Without Conscience - review

Vangelis · 07-12-2005 05:38PM #1

Without Conscience: The Disturbing World of the Psychopaths Among Us
Canadian Psychology, May 2000 by Stephen Wormith

ROBERT D. HARE Without Conscience. The Disturbing World of the Psychopaths Among Us. New York: Guilford Press, 1999, 236 pp. (ISBN 1-57230-451-0). Reviewed by STEPHEN WORMITH

Too often we hear about adults, and now more than ever, adolescents, who perpetrate violence so horrific and seemingly meaningless that their actions defy the understanding of professionals, let alone of the perpetrators' families. The republication of Robert Hare's popular work on the psychopathic personality (originally published in 1995 by Pocket Books, New York) is a testament to the success and importance of this book. Hare paints an intriguing yet scary portrait of this, the most dangerous type of personality disorder. His colourful, but accurate portrayal of the psychopath makes this book equally important alike for parents and clinicians.

Without Conscience is based on more than 30 years of the author's research on psychopathy. The book is written in a sincere and easily readable fashion for a general audience. The research and clinical literature is described in nontechnical terms with a minimum of jargon, making the work accessible to a wide audience. To his credit, Hare does not succumb to the temptation of overstating the findings, as is commonly the case when scientific knowledge is translated for a popular audience. References, which are fewer than one would expect in an academic text but more than in most popular works, are relegated, appropriately, to chapter notes. The empirical literature is interwoven with many personal anecdotes, as well as descriptions of psychopaths and their behaviour from film, literature, and the popular press. With celebrated cases including Clifford Olson, Jack Abbott, Ted Bundy, Jeffrey Dahmar, and the fictional Hannibal Lecter, references range from Ann Landers and Oprah Winfrey to Truman Capote, Joseph Wambaugh, and Norman Mailer. This is a refreshing change from most psychological works and makes compelling reading for the lay person. Yet Without Conscience will also be of interest to any student, clinician, or researcher in the field of forensic or correctional psychology.

By describing the behaviour of dozens of individuals, all of whom "scored high on the PCL" and presented behaviour that shared a number of common themes, Hare, indirectly, provides insight into the personality, if not the mind (he rejects psychodynamic approaches), of the psychopath. It is a personality that is characterized by egocentricity, grandiosity, impulsivity, recklessness, contentment with self, and, most disturbing, a total lack of conscience.

Much of Hare's research has been devoted to the reliable identification of psychopaths. His development of the Psychopathy Checklist (PCL) may represent the single, most important advancement to date toward what hopefully will become our ultimate understanding of psychopathy. Most of Hare's more recent research has used the PCL to study the construct of psychopathy and, in so doing, has contributed to the ongoing validation of the instrument. Therefore, it comes as no surprise that much of the book hinges on his definition, assessment, and diagnostic approach to psychopathy, nor is it a surprise that he is critical of those who would equate psychopathy with "antisocial personality disorder" (APD ) and its diagnostic criteria as set out by the American Psychiatric Association (1994). Hare notes that many APD clients are not psychopaths and therefore should not necessarily share the same pessimistic prognosis. In this vein, he blames professionals, as well as the media, for confusing the issue and he chastises clinicians who conduct mediabased diagnoses for the popular press.

There are a number of important messages conveyed in this book and all of them are based on the author's fundamental perspective about psychopaths. Although not explicitly stated, Hare portrays the psychopath as one who seems to be born, not made. He does this by presenting numerous stories of individuals, who, without explanation, since their home environments appear to be quite normal, begin to behave in a disturbingly egocentric and aggressive manner. Yet Hare is quite candid about the fact that we do not know how or why these children are impervious to the most skilled efforts to foster appropriate socialization. He does, however, cite neurological, biochemical and genetic studies to suggest possible mechanisms and he invokes the heredity-environment interaction to explain how psychopathy may become manifest in very different ways, from con man to killer.

This stance leads to three particular messages of Hare's book. First, the parents and spouses of psychopaths should not feel responsible or guilty about the psychopath's behaviour. Rather, they should consult clinicians with special diagnostic expertise, and if it is determined that one is dealing with a psychopath, specific strategies should be established, basically involving a structured environment with well-defined contingencies and other behavioural management techniques. Second, the personality and behaviour of a psychopath are unlikely to change in any substantial manner, except for some possible diminution with age. Moreover, treatment efforts, especially conventional psychological therapies, are unlikely to be effective, largely because psychopaths are quite content with themselves and believe that their approach to dealing with other people is fully justified and profitable. Therefore, Hare is very critical of insight-based approaches, particularly such as the therapeutic community, which might teach the psychopath to be even a better manipulator. Instead, he insists that any effort to work with psychopaths should incorporate their pervasive self interest, pointing out how, time after time, their antisocial behaviour has not, ultimately, been in their own best interest.

Rest of review: http://www.findarticles.com/p/articles/mi_qa3711/is_200005/ai_n8895854

snorlax · 07-12-2005 06:54PM

we do not really need three threads on psychopaths in the space of less then a week so please do not make duplicate threads of the same topic, thank you Vangelis.

iv already said i disagree with the term alone but i will leave this thread open so long as it remains objective.

Myksyk · 07-12-2005 07:13PM

I'm interested in this subject and have read Hare's book which is pitched at lay audiences (but is a good read for the professional too).

I'd have to take issue with Snorlax's contention (on another thread) that the term Psychopath is disrespectful. It is actually a clinical term and is a legitimate diagnosis (usually in the form of Antisocial Personailty Disorder). Given that it is an Axis II disorder it is often not considered a mental illness per se and is, for example, specifically excluded from the Mental Health Act 2001 as a reason for (involuntary) admission to an approved centre under the Act. The term 'psychopath' has nothing whatsoever to do with Axis I illnesses like bipolar disorder, schizophrenia etc from a clinical point of view. Perhaps Snorlax may have misconstrued this generally accepted clinical term for the derogative vernacular term 'psycho'. This term is a shortened version of psychopath, referring usually to irrationally aggressive or destructive people and not usually to people with mental illness (although I agree that some people in their ignorance may use it to refer to psychiatrically unwell people). However, I wouldn't be in favour of allowing the ignorance of some stopping us discussing a fascinating topic. Having said all that I agree that the thread that you locked Snorlax was correctly locked. There are better ways to discuss this subject.

snorlax · 07-12-2005 07:37PM

in the context of working with any clients, im sure such a term would impair my communciation with them and possibly lower their self esteem further, as such i have to treat them like people and avoid putting labels on them in so far as is possible as this can stigmatises them further . in my discipline the person is the most important agent in any treatment and as such most OTs would perscribe to the humantistic theory, especially Carl Rogers while working with patients.

also the context in which the term psychopath is often used is usually in a negative or ignorant context, rather then a scientific one in the media which is probably why i take issue with it being used flippently like in a previous thread i locked earlier which had no merit or any kind of scientific basis.

Vangelis · 08-12-2005 01:06AM

snorlax wrote:

we do not really need three threads on psychopaths in the space of less then a week so please do not make duplicate threads of the same topic, thank you Vangelis.

iv already said i disagree with the term alone but i will leave this thread open so long as it remains objective.

You disagree? I bet you don't know a thing about psychopathy. Psychopathy is a fact, it's not an opinion. Disagreeing doesn't help. And it won't make Dr Robert Hare change his mind. To you it is a term full of shame and derogation I suppose. Well, it is not. It's a clinical term for a person who displays an extreme anti-social behaviour.

The word psychopath is not to be used as a curse-word or in teasing. Psychopathy is not something you **** with, excuse the language.

snorlax wrote:

also the context in which the term psychopath is often used is usually in a negative or ignorant context

That doesn't make it wise to lock a thread. Keeping society out of debate will make no one more informed about what psychopathy really is and will leave people dumb-founded with prejudice and ignorance of how to behave in the presence of psychopaths. It's important to spread knowledge about it.

Do you work with psychopaths? Then your reaction seems extremely bizarre.
If a psychopath is named a psychopath he is offended, yes, but they will remain psychopaths. Being careful not to aggrevate them is a good idea, yes, but their mood is independent of others. They do what they like to do.

And if you doubt Dr Hare's observations, I'm embarrassed on your behalf. He is a world expert on psychopathy and has interviewed psychopaths and researched their behaviour for 30 years. There you've got your science, miss.

No one has told you to call your clients psychopaths. My impression is that you hardly know what psychopathy really is! Because then you wouldn't be so averred to a discussion on it, and you would not DISAGREE on the term psychopath. I'm shocked at your reaction. Being an occupational therapist and being so nervous about psychopathy? Ho yeah, they can surely make you sweat with their stare and their narcissistic brains, and ruin your life because all they think about is themselves. But don't make conclusions for the whole forum based on your own ignorance. That's appalling, I'm really disappointed.

And let me tell you something. If you offended a client of yours who was a psychopath, he would want revenge and probably make your life a living hell. Depending on his/her nature of course. All that triggered by the offense you would have cause by naming him/her a psychopath.

Vangelis · 08-12-2005 01:25AM

This might be helpful.

"Psychopathy is a concept subject to much debate, but is usually defined as a constellation of affective, interpersonal, and behavioral characteristics including egocentricity; impulsivity; irresponsibility; shallow emotions; lack of empathy, guilt, or remorse; pathological lying; manipulativeness; and the persistent violation of social norms and expectations (Cleckley 1976; Hare 1993). The crimes of psychopaths are usually stone-cold, remorseless killings for no apparent reason. They cold-bloodedly take what they want and do as they please without the slightest sense of guilt or regret. In many ways, they are natural-born intraspecies predators who satisfy their lust for power and control by charm, manipulation, intimidation, and violence. While almost all societies would regard them as criminals (the exception being frontier or warlike societies where they might become heroes, patriots, or leaders), it's important to distinguish their behavior from criminal behavior. As a common axiom goes in psychology, MOST PSYCHOPATHS ARE ANTISOCIAL PERSONALITIES BUT NOT ALL ANTISOCIAL PERSONALITIES ARE PSYCHOPATHS. This is because APD is defined mainly by behaviors (Factor 2 antisocial behaviors) and doesn't tap the affective/interpersonal dimensions (Factor 1 core psychopathic features, narcissism) of psychopathy. Further, criminals and APDs tend to "age out" of crime; psychopaths do not, and are at high risk of recidivism. Psychopaths love to intellectualize in treatment with their half-baked understanding of rules. Like the Star Trek character, Spock, their reasoning cannot handle any mix of cognition and emotion. They are calculating predators who, when trapped, will attempt escape, create a nuisance and danger to staff, be a disruptive influence on other patients or inmates, and fake symptoms to get transferred, bouncing back and forth between institutions. The common features of psychopathic traits (the PCL-R items) are:

List of Common Psychopathic Traits

Glib and superficial charm; Grandiose sense of self-worth; Need for stimulation; Pathological lying; Conning and manipulativeness; Lack of remorse or guilt; Shallow affect; Callousness and lack of empathy; Parasitic lifestyle; Poor behavioral controls; Promiscuous sexual behavior; Early behavior problems; Lack of realistic, long-term goals; Impulsivity; Irresponsibility; Failure to accept responsibility for own actions; Many short-term marital relationships; Juvenile delinquency; Revocation of conditional release; Criminal versatility"

[END]

By the way, the reason I asked in the other thread for people to tell about psychopaths whom they know is because I want to learn. And it is good for the rest of the forum members too to learn about psychopathy in real-life. Real-life experiences are important to make people understand. I have no intention of labelling anyone, I'm not like that. And if anybody does, you can simply ban them.

John · 08-12-2005 01:26AM

Vangelis wrote:

You disagree? I bet you don't know a thing about psychopathy. Psychopathy is a fact, it's not an opinion. Disagreeing doesn't help. And it won't make Dr Robert Hare change his mind. To you it is a term full of shame and derogation I suppose. Well, it is not. It's a clinical term for a person who displays an extreme anti-social behaviour.

Not just extreme, it's a spectrum of disorders.

That doesn't make it wise to lock a thread. Keeping society out of debate will make no one more informed about what psychopathy really is and will leave people dumb-founded with prejudice and ignorance of how to behave in the presence of psychopaths. It's important to spread knowledge about it.

Yes public debate is important but only when done maturely and resposibly. Your thread that was locked was neither in my opinion and I think snorlax was right in locking it.

Do you work with psychopaths? Then your reaction seems extremely bizarre.
If a psychopath is named a psychopath he is offended, yes, but they will remain psychopaths. Being careful not to aggrevate them is a good idea, yes, but their mood is independent of others. They do what they like to do.

It's not pyschopaths that she's worried about offending, it's the people who are given the term psychopath because it's a convenient label. Would you call ADHD children psychpaths? What about autistic people? They both show some of the symptoms of psychopathy.

And if you doubt Dr Hare's observations, I'm embarrassed on your behalf. He is a world expert on psychopathy and has interviewed psychopaths and researched their behaviour for 30 years. There you've got your science, miss.

I've never read the book but one man's opinion is not enough no matter how long he's been doing it. Newton was the be all and end all of physics until quantum theory came along.

And let me tell you something. If you offended a client of yours who was a psychopath, he would want revenge and probably make your life a living hell. Depending on his/her nature of course. All that triggered by the offense you would have cause by naming him/her a psychopath.

Vangelis, you seem to think that psychopathy is only the violent madmen you see in movies which is precisely the ignorance that snorlax is talking about. Psychopathy isn't just violent and aggressive behaviour, antisocial behaviour could mean being a loner or skipping a queue. There is a wide spectrum of psychopathologies and you can't tar them all with the one brush.

EDIT: You posted a reply while I was typing this that corrects what I thought you got wrong. Apologies.

However I do still think you're acting hysterically to the topic. The thread that was locked didn't seem like an "I want to learn" topic but something more like staring a train wreck.

Vangelis · 08-12-2005 02:07AM

I don't think that psychopaths are the "madmen you see on tv".

And how do you know what snorlax is talking about? She never mentioned "madmen on tv". She seems to have an unfounded prejudice about discussing psychopathy which is alarming. It's like psychopathy is a taboo.

snorlax locked it because she thought the word 'psychopath' was derogatory. Ergo, she locked the thread because she knows little about psychopathy.

I don't like it when you underestimate a researcher's long time observations of psychopathic behaviour. I really don't like that.

"Would you call ADHD children psychpaths? What about autistic people? They both show some of the symptoms of psychopathy."

No I wouldn't call them psychopaths. Those who would are silly and need some serious education. But did I request anyone to say that they were? No. And those who would could simply be banned!

"The thread that was locked didn't seem like an "I want to learn" topic but something more like staring a train wreck."

Well, that was not my intention. But I am not going to apologise because you misinterpreted me that way.

solicitous · 08-12-2005 02:52AM

Your last post was just a little bit sensationalist to be honest. I think most people in the psychology profession would frown upon the points you put across.

I quote you:
"Would you call ADHD children psychpaths? What about autistic people? They both show some of the symptoms of psychopathy."

I'm not judging you, I just do not agree with you on this matter.

Myksyk · 08-12-2005 09:16AM

Quick point. APD is an adult diagnosis, not relevant to children. Children with serious anti-social behaviour are usually clinically described through diagnoses like Conduct Disorder or Oppositional Defiant Disorder. A diagnosis of Psychopathy in adulthood usually requires that the person had some sort of conduct disorder as a child.

With regard to therapy, all the current research with regard to clinical outcomes for people with APD depressingly indicates that it does more harm than good.

Myksyk · 08-12-2005 09:54AM

In addition, we should note that all diagnostic criteria are 'convenient labels' ... this is why we use them. For example we use the label 'depression' to describe a wide and varying array of cognitive, behavioural, physical and emotional symptoms. These labels are semantic shortcuts. Nonetheless, this is a valid and appropriate process as long as people are aware of individual differences across any one diagnostic category. So yes, people with APD vary greatly in their presentations but all will fit certain essential criteria (jumping a queue therefore would not be enough to fit anyone within the category

). This is similar for example to schizophrenia, where presentations can vary very widely (in fact they can be entirely different) but they meet the diagnostic criteria by which mental health professionals work (e.g. DSM-IV or ICD manuals).

With regard to the 'naming' of problems for clients, this is a complex issue. Given the negative connotations of psychopathy it would probably not be constructive to discuss this with a prospective client with APD. Instead you would probably concentrate on ways of assessing and addressing their pervasive maladaptive patterns of behaviour, cognition and emotion. However, as I said current outcome research indicates that therapy with people with APD is not useful. On the other hand it may be useful at times to name someone's problem for them - schizophrenia comes to mind (even though this too has negative associations inthe public mind with the desigantion 'schizo' often being ignorantly and abusively thrown around).

And just so we don't confuse the issue. Psychopathy is a term related to the diagnosis of Antisocial Personality Disorder. Psychopathology on the other hand is a very general term for any sort of mental health problem, referring to any and all psychological problems, from mild depression to chronic schizophrenia.

Oh yes ... Vangelis ... calm down!

snorlax · 08-12-2005 10:55AM

Im a mental health worker and recieved 64%in psychiatry so i am aware of the terms used by psychiatry. you must also bear in mind that DSM classified homosexuality as a mental illness, im sure many people would take issue with that.

my views are personal not scientific in that i dislike that term becuse of the context people use it in (and often misuse it in that regard), as such i have a disliking to the term wether recommended by DSM IV or not, also it goes against OT and humansitic theory which i take it you nnkow nothing about and is based on the belif that a person is more then the sum of their condition. people rarely use the term mental illness in an ignorant or negative way so i have to say i prefer the term wether im being pedantic or not.

on another note that thread was locked for the sole purpose it has no merit except to seve the purpose of satisfying a user's curiosity. it could also violate confidentiality if people know other partys or give details you should know that if you work in the area. also i don;t think it was very well, thought about and we certainly do not need three threads on the same topic. duplicate copies of threads results in a banning in most forums.
also you should show more respect and avoid personal abuse, and not act so hysterically if someone questions your judgement. obvioulsy you know nothing about humanistic psychology or what an OT does.

btw personal abuse also merits a ban

Myksyk · 08-12-2005 01:55PM

Another quick point. DSM-IV does not classify homosexuality as a mental illness. It was removed as such in 1973.

snorlax · 08-12-2005 05:14PM

it actually was altered in 1980 but not fully till removed as condition till 1986.

it still considers transvestites as having a psychiatric disorder in the most modern edition of DSM IV.

American Psychiatric AssociationIn 1973, the voted to remove homosexuality from their Diagnostic and Statistical Manual of Mental Disorders (DSM).
Subsequently, a new diagnosis, "ego-dystonic homosexuality," was created for the DSM's third edition in 1980. This meant someone who had "distress" about their sexual orientation.

. Ego dystonic homosexuality was indicated by: (1) a persistent lack of heterosexual arousal, which the patient experienced as interfering with initiation or maintenance of wanted heterosexual relationships, and (2) persistent distress from a sustained pattern of unwanted homosexual arousal.
Gregory M. Herek, Ph.D. writes:
"The new diagnostic category, however, was criticized professionally on numerous grounds. It was viewed by many as a political compromise to appease those psychiatrists – mainly psychoanalysts – who still considered homosexuality a pathology. Others questioned the appropriateness of having a separate diagnosis that described the content of an individual's dysphoria. They argued that the psychological problems related to ego-dystonic homosexuality could be treated as well by other general diagnostic categories, and that the existence of the diagnosis perpetuated antigay stigma."
In 1986, the diagnosis was removed entirely from the DSM. The only vestige of "ego-dystonic homosexuality" in the revised DSM-III occurred under "Sexual Disorders Not Otherwise Specified," which included persistent and marked distress about one's sexual orientation.
The DSM 4th Edition (DSM-IV) was published in 1994, followed in 2000 by the DSM IV, Text Revision, or DSM-IV-TR. These editions include "transvestic fetishism" and "gender identity disorder" (GID) as disorders.
As Katherine Wilson, Ph.D. notes:
"Recent revisions of the DSM have made these diagnostic categories increasingly ambiguous, conflicted and overinclusive... The result is that a widening segment of gender non-conforming youth and adults are potentially subject to diagnosis of psychosexual disorder, stigma and loss of civil liberty."

The APA voted in 1987 to "urge its members not to use the '302.0 Homosexuality' diagnosis in the current ICD-9-CM or the '302.00 Ego-dystonic homosexuality' diagnosis in the current DSM-III or future editions of either document" (APA, 1987). They took this action because, although the American Psychiatric Association dropped homosexuality from the DSM-IIIR, the revised manual was not expected to be published immediately. Furthermore, at the time, another widely used listing of mental disorders – the World Health Organization's International Classification of Diseases 9th edition (ICD-9) – still included homosexuality as a diagnosis. In 1992, the WHO removed homosexuality from the ICD-10.

Myksyk · 08-12-2005 05:52PM

Good. I think it is impotant to clarify that homosexuality is not considered a mental disorder.

I would ask for caution around uses of terms like 'psychiatric disorder'. This is not useful. The diagnostic manuals, flawed as they are, attempt to describe a vast range of problems which may have a psychological factors as causes or which cause psychological problems. Their appearance in DSM does not mean that they constitute a 'psychiatric disorder'. For example, premature ejaculation is included ... clearly not a psychiatric disorder but may have a psychological cause. Likewise problems like 'sleep disorders', 'anxiety disorders' and 'substance-related disorders' are included but are obviously not 'psychiatric dosorders'. In other words I'm not 'psychiatric' just because I have 'caffeine Intoxification, insomnia or an irrational fear of spiders

.

I don't fully understand some of your arguments regarding psychopathy (or APD or Sociopathy). You say it 'goes against OT'. How can a specific disorder 'go against OT'? Do you mean the label of Psychopathy or APD goes against OT? If so, surely no more than the label 'Schizophrenic' or 'Depressed'. 'Psychopathy' is just another label for a category of symptoms (or more correctly in this case, a pervasive pattern of behaviours, cognitions and emotions).

'Psychopathy' is estimated to occur in approximately 1% of the population and is therefore as common as schizophrenia. It is a real and identifiable disorder of personality as we understand it at present. It has very serious implications for society and is worthy of our serious attention. It is not just serial rapists, murderers or sadists who 'may' be psychopathic (sociopathic is another term for the same presentation), the vast percentage of people with APD/Psychopathy/Sociopathy are never violent but may engage in seriously anti-social behaviour all the same (You may be far more likely to find them in big business or politics).

You say that you prefer the term 'mental illness' but I think this is a flawed position. Personality disorders are specifically regarded as being examples of psychopathology but not necessarily mental illness. This is why they are categorised as Axis II disorders in DSM classificatons. People with Personality Disorders are not psychiatrically unwell. They do not lack social comprehension or a knowledge of social norms. They are not 'ill'.

Good examples in film take us through the whole range (e.g. the extreme psychopath as seen in films like 'Silence of the Lambs' or 'Seven' to characters like that played by Michael Douglas in 'Wall Street' or the husband in 'Sleeping with the Enemy'). Of course there are people with dual diagnoses who are clearly anti-social and psychiatrically unwell but these are a small subset of people with APD.

snorlax · 09-12-2005 12:01AM

i am still a student and i also study a wide spectrum of physical disablities aswell as learning and psychiatric illnesses.
it takes a few year of specialisation in either field to become a relative expert, that of which i have never claimed to be.

however i must say disagree with labelling on the basis that it puts people into boxes and other they are used in a wrong or derogatory context like in previous thread i locked( which had no merit scientific or otherwise and as you can see was used in the wrong context and did seek to put people in boxes, so of course i am going to be warey of yet another thread by the same user if i know that they do not seek to understand just to label and stigmaise people further, the title of the previous thread says it all).

i further disagree with the term pyschopath on a personal basis and because it often causes people to overlook the person and just see the condition/ pathology, which is not really what OTs are concerned with, although we study conditions to make us understand better where the person is at we still see the person as capable of change, as an individual who is worthy and deserves individual intervention or client centered therapy as Rogers likes to call it.
most of this theory would stem from the Canadian Model of Occupational performance which uses COPM (Canadian Occuaptional performance measure) as it's assessment tool and whereby people rate themselves and their occupational performance and satisfaction with it. then they set goals for themselves in conjunction with the OT eg be able to communicate more effectively with people may be a goal, whereby the OT would use social groups or even CBT type activity groups to achieve this goal. if anyones interested i could probably further try and clairify what an OTs role with mental illness is as there's lots of people out there who still don't have clue what we do and and who also feel obliged to make sweeping generalizations and judgments on a profession they don't have a clue about.

Myksyk · 09-12-2005 03:25PM

I think you're right to question the whole process of labelling people. However, I'm not sure that that is at the core of diagnoses. The fact is that certain symptoms are indicative of certain distinct disorders. I wouldn't underestimate the importance for people of getting a specific diagnosis (not unlike physical illnesses). In my experience people are often delighted to get a 'name' for their difficulties, the symptoms of which can often initially seem to be vague, pervasive and without cohesion. The purpose of diagnosis and formulation is to render often diffuse symptoms into a recognisable category of problem, within which apparently unconnected symptoms can be understood as part of a greater whole. This is certainly the case for most of the Axis I disorders. I would contend that this is usually a useful exercise for clinician and client.

However, I agree with you that when it comes to Personality Disorders it is less clear if identifying the specific diagnosis for the client is helpful. Usually it probably isn't. The categorising of these particular problems is still a very useful tool for the clinician/researcher/academic but the general consensus with personality disorders is to work with the patterns of behaviour, interaction, cognition etc without reference to some overarching diagnostic label.

snorlax · 09-12-2005 06:08PM

when we're on placement we often get asked by clients if we aggree/ disagree with the doctor's diagnosis as they often are more willing to speak us then the doctors about it.

i'd say it could be one the worst things for an individual and their family to deal with if their son/ daughter gets diagnosed as having an illness such as Schizpophrenia. the stigma that exists in society is huge as they're is a lot of misunderstanding about the disease. it doesn't change the fact that the person is a person and is also a son or daighter and should be treated as such, often the label itself can do as much damage as the illness in that employers if they find out are reluctant to hire someone with the illness or may even give them the sack. i m sure we could spend all day listing some of the terms people use to label them; lunatic, crazy, mad, psycho...iv met some people with Schizophrenia who completely changed my view on it as i saw that these we're real people and not just symptoms of a condition i had read in a text book, they also had real hobbies and often had low self esteem as a result being isolated from their family/ family as a result of some of the negative symptoms.

the thing about it is often a good support network for these people, support in pursuit of their leisure interests and a job they enjoy doing can go a long way in helping to prevent a relapse of acute or positive symptoms. sometimes patients are discharged without this sort of intervention planning and often they don't know how to spend their day, feel lonely and isolated, and find it hard to make new friends and these people will often relapse far quicker then those who are provided for in terms of leisure/ social supports/ a job to occupy their time(which is primarily what OTs do for them, eg facilitate greater independence in their lives and greater enjoyment of it through meaningful occupations).

Myksyk · 09-12-2005 07:43PM

Of course you are right. Getting a diagnosis of a serious mental illness is devastating. However, it is devastating because of what it means in practical terms not because someone used the word bipolar depression or schizophrenia. It is still crucial for someone to know what it is they have so that they can make informed choices about their healthcare on the basis of the evidence out there for its treatment. If I have cancer it will be absolutely devastating to be told so but under no circumstances would it be right to avoid telling the person they have cancer. It does not follow from the use of a label that a person will be treated with disrespect. Diagnosis is merely the first step towards appropriate treatment which in mental health matters clearly includes treating the individual with respect. It also, quite obviously, means seeking to help the person in a multi-disciplinary way ... looking at a vast array of areas where they will need help (physical, psychological, social, occupational, medical, educational, familial etc). This is not some great insight deriving from OT, it is common mental health practice for the last 20 years.

By the way snorlax, if you are a student on placement I sincerely hope your supervisor is strongly advising you of the inappropriateness of agreeing or disagreeing with the diagnoses of senior staff directly to clients.

snorlax · 09-12-2005 08:05PM

of course i would never disaggree with a diagnosis it's not my place and would be a bit stupid, but i don't but it is a topic that comes up frequently, of course i understand the relevance of understanding and knowing the diagnosis but we believe that the person is more then that and as such no two people should be treated in the same way. i don't think i mentioned anything about disagreeing with diagnoses in my posts rather i disagree with the terms being misused/ and being used as labelling/ like the way they are used in the media. if they are used correctly in a medical context for a diagnosis etc i have no problem with that, and im sorry if you misinterpreted me on that.
most of what i posted eg independence in occupation primarily stems form OT practice, eg leisure, self care and productivity are the three main occupational areas we work with. Then other members of MDT would help out with personal care, psychology, medical, and then of course support groups for them and their families.
actually OT has been stemed from the last century(around the 50s and before) when they got people in mental health institions to engage in activities like arts, crafts, exercise and discovered that people actually got better and many of which shouldn't have been submitted to the instuition in the first place, so strictly it has been around for about 50 years and practice theory has evolved a good bit since then as has occupational science which is also derived from physical practice (we worked with people with disablities around the smae time, ill have to check up my books for the exact dates on both)

snorlax · 09-12-2005 08:14PM

iv been looking around the web for a few articles that may help explain our history a bit better

The history of Occupational Therapy(OT) had it's origin in the 1700's during Europe's "Age of Enlightenment". At this time, radical new ideas were emerging for the infirm and mentally ill. Normally, they were excluded from work activities and were treated like criminals and locked in prisons. During this new era concern was given to their mental well being. This dramatic change can be attributed to two very different men, Phillipe Pinel, a French physician, scholar and natural philosopher and William Tuke, an English Quaker.

Phillipe Pinel was of the belief that morally treating the mentally ill meant treating their emotions. The doctrine of Moral Treatment utilized occupation; man's goal directed use of time, interests, energy , and attention; in combination with purposeful daily activity for treatment. Music and various forms of literature, physical exercise and work were used as a method to release the mind from emotional stress and thereby improve the individual's activities of daily living.

William Tuke and his family were also redefining the direction of mental health care. Because Tuke was appalled at the inhumane treatment and the deplorable conditions which existed in the public insane asylums, he developed several principles for the moral treatment of this population. The main approach use was that of the moral concepts of kindness and consideration. He also encompassed the concept of religion which created an atmosphere of family life. Occupations and purposeful activities were prescribed in order to minimize the patient's disorder.

The progression of moral treatment continued into the 1900's as Sir William Ellis and his wife came to be in charge of England's county asylums. This community became a family atmosphere and the men and women both were encouraged to enhance their previous trades or establish new ones in order to support purposeful activity. Sir and Lady Ellis were able to prove that the mentally ill were not dangerous with tools, and were far less dangerous than other unoccupied individuals. The Ellis' were also responsible for developing the idea of an "after care" house, very similar to the halfway houses of today. These places functioned as stepping-stones from total care to limited assistance living care.

The Progressive Era of the twentieth century in the United States initially was not progressive at all for the mental health field. The moral treatment philosophy had waned during the civil war and nearly disappeared with no one to carry on the philosophy. A lack of concern and lack of moral treatment was ushered in with the use of sterilization of the "mental defectives", the insitutionalized insane. Fortunately, in the early 1900's, Susan Tracy, a nurse, employed occupation for mentally ill patients. She also initiated activity instruction to student nurses and coined the term "Occupational Nurse" for this specialty.

Other professionals involved in the rebirth of OT include Eleanor Slagle, a partially trained social worker; George Edward Barton, a disabled architect; Adolph Meyer, a psychiatrist; and William Dunton, a psychiatrist. These professionals, along with Susan Tracy, formed the backbone of modern occupational therapy and ensured acceptance as a medical entity with the establishment of the National Society for the Promotion of Occupational Therapy leading to the present day American Occupational Therapy Association.

Occupational therapy has continued to develop from a deeply-rooted belief in the critical importance of "doing"; of active enjoyment in purposeful activity as a catalyst in the development of self, fulfillment in social membership, social efficacy and self-actualization

Without Conscience - review

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