This is where the distinction between diagnosis and assessment becomes salient. DSM is not intended as a tool for assessment of the environment in which psychopathy takes place. There is no room for looking at a neurotogenic or psychotogenic setting in which the client/patient is living. These odd terms were not even used during the 1950s and 1960s (and still aren’t being used). The closest thing to these terms was schizophrenogenic—which as used to describe families and institutions that produce schizophrenia (a concept that is currently in disrepute).
Psychopathy was (and still is) assumed to be a personal condition, not a condition of the environment in which one lives. We only begin to get a taste for this environmental (assessment-based) categorization when addressing the issue of “institutionalization” in a mental hospital: the pathology that is manifest in many patients after the first few months of institutionalization often overshadows their entering pathology. This dynamic is dramatically portrayed in the novel, play and movie, One Flew Over the Cuckoo’s Nest, and in the accounts of many patients in mental institutions (to which we turn in a later essay in this series).
What then about the third category: character disorder? This category was not only an assemblage of diverse, dysfunctional behavior patterns and a source of considerable controversy and modification over the past 70 years—but was also carrying considerable freight in terms of the assumptive world in which it typically resided. The third assumptive world, social deviation, that I identified and described in a previous essay in this series (Bergquist, 2019) is prevalent. It seems that character disorders are often considered dysfunctional not because they are considered harmful to the person with this “disease”, but because of the potential harm the behaviors resulting from this disease have on other people and society in general.
It is typically assumed (even today) that character disorders cannot easily be treated with psychotherapy (as is the case, supposedly, with neuroses); not does institutionalization do much good—except to keep the person out of the general public. One Flew Over the Cuckoo’s Nest describes the way in which one person with a “character disorder” (Randle McMurphy) can create mayhem in a carefully run and dictatorial mental institution (the novel and movie being based on actual practices in two mental health institutions in California and Oregon).
