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."

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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.