
EP of larger groups
  • EP has postulated that human psychology largely
    evolved for hunter-gatherer societies. It has
    paid attention to the role of the extended family
    as much as small groups through its examination
    of primate societies and non-industrialized human
    societies.
  • We should be examining disorders of the extended
    family as much as disorders between infants

17
EP of extended family
  • If there is a dysfunction of the extended family
    and it is harmful, then by Wakefields analysis,
    it is a medical disorder.
  • This is counter-intuitive.
  • Suggests that Wakefields approach does not
    capture our intuitive concept of medical disorder.

18
Conclusions about EP
  • There's significant doubt for the claims about
    the natural functions of relationships between
    mothers and infants that Wakefield hopes that
    evolutionary psychology can deliver.
  • If this is the strongest basis for a natural
    science of relationship functions, then it does
    not provide much reason for including relational
    disorders in DSM.

19
Problems in marriages and friendships
  • Wakefield expresses concern about pathologizing
    normal incompatibility between people.
  • He argues that there is little ground to
    categorize these as medical problems.

20
Pragmatic Approach to Classification
  • The categories of medical and biological
    disorders are flexible and can change over time.
  • Psychiatry can and has added psychological
    disorders to medical disorders.
  • Psychological disorder is an especially
    flexible category.
  • We should embrace such changes but guide them
    according to our values and best judgment.
  • Conditions that might not have been dysfunctional
    in hunter gatherer societies can still be
    significant problems in modern society.

21
Deciding whether Relationship Problems are
Disorders
  • What categorizations would allow mental health
    professionals to help people?
  • What categorizations might lead them to start
    acting out of their areas of expertise?
  • Benefits opportunity for systematic study, drug
    trials
  • We need to be especially careful in the social
    consequences of giving mental health
    professionals power over saying which
    relationships are worthwhile or problematic.
  • Worry about credibility of psychiatry moving away
    from medical model (Spitzer).

22
Pragmatist Theories of Classification
  • There is no definitive statement of a Pragmatist
    Theory.
  • Differences between Pragmatism and Values-Based
    Classification are not particularly clear.

23
Zachar (2002)
  • "Deciding what counts as practical is
    complicated. With respect to categorizing
    psychiatric disorders, we should consider many
    things, including, but not limited to available
    treatments potential management strategies the
    effects of labeling maximization of true
    positives and true negatives in identification
    establishing within category homogeneity
    scenarios (especially for spectrum disorders)
    mapping time courses predicting prognosis
    achieving coherence with basic science in
    genetics, physiology, and psychology being both
    clinically informative and easy to use and
    meeting psychometric standards such as
    reliability and validity."

24
Conclusion
  • The case of relationship problems suggests that
    the factors to be taken into consideration in a
    pragmatic approach to classification need to be
    expanded, to include social factors and the
    public reputation of psychiatry.

25
References
  • Ainsworth, Mary, D. Salter, Mary C. Blehar,
    Everrett Walters, Sally Wall. (1978) Patterns of
    Attachment A Psychological Study of the Strange
    Situation. Hillsdale, NJ Erlbaum.
  • David F Bjorklund, Anthony D Pellegrini (2000)
    Child Development and Evolutionary Psychology.
    Child Development 71 (6) , 16871708
  • Bowlby, J. (1969). Attachment and Loss. Volume
    1. New York Basic Books.
  • Bowlby J. (1988). A Secure Base. New York
    Basic Books.
  • David C Geary, David F Bjorklund (2000)
    Evolutionary Developmental Psychology
  • Child Development 71 (1) , 5765
  • Eyer, Diane E. (1992) Mother-Infant Bonding A
    Scientific Fiction. New Haven Yale University
    Press.
  • Klaus, M and J. Kennell. (1976) Maternal Infant
    Bonding The Impact of Early Separation or Loss
    on Family Development. St. Louis, Mosby.
  • LeVine, Robert and Karin Norman. (2001) The
    Infant's acquisition of culture early attachment
    examined in anthropological perspective. From
    The Psychology of Cultural Experience, edited by
    Holly Matthews and Carmella Moore. New York
    Cambridge University Press.
  • Perring, C. (2005). Can a family have a mental
    disorder? APA annual meeting, Atlanta, GA.
  • Perring, C. (2006). Conceptualiser les troubles
    mentaux chez les enfants et les adolescents,"
    Philosophiques 33(1), pages 65-80, in special
    issue on "Philosophie et Psychopathologie" edited
    by Luc Faucher, available online at
    http//www.erudit.org/revue/philoso/2006/v33/n1/01
    2947ar.pdf
  • Wakefield (2006) The Family Psychologist 22(4)
    Can Relational Problems be Genuine Medical
    Disorders? A Harmful Dysfunction Perspective.
    Pp. 8-14.
  • Zero to Three. (1994). Diagnostic classification
    of mental health and developmental disorders of
    infancy and early childhood. Washington, DC
    Author.
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