Ok, so first of all, this blog is not in anyway saying that you should doubt the existence of the psychiatric condition that I am going to reference herein (schizophrenia). Secondly, I am not saying that you should doubt, ignore or reject the clinical advise or prescriptions given to you by your healthcare professional. Nor does what I am about to say, invalidate a diagnosis. Assuming this, would be ill-advised and potentially dangerous to the health and well being of a person who may really need the help that professionals provides.
What I am saying is that the diagnostic process should ideally be a collaborative process between the patient/client and that persons’ loved ones where every possible. This should be a process that is exhaustive and only places a label where rigours analysis of the data has left no other credible explanation for the clusters of manifested behaviours. This conversation is not designed to make the life of healthcare professionals more difficult, it is intended to create a situation where healthcare professionals are encouraged to transparently share the diagnostic process and drive a level of rigour that can only be achieved through strong levels of accountability.
So, lets start off with the statement that medical science is not an exact science and more specifically psychiatry is potentially even less so. For this reason, we should be particularly careful of labels that are used to define point at which we depart from what is considered to be the realm of normality. Now I am not trying to initiate an metaphysical argument about the nature of reality and the mind’s supposed transcendent qualities. No, this is a simple point about false assumptions, biases and heuristics.
The case that I am going to talk about, is not without methodological flaws as a quantitative analysis, but as qualitative example, the outcomes are, if nothing else, instructive.
In 1973, the journal Science published an article by David Rosenhan, which detailed his and his confederates’ actives between 1969 and 1972 where they attempted to gain admission as psychiatric patient into a total of 12 psychiatric hospitals as patients.
Let me be clear. The they were fake psychiatric patients because none of them had ever had a history of mental illness and the one symptom that they were told to present with, was auditory hallucinations of a voice that said the words, thud, hollow and empty.
All of the hospitals accepted the pseudo-patients in and all but one were diagnosed with schizophrenia and the one was diagnosed with manic depressive psychosis. Upon admission, the pseudo-patients were instructed by Rosenhan to act completely sane and to advise staff that they no longer experienced the hallucinations. The idea here was that the hospital staff would recognise their mistakes and discharge the patients minus their label, and be considered perfectly sane.
What actually happened was that each one of them was discharged with the label of schizophrenia in remission after an average of 19 days inside, with a range of 7 to 52 days.
This study calls into questions the reliability of a diagnostic system that relies so heavily on self-report, ambiguous behaviours and the judgement of professionals who are immersed within a context that clearly biases their interpretation of what may otherwise be perfectly normal acts. To illustrate this point, the note taking behaviour of the pseudo-patients who were documenting their experience in the hospital, was identified by a nurse as “writing behaviours” and inferred to be pathological.
It is fairly easy to understand why the professionals who did the diagnosis would be more likely to diagnose an illness rather than not. The idea of misdiagnosing a sick person as healthy, carries significant implications that may see a misdiagnosis as a lesser of two evils, that is erring on the side of caution. However, when we are talking about mental illness, we are talking about conditions that carry with them a certain stigma and the label of crazy is clearly hard to shake. You are unlikely to be shunned, or hidden away from society, or discriminated against with a diagnosis of cancer, like you are with a diagnosis of crazy. There is so much that people do not know or understand about mental illness, and popular culture has lead us to believe that a sensationalised version of every case of insanity, is a probabilistically a real cause for concern.
To finalise the story, as a reaction against the findings of David Rosenhan, a teaching hospital challenged him to send his pseudo-patients to them over a period of three months. The hospitals staff, doubted the outcomes of his study and were willing to put their diagnostic capability up as a demonstration that Rosenhan was fabricating his out results. In the 3 months that followed, 193 patients were admitted for psychiatric treatment. All staff that had significant contact with the patients, that is attendants, psychologists, psychiatrists, physicians and nurses, were asked to rate the likelihood that there patient was in fact a pseudo-patient. Of those patients, 41 were rated, with high confidence, as likely to be pseudo-patients but at least one member of staff, 21 by one psychiatrist and 19 by one psychiatrist and one other member of staff. These professionals were clearly on their game. The problem was that Rosenhan did not send any pseudo-patients at all.
Labels are often useful and necessary. They allow us to convey a concept and a set of implications of that concept in a succinct and arguably accurate manner. They support a taxonomy that facilities the treatment and rehabilitation of people in need by caring and mostly competent health professionals. That is presumably their intent.
However, they can, at times, convey more destructive and corrosive ideas about what that person is likely to do and misguided implication about their value to a society as a whole, which may contribute to the unfortunate dehumanisation of people who more than most, need to be members of a society that wants them.
To avoid this, we should be positive, active participants in the diagnosis and treatment processes of mental illness, to ensure that recovery is achieved and that the label does not become the end in itself.
Thank you very much for reading, I will catch you again soon.
-Rod Peredo - SOCM Services
Watch the video to this post at: https://youtu.be/9WEcXSSREpc
