Learning Log

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I would have to conclude, given the historical account provided by the text, that the mentally ill are often treated inhumanely when economic resources are low. Initially I would have thought that etiological theories would have played a greater part, with belief in supernatural causes for mental illness resulting in more cruel treatments than with belief in natural causes. However this does not seem to be a particularly significant factor. Supernatural theories of demonic possession have been linked with both compassion (e.g. ancient Egypt) and torture (e.g. Europe during the Middle Ages) (Firestone & Marshall, 00). Similarly, natural theories have involved both humane (e.g. Europe during the early Renaissance period) and inhumane treatment (North American institutions prior to the 170s) (Firestone & Marshall, 00). On the other hand, there do appear to be several instances of particularly cruel treatment that seem to have been related to economic factors. For example, patients at the Bethlem Royal Hospital (c.1547) were made to partake in a sort of freak show for tourists in order to raise much needed operating funds for the institution (Firestone & Marshall, 00). Also, during the 18th century, large numbers of poor people resulted in increases of admittances to “workhouses” such as the Bicetre. Despite Phillipe Pinels’ efforts to improve the quality of treatment being provided in these institutions, overcrowding made better care impossible and the mentally ill were treated as less than human (e.g. chained to walls, beaten and starved) (Firestone & Marshall, 00). Thus it seems that the care we provide the disadvantaged is often greatly influenced by the economic resources at our disposal � good intentions simply aren’t enough.

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In a sense, one could argue that anyone who commits a serious crime is suffering from some sort of mental illness. After all, mustn’t there be something wrong with a person’s psychological functioning, even temporarily, to allow them to murder of harm another? More specifically though, I can think of three types of disorders that we treat more as criminal than as illness that is, the actions of psychopaths, pedophiles and sexual offenders (people with courtship disorders). Often, due to the nature and severity of the crimes committed by people with these disorders, we are reluctant to treat them as ill, preferring instead to think of them as simply “evil”. The problem with this tendency is that treatment is perhaps not given enough attention, reducing the likelihood of helping people with these disorders improve their behaviour.

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There are certainly several pros and cons that can be highlighted concerning the use of the term ‘mental illness’. First of all, it has the advantage of being fairly clear in its meaning � conveying to the listener that there is problem with ones’ ‘mind’. On the other hand, unlike the term ‘psychological abnormality’, ‘mental illness’ transmits very strong implications of biological rather than psychological causes for the disorder. In this sense it would seem useful to distinguish between ‘mental illness’ and ‘psychological abnormality’ to reduce potential confusion (though the two terms are usually used interchangeably). For instance, it may be useful to make such a distinction between (for example) developmental disorders of known biological causes and eating disorders, which are generally assumed to be more psychological in nature. Perhaps the biggest ‘con’ for both of these terms is that they carry somewhat negative connotations. Misuse of these terms (e.g. calling people ‘mental’ or ‘abnormal’ in a derogatory sense) places a stigma on those who would be diagnosed with a mental illness or psychological abnormality. I’m sure that few people would like to think of themselves as being ‘mentally ill’ or ‘abnormal’ (even if these labels are an accurate description of the problem).

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Concordance refers to the presence of the signature problem of a ‘proband’ (individual case of interest) in another person, usually within the same family. It is thought that the degree of concordance between family members provides a measure of genetic heritability for the disorder in question (Firestone & Marshall, 00). Unfortunately, concordance is in fact a poor measure of genetic influence because it cannot account for environmental influences (Firestone & Marshall, 00). Thus it is unable to tell us whether the disorder was inherited, adopted from shared environmental factors, or even the interaction of the two.

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One advantage to treating the specific, problem behaviour as the disorder could be a more immediate improvement in functioning. However, viewing the whole as the unidirectional sum of its parts may disguise the greater issue and inhibit effective treatment. By failing to examine the over-arching syndrome, we risk ignoring other causal factors or route problems that might have a significant impact on the behaviour in question. Systems theory however, unlike reductionism, views the whole as being greater than the sum of its parts (Firestone & Marshall, 00). In this way, treatment includes examination of multiple factors (i.e. social, biological and psychological) and their bi-directional influences (Firestone & Marshall, 00). This approach offers a more well-rounded and thorough assessment of the problem and a better chance at effective long-term treatment.

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Another explanation for the weak inter-rater reliability of the DSM-IV might be the influence of the professionals who use it. First of all, nobody is perfect. Despite training, professionals often make incorrect assessments with the DSM in the same way that medical doctors often misdiagnose patients. For instance, they may fail to ask a specific question, make an incorrect assumption, or even pose ‘leading’ questions that completely alter the resulting diagnosis. This is an even greater problem in the psychological profession than it is in the medical profession, given the high degree of subjectivity and complexity involved in psychological processes. Even the subtlest of socio-cultural biases (a virtually unavoidable problem) held by the interviewer can have a profound impact on their diagnosis.

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Certainly the DSM has many problems, but at present it seems to be the best available system of diagnosis. As such it would seem prudent to continue with its use, while maintaining an acute awareness of its limitations and biases. Efforts to improve the system should by no means be abandoned however. If we hope to ever find some degree of objectivity in psychological assessment, we must continually question and challenge the system (i.e. ‘think outside the box’). At present, the problems inherent in the DSM-IV could potentially be lessened with more thorough assessment procedures. For example, the cooperation of numerous professionals from several vantage points (e.g. psychologists, doctors, naturopaths, religious and cultural experts…) and more thorough personal assessments (e.g. social and physical environment, current states and life circumstances, detailed patient history…) might improve diagnostic problems. Unfortunately, such procedures would likely prove too costly for practical application.

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The first thing that appears to be weak surrounding Doris’s case is a complete interview with the patient and family/friends of the patient. Although there is mention of an interview with Doris, it is unclear whether or not this interview was sufficiently detailed or whether or not there was a proper interview conducted with her husband. Her assessment also appears to be missing a detailed history altogether. Although there is a description of her current emotional functioning (i.e. feelings of helplessness, inability to survive, and suicidal thoughts) there is no information pertaining to her past functioning (e.g. social, developmental, work histories). Another problem with Doris’s case is that it seems to be missing any sort of standardized testing or naturalistic observation of her symptoms by the professional in charge of her case. It appears as though he simply made a quick diagnosis from a short interview and decided to err on the side of caution. While this was likely a good decision, considering Doris’s suicidal threats, had more time and consideration gone into the assessment process it may have turned out that Doris did not require medication at all.

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Diagnostic procedures The recent increased prevalence of ADHD may in part be the result of advances in childhood behaviour-rating scales and computerized testing (Firestone & Marshall, 00). With the help of these improved techniques for childhood assessment, we may be catching more cases that would have otherwise slipped through the system or been labelled as some other disorder.

Societal Expectations Society in general has seen an increasing trend in favour of biologically based theories of behaviour. We prefer to think that our children are suffering from a neurological disorder, beyond their control, rather than that they are ‘bad’ or ‘unruly’ children. As such, the treatment is simple and easy medication. Unfortunately, once a medical trend begins, it is often over-diagnosed. So the increased prevalence of ADHD may be partially the result of overmedication or misdiagnosis (e.g. hypoglycemia is often misdiagnosed at ADHD).

Child rearing practices A few things with respect to child rearing practices may be implicated in the increased prevalence of ADHD. First of all, some would say that poor dietary habbits (i.e. food additives, food dyes, and high sugar intake) might play a role in the development of ADHD (Firestone & Marshall, 00). Certainly it can be said that the average diet in Western societies has seen a steady decline in quality. Secondly, it is also thought that the high amounts of television viewing by children in more recent years might play a significant role in the prevalence of ADHD (Firestone & Marshall, 00). Children exposed to high amounts of television from an early age may become ‘wired’ for high levels of stimulation, making it difficult for them to concentrate or sit still.

Neuro-biological make-up Interest concerning ADHD within recent years has lead to research using MRI brain scanning technology (Firestone & Marshall, 00). The results have shown that when comparing the brains of children with ADHD and without, matched by age, those with ADHD have significantly smaller right frontal regions (Firestone & Marshall, 00). The advent of such ‘hard’ evidence for this disorder might have added to increasing prevalence by legitimizing parents’ concerns.

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I think that ultimately, decisions regarding treatment for a child should be left in the hands of the parents. Of course making such a statement is not easy when you consider the potential problems that this might create. It hardly seems fair to force treatment on an unwilling child simply because we don’t recognize them as capable adults under the law. On the other hand, just because a child has an opinion does not mean they know what’s in their best interests in the long run. While in some cases the professional may know best, we cannot remove the fundamental rights of patients and their legal guardians. Unless there is sufficient cause for enforcing treatment (for example as a matter of public safety) professionals should not have the power to force their own personal/cultural morals and biases on the parents involved.

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Whether or not individuals with intellectual disabilities should have the right to have children is a difficult question with no easy answers. Ultimately I would have to say that they should be given that right, but only to the extent that they can provide a safe and adequate environment for their children. Adequate social services should be in place both help these parents and to intervene should the safety of the child be compromised. That being said, I do think that with proper support systems a mildly retarded person could make just as good a parent as most. While such a person may not make an ‘ideal’ parent, where do we draw the line? Considering the subjective nature of IQ tests, how can we be sure that someone’s IQ isn’t sufficient to raise a child? Considering teenagers are also less than ideal parents, how should we deal with teen pregnancy? Rather than removing peoples’ rights altogether, I think it’s necessary to deal with each case on an individual basis to determine whether or not someone is capable of caring for a child.

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‘Learning disabilities’ are developmental disorders related to skills such as reading, mathematics, verbal and written communication and motor coordination (Firestone & Marshall, 00). On the other hand, although affecting similar skills, ‘mental retardation’ refers to more severe developmental disorders (Firestone & Marshall, 00). In these cases there are usually more profound limitations with regards to adaptive behaviours (e.g. self-care) (Firestone & Marshall, 00). Finally, ‘autism’ is characterized by an almost complete absence of social responsiveness, obsessive interests, self-stimulation (Firestone & Marshall, 00). Unlike the first two disorders, autistic people are often said to appear to exist in their own world, with little awareness of others.



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