It’s interesting how the field of psychiatry is still battling the same questions it did 40 years ago. This talk by Jon Ronson reminds me of a 1973 experiment by D.L. Rosenhan that tried to get 8 psychologically stable people admitted to mental hospitals. All 8 “pseudopatients” gave accurate histories, except for their names and professions (some of them were involved in the mental health profession), and they added only one false claim— that they had been hearing voices.
Seven of the pseudopatients were diagnosed as schizophrenic and admitted as mental patients. Once inside the mental institution, they behaved normally, were cooperative and especially courteous, and made no further references to hearing voices. They were all eventually discharged, with the duration of their stays averaging 19 days. Throughout their stay in the institution, not one of them was discovered and exposed by the staff as a fraud, although Rosenhan observed that the real mental patients constantly accused the pseudopatients of being sane, and even insisted that they were professionals sent in to inspect the hospital. Well, I guess it indeed does take one to know one.
Rosenhan concluded that “those whose business it is to distinguish between the sane and insane are unable to do so with any accuracy,” as all of their future evaluations of admitted patients are inevitably distorted by initial diagnoses. To Rosenhan, that sane people can lie their way into being admitted as mental patients, and that their normal behavior once admitted was not detected at all by the staff, can be counted as proofs that the psychiatric diagnostic system is invalid.
Although Rosenhan does raise a sound point, I am leaning more towards agreeing with the argument presented by one of the study’s critic, Spitzer. Spitzer argues that Rosenhan’s study results do not warrant an invalidation of the diagnostic system. Mental health professionals base patient diagnoses on the presenting symptoms. Much like the diagnostic criteria for a bleeding ulcer cannot be invalidated just because someone swallowed a cup of blood and spit it up in an emergency room, leading a physician to diagnose the condition as a bleeding ulcer, so can’t the psychiatric diagnostic system be considered invalid just because a sane person can successfully fake insanity.
Spitzer also pointed out that simply because the pseudopatients did not exhibit any more auditory hallucinations or other signs of mental illness for two weeks, does that indicate the absence of a psychiatric abnormality. This is because aside from the presenting symptoms, psychiatric diagnoses are also based on past behavior. In fact, as Spitzer highlighted, it would’ve been extremely careless for the staff to discount a history of auditory hallucination and declare the patients as being free of psychiatric illness, after just a few days of exhibiting normal, hallucination-free behavior. In Rosenhan’s study, the pseudopatients were released as being “in remission,” and to Spitzer, the fact that they were discharged with such a diagnosis (which was rare) shows the staff at least recognized the cases as atypical, if not faked. Also, that the pseudopatients were discharged in an average of just 19 days constitutes a fairly rapid response to the absence of further presenting symptoms, Spitzer added.
I think there will always be a hovering doubt over the accuracy of psychiatric diagnosis in general. After so many years of dedicated study in the field, mental illness remains a concept hazier and less understood than physical disease. We are all hoping for a more reliable diagnostic system, yes, but as for now, I guess — to borrow some words from Roosevelt — we do what we can with what we have.
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