A Thesis entitled The Impact of Medicalization on Individuals Labeled with Antisocial Personality Disorder by Abberley E. Sorg Submitted to the Graduate Faculty as partial fulfillment of the requirements for the Master of Arts Degree in Sociology ___________________________________________ Patricia Case PhD, Committee Chair ___________________________________________ Barbara Coventry PhD, Committee Member ___________________________________________ Dwight Haase PhD, Committee Member ___________________________________________ Cyndee Gruden, PhD College of Graduate Studies The University of Toledo August 2019 Copyright 2019, Abberley E. Sorg This work is licensed under a Creative Commons Attribution-NonCommercial- NoDerivatives 4.0 International License. https://creativecommons.org/licenses/by-nc- nd/4.0/ An Abstract of The Impact of Medicalization on Individuals Labeled with Antisocial Personality Disorder by Abberley E. Sorg Submitted to the Graduate Faculty as partial fulfillment of the requirements for the Master of Arts Degree in Sociology The University of Toledo August 2019 Though the literature surrounding antisocial personality disorder (and the associated label, psychopathy) is vast, there remains an almost total absence of the voices of people who have been assigned this label from the discussion. ASPD differs from the majority of medicalized diagnostic labels, in that patients who have been given this label are frequently framed as untreatable. The clinical pessimism surrounding this label has led some researchers to argue that the purpose of the ASPD label is not to provide patients with access to appropriate care, but rather to exclude them from treatment by flagging them as lost causes in their medical records. Utilizing a qualitative analysis of online posts written by individuals diagnosed with ASPD, this project seeks to provide a new perspective on the debate surrounding ASPD and medicalization - that of the patient diagnosed as antisocial. I explore how these patients engage with the medicalization of their social and emotional problems, their experiences with mental health service providers, and their critiques of how ASPD is viewed by those who have not been labeled with this disorder. I seek to understand if these individuals accept the clinical pessimism iii associated with the medicalization of their problems, if they desire changes to how ASPD is viewed clinically, or if they reject ASPD as a flawed construct. iv Table of Contents Abstract iii Table of Contents v I. ASPD and Medicalization: The Problem 1 A. Research Questions 3 B. Theoretical Approach 4 C. Conclusion 7 II. Literature Review 9 A. Medicalization and the Creation of ASPD 10 B. Three Orientations Towards Patients Labeled as Antisocial 19 C. Approach One: Clinically Pessimistic Medicalization 20 D. Approach Two: Reformist Medicalization 23 E. Approach Three: Demedicalization 32 F. Critique of the Literature 37 G. Conclusion 44 III. Methodology and Data Collection 46 A. Data Collection 47 B. About This Sample 49 C. Further Sample Demographics 51 D. Conclusion 54 IV. Analysis and Discussion 56 A. An Antisocial Identity in Online Spaces 60 B. Antisocial Social Etiquette: Rules of Social Engagement within v “ASPD Tumblr” 63 C. “Poserpaths” VS “Actual Antisocials:” The Boundaries of “Antisocial Tumblr” 68 D. Medicalization and an Antisocial Identity 72 E. ASPD and Abuse: Experiences Prior to Diagnosis 79 F. After Diagnosis: The Effects of Being Labeled with ASPD on Access to Mental Health Services 85 G. “Is ASPD Even a Real Disorder?”: Critiques of the ASPD Construct 88 H. Conclusion 92 V. Conclusion: The Failures of “Fear-based Discourse” 93 A. Limitations of this Study 94 B. Directions for Future Research 95 C. Concluding Remarks 97 References 99 vi Chapter One The Problem Though the literature surrounding antisocial personality disorder (and the associated label, psychopathy) is vast, there remains an almost total absence of the voices of people who have been assigned this label from the discussion. ASPD differs from the vast majority of medicalized diagnostic labels, in that patients who have been given this label are frequently framed as untreatable. The clinical pessimism surrounding this label has lead some researchers to argue that the purpose of the ASPD label is not to provide patients with access to appropriate care, but rather to exclude them from treatment by flagging them as lost causes in their medical records (Blackburn 1988; Glyn and Appleby 1988; Gunn 1998; Bernstein 2015). This has led some to advocate for major reforms to how ASPD is approached by metal health service providers (Bernstein 2015). Others advocate for a kind of demedicalization, the retirement of the antisocial label in exchange for a new approach to patients with behavioral and emotional problems. Whether mental health service providers and researchers continue to approach ASPD through a lens of clinically pessimistic medicalization, reformist medicalization, or demedicalization, the outcome of this debate will have major impacts on those diagnosed with ASPD, and yet the experiences, opinions and priorities of the people who have been assigned these label are entirely absent from the discussion. While individuals said to have ASPD or psychopathy are often portrayed in fiction, written about in popular psychology books like Kent A. Kiehl’s The Psychopath Whisperer and Martha Stout’s The Sociopath Next Door, and are the subject of much debate across multiple academic disciplines and contexts, real life “antisocials” have been 1 denied a voice in this discussion. Some researchers even argue that the perspective of these individuals is fundamentally unknowable and incomprehensible to “normal” people. Robert Hare claims that “for those of us who have been successfully socialized, imagining the world as the psychopath experiences it is close to impossible” (1993:78). Genre fiction, “true crime” media, self-help and pop-psychology books often present dubious information about ASPD and its associated conditions to a lay audience, which contributes to the alarmism and stigma surrounding this disorder. In academic circles, particularly among criminologists and psychiatrists, ASPD is often approached as a problem of morally deficient individuals rather than a socially constructed label which has developed under certain political, social and historical conditions. This disorder has historically been viewed by many researchers as being “constitutional,” or a product of genetic inheritance, a belief that persists among many (Hare 1993; Milton et. al 1998:16). The primacy of the biomedical model in discourses around this disorder has contributed to an aggressive disavowal of efforts to better understand those labeled antisocial. Some researchers dismiss the idea that there is any point at all to social scientists or others attempting to understand the causes of ASPD or the people who are said to “have it.” Reid writes that this population is “qualitatively different from the rest of us. I care less and less about why they’re not the same... The enemy is at our door. Most of our energy must be diverted to immediate defense, not merely to studying his motivations” (1998:115). Such arguments not only serve to obscure the humanity of individuals with ASPD, but also are predicated on the assumption that social problems are caused by deviant individuals rather than structural inequalities. In fact, opponents to opinions like those expressed above by Reid have written at length on how ASPD and psychopathy 2 function on an ideological level to isolate the origins of social problems like crime and violence in pathological individuals, rather than approaching these problems as a result of flaws in our social system (Jalava et. al 2015; McCallum 2001). Whether ASPD and psychopathy are being framed by biological essentialists as having their origins in an inherently evil set of genes, or critiqued by social constructivists as an ideologically motivated smokescreen calculated to create scapegoats for social problems that extend far beyond deviant individuals, what remains absent from this discussion is the voices of people who have been assigned this hotly contested construct This project seeks to correct this problem, by drawing into the discussion the writings of individuals diagnosed with ASPD, as well as some of their friends and allies. In the following chapters, I engage in a content analysis of blog posts on ASPD written by a total of seventy-five individuals. These writings offer a firsthand perspective on what it is like to be assigned this highly stigmatized label. My goal is to provide insight into the ways in which those diagnosed with ASPD engage with the label they have been assigned. Research Questions The primary research question of this project is as follows: Do individuals diagnosed with ASPD accept this diagnosis as a valid clinical construct? When they think about their diagnosis and how it influences the manner in which mental healthcare service providers interact with them, do they look at ASPD through the lens of clinically pessimistic medicalization, reformist medicalization, or demedicalization? This project also seeks to answer the following research questions: 3 1. Online illness communities operate around a set of mutually agreed upon set of social norms and rules (Gold 2001). What rules exist in online antisocial communities, and how are they enforced? 2. How does being diagnosed with ASPD impact an individual's identity and sense of self? How does