Who’s the SilLIer?

It’s funny how things come together sometimes.  A few months ago, I mentioned a slightly strange JAMA paper that suggested that non-compliance with treatment regimes should be treated as a treatable condition in its own right.  The subtext there was fairly clear: that there’s potential scope for what we might term “psychiatric mission-creep”, whereby behaviour gets seen as pathological just if it’s undesirable and can be changed with drugs.  I was reminded of this by a couple of things I found last weekend.

I was avoiding work by pootling away on the internet, and stumbled across a couple of things.  This – an article about American politics that notes the use of psychiatry as a means of social control – was one of them:

[In 1980] an increasingly authoritarian American Psychiatric Association added to their diagnostic bible (then the DSM-III) disruptive mental disorders for children and teenagers such as the increasingly popular “oppositional defiant disorder” (ODD). The official symptoms of ODD include “often actively defies or refuses to comply with adult requests or rules,” “often argues with adults,” and “often deliberately does things to annoy other people.”

Many of America’s greatest activists including Saul Alinsky […] would today certainly be diagnosed with ODD and other disruptive disorders. Recalling his childhood, Alinsky said, “I never thought of walking on the grass until I saw a sign saying ‘Keep off the grass.’ Then I would stomp all over it.” Heavily tranquilizing antipsychotic drugs (e.g. Zyprexa and Risperdal) are now the highest grossing class of medication in the United States ($16 billion in 2010); a major reason for this, according to the Journal of the American Medical Association in 2010, is that many children receiving antipsychotic drugs have nonpsychotic diagnoses such as ODD or some other disruptive disorder (this especially true of Medicaid-covered pediatric patients).

For some reason, I had foxes on my mind as well, and so I entered the word “Fox” into google; and I should have known that it’d provide lots of hits for the US TV conglomerate.  One story that came up on the search had to do with a twitter account called @LIPartyStories.  This was apparently a feed that would repost pictures sent from its teenage followers of themselves in various states of intoxication and déshabillé.  So far, so straightforward: the day that teenagers stop getting drunk and doing stupid things at parties is the day that the world will stop turning.  Granted, when I was young, we didn’t post stuff online – but if the internet had been around, we probably would have.  Kids do daft stuff; they sometimes regret it; then they grow up, and do daft stuff less.

Keith Albow, a Fox pundit, doesn’t see it quite like that:

Here’s what the parents of all the young people who fed the [sic] @LIPartyStories inappropriate images of themselves should do:  Confiscate their phones, shut down their Twitter and Facebook accounts and test them randomly for drugs and alcohol every two or three weeks for the next year.  Each positive test should result in being grounded for a month.  And every one of the teenagers directly involved should be in psychotherapy.

School administrators should suspend each and every one of them from school for two weeks and admit them back to school only with a note from a psychologist or psychiatrist or licensed social worker stating that the student has begun treatment.

[E]very, [sic] single teenager who sent out a photograph of himself or herself involved in sex or obviously drunk or on drugs via @LIPartyStories is emotionally disordered — probably suffering with one or more symptoms of a brewing personality disorder (narcissistic personality disorder), very possibly depressed, likely abusing alcohol or drugs or both and very likely addicted to at least one very potent drug:  the Internet.

Yes, but for the real Lindsay Lohans of the world who have real movies to promote by faking wardrobe malfunctions, distributing a single photograph of oneself publicly in a state of undress or intoxication or voiding means one is psychologically not well. [sic]

That conclusion would have once seemed obvious:  A 16-year-old wandering her high school’s hallways handing out photographs of herself urinating in a sink would have been disciplined, dismissed from school and taken to a psychiatrist post-haste. The Internet has simply camouflaged how bizarre such behavior is by making it go viral.

Now, it might be tempting to discount all this as the kind of stuff that you’d expect from Fox News, and to write it off as all-too-predictable clutching of pearls.  But look at the bits I’ve highlighted; they seem to me to indicate something quite dysfunctional about parenting, and about doctoring.  I mean, you have to wonder about the parenting skills of people whose first reaction to their kids getting drunk would be to send them for therapy.  Therapy for what, exactly?  Isn’t it possible that, allowing for the sake of the argument that there is something pathological about the behaviour described, that pathology would be at least in some way informed by the kind of parenting that sees breaking social norms as a medical problem, rather than as something best handled with… oh, I don’t know… a conversation, maybe?

But I’m also wondering about the professional ethics of the practitioners Albow has in mind.  Of course, I don’t know whether anyone actually would prescribe medication or therapy for slightly boozy schoolkids – but Albow seems to think that it’s at least plausible.

So imagine that you’re the psychiatrist and someone comes to see you asking for treatment for their child, on the basis that she was drunk and stupid a couple of times: what should the response be?  I mean, it seems fairly obvious to me what any responsible psychiatrist would say – but maybe my intuition is wrong, or overly optimistic, or something.  Whatever: I’m tempted to think that the duty of the professional in cases such as this would be to send parents away with a flea in their ear.  Idiocy per se isn’t a sign of pathology, and trying to pathologise it is itself dysfunctional.

But there’s another aspect to consider here: is it beyond the realm of possibility that a column like Albow’s itself presents a significant moral problem, inasmuch as that there will be at least some people who take his advice seriously, and treat it as some kind of approval of medical intervention to “cure” undesirable behaviour.  I’m not really a big fan of worries about bringing a profession into disrepute – but I do wonder whether inflammatory stuff like this might be pretty close to the mark at best.  After all, it does imply a picture in which the role of the HCP is to “cure” undesirable behaviour – but also one in which psychiatry is a legitimate method of social control.

I don’t mean here that it isn’t.  There’s plenty of people who have problems with psychiatry because it is all too often a means of social control – at the very least, that’s how the argument goes.  But that’s a long way from saying that it is such as a matter of necessity, or that it should be, or that it even may be.  You can be cynical about the role of the shrink while still admitting that there are cases in which it does some good, however rare those cases are.  So while the cynics might read Albow’s piece and at least grant him that he’s at last being honest about what psychiatry does, there does seem to be a problem.  If he wants to be taken seriously, he’s proposing something quite sinister.  And if he doesn’t want to be taken seriously… well, then why’s he bringing his medical credentials to the table?

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