John Oliver on the Mental Health System

who said personality disorders don't count? I said antisocial personality disorder isn't a mental illness. it isn't. and it's not a personality disorder either. which I already said. Look at the criteria and you should see why the idea of this as a personality disorder let alone illness should raise some eyebrows:

(1) failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest
(2) deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure
(3) impulsivity or failure to plan ahead
(4) irritability and aggressiveness, as indicated by repeated physical fights or assaults
(5) reckless disregard for safety of self or others
(6) consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations
(7) lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another

the criteria including things like "failure to conform to social norms" and ending up being arrested or "assaults" essentially invalidates the criteria for looking at its association with criminality and violence because you are essentially building it into the criteria. also the whole category of personality disorders are contentious. they are supposed to be stable over time but the reliability and validity of personality disorder diagnoses is extremely low. You follow people up and they no longer meet criteria. yet these disorders are supposed be stable and enduring. It is clear they are not. Many personality disorder experts suggest we shift with thinking about personality functioning instead of personality disorder, which would look at a persons' level of personality functioning at a given time rather than making assumptions not borne out by the evidence that this is reflective of a more stable pattern.

btw I have a special interest in severe personality disorder and forensic psychotherapy, but at the current time antisocial personality disorder does not belong in the traditional mental health system unless there is co-existing major mental disorder. This could be a moving target, there is some evidence that mentalization based treatment may be helpful for people with antisocial personality disorder. but this cannot be delivered to these individuals within a standard mental health setting. We need more community forensic programs in this country. Psychiatrists have been advocating for the psychoanalytic treatment of criminals for a long time, Karl Menninger wrote The Crime of Punishment which was impassioned plea against punitive approaches to criminality and instead focusing on rehabilitation. For Menninger and his ilk, it was was psychoanalytic approach that would heal these unfortunate souls and society (I'm going to talk a little bit about this at the IPS meeting this week...), but it was an abject failure. Some countries, particularly the UK still pay for intensive psychoanalytic treatment of extremely violent or sexually violent criminals but there isn't great evidence to support this. Incidentally, in the UK there is also a subspecialty of forensic psychotherapy, which is focusses on the psychoanalytic treatment of these violent individuals with severe personality disorders.

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John Oliver on the Mental Health System