Psychiatric evaluation has been used in many cases to define normal and differentiate between what we perceive to be normal and what is generally not. Is psychiatric diagnosis and evaluation really useful and where does its usefulness end? In this paper we examine the usefulness of psychiatric diagnosis and understand why it is somewhat limited. We study this question with reference to Rosenhan’s “On being sane in insane places” and its response from Spitzer “More on pseudoscience in science and the case for psychiatric diagnosis.
A critique of D. L. Rosenhan’s “On Being Sane in Insane Places” and “The Contextual Nature of Psychiatric Diagnosis”. Psychology has been touted as a pseudo-science and in some sense this is true. To an extent there is evidence that supports this, questioning the usefulness of psychiatric diagnosis considering we are never able to see inside the minds of any one individual. The two positions on psychiatry: for and against: The position of psychiatry has changed over the years and is used in many fields of inquiry which include the criminal justice system which Rosenhan uses as an example.
There has also been substantial argument as to whether psychiatry is a pseudo science or not, with many arguments supporting it. However, as Rosenhan so eloquently puts it: “If sanity and insanity exist, how shall we know them? ”(Rosenhan, 1973: 250). Indeed, ‘insanity’ is an awkward term to define considering that mental elements are only visible in actions and not in their entirety. Rosehan maintains that ideas of what normality is and abnormality are not universally accepted definitions (Rosenhan, 1973: 250).
He also maintains that views on psychiatric diagnoses are not dependent on any hard and fast data, but on the soul discretion of the observer (Rosenhan, 1973: 251). The article by Rosenhan uses an experiment where 8 pseudo-patients are infiltrated into psychiatric hospitals and undergo psychiatric evaluations. These ‘patients’ were of varying social standings and levels of education (Rosenhan: 251). Rosenhan explains how circumstances surrounding the admission of the ‘patients’ was largely fabricated.
What fascinated Rosenhan the most was how easily they were admitted, not having displayed any real pathological symptoms (Rosenhan, 1973: 251). The ‘patient’ spent most of their time writing notes about observation and responded to all rules within the hospital (Rosenhan, 1973: 251-252). Rosenhan explains that all the hospitals were considered good hospitals, that patients behaved normally and that the length of stay was long enough to determine whether or not the patient was sane (Rosenhan, 1973: 252).
Rosenhan introduces false positives, believing that doctors biases are based on the need to rather diagnose a healthy person as sick than take the chance and let a sick person go as healthy (Rosenhan, 1973: 252). Rosenhan tackles the difficult issue of ‘labelling’ and how difficult it is to shake the label of a psychiatric disorder. He states the following: “Having once been labeled schizophrenic, there is nothing the pseudopatient can do to overcome the tag. The tag profoundly colors others’ perceptions of him and his behavior. ” (Rosenhan, 1973: 253).
The question as to whether a person can ostensibly be recognised as psychotic but in remission raised the question as to whether abnormal behaviour can really be defined and noticed. Rosenhan takes one pseudo-patient and explains how perfectly ‘normal’ circumstances are distorted and interpreted into something that may not necessarily exist (Rosenhan, 1973: 253). Spitzer’s critique on Rosenhan and says that in the case of detecting insanity in sane people, or at least detecting insanity in those who are sane but feigning insanity would be detecting just that: the feigned insanity.
The first is the recognition, when he is first seen, that the pseudo-patient is feigning insanity as he attempts to gain admission to the hospital. This would be detecting sanity in a sane person simulating insanity. ” (Spitzer, 1976: 460). He also says that at a stage where the patient is recognised as being sane and acting normal that at this stage they are in remission rather than never having been insane (Spitzer, 1976: 460). Spitzer also says that while Rosenhan had said that the patients were released ‘in remission’, which he argues means ‘without signs of illness’ (Spitzer, 1976: 460).
Arguably then, yes, they are in remission and strictly speaking all ‘normal’ people are in remission. However, Spitzer also argues that while Rosenhan had said that Schizophrenics had been released for the same remission, that this was extremely unusual (Spitzer, 1976: 461). He makes clear what he believes are inconsistencies within the experiment. Spitzer also argues that Rosenhan had written that the notes taken by the pseudo-patients were considered ‘pathological’ by nursing staff, thereby compounding their original diagnosis (Spitzer, 1976: 461).
Spitzer argues that psychiatrists are in fact responding to the pseudo-patients observable behaviour and not to salient characteristics that are underlying in the patient at the time (Spitzer, 1976: 462). Fake hallucinations in patients led to the diagnosis of schizophrenia and Rosenhan had been ambivalent to the this diagnosis and insisted that a number of disorders could be responsible for hallucinations (Spitzer, 1976: 462).
He argues that while Rosenhan is correct, that in the absence of other considerations and process of elimination (drugs, alcohol, concussive histories), the patient can be diagnosed as schizophrenic (Spitzer, 1976: 462). Evident are the differences between Rosenhan and Spitzer. The problem is that while Rosenhan develops his idea of pseudo-scientific explanations via use of experiments, Spitzer defends the psychiatric practice. Spitzer does not in fact deny the complications of psychiatric diagnosis, he does defend it in what he sees to be inconclusive evidence denying it.
If the efficacy of psychiatric diagnosis is questioned, then the usefulness of it is also put under investigation. Rosenhan obviously puts a spoke in the wheel of the psychiatry strong-hold but Spitzer appears to be intent on supporting the usefulness of psychiatry by discrediting much of the research conducted by Rosenhan. Psychiatry as a pseudo-science: The argument surrounding pseudo science and real empirical science has been one to take center stage since Rene Descartes and even beyond. The problem with the efficacy of psychiatry or even psychology is that it is never provable beyond reasonable doubt.
Reasonable doubt: If we are to take the film Primal Fear as an example for this purpose, we see a ‘mentally ill’ youngster playing the mental illness card against the legal influences. It is a convincing act the child plays on both the courts and the psychiatric world as well. What we are able to do in psychiatry is to observe and from that draw a hypothesis but we can never prove that this is the truth. In other words, what is in the mind stays there and only the person in question knows the truth. There is no way to prove beyond reasonable doubt that the person does or doe not experience hallucinations.
Empirical data: Without prove that can be seen the reasonable doubt is always there. We can prove that water can be boiled, frozen or even evaporated because we can see it. Rosenhan therefore has the correct attitude in saying that sanity is defined by various attributes which include, if we dare forget, cultural beliefs. In deepest Africa, what would be termed insanity to Western culture would be considered ‘possession’. The opinion of what mental illness varies from one person to the next. Rosenhan beliefs that hallucinatory illnesses like any other are based only on the visible and observable characteristics of the patient in question.
More mental than the mental: Spitzer argues that, as previously mentioned, diagnosis is made on the characteristics presented even when it is faked. Some may argue that fake actions themselves may constitute a mental illness, making diagnosis once again subject to personal stand-point. The illness presented in Girl, Interrupted is another example of the difference between severe mental illness and that which is merely a symptom of our sickened society. Social aspects are also not taken into account in many instances, making the psychiatric divisible by the social.
Some aspects of mental illness are not determined by intrinsic mental illness, but by social pressures and a changing society. The Marquis du Sade was considered transgressive and over-sexed (nymphomaniac) but by today’s standards he would probably be considered more normal. What we consider normal and what we know to be true and observable are different to what we assume to be true because a psychiatrist tells us it is. In the 1400’s it may have been an abomination to be homosexual, but today it is almost as acceptable as being heterosexual.
Rosenhan makes it clear that mental health is dependent on how much you are able to observe rather than how much you know about the mind. Conclusion: Rosenhan makes use of experiments to see how much of psychiatry is evidence based and how much of it is pseudo-scientific and how much is conclusive and irrefutable proof. The idea of scientific experimentation is based fist on observation, then on a hypothesis, testing the hypothesis and retesting it. Scientific method is necessary to prove whether something can be given as true of false but in the case of psychiatry it can never be proved or disproved.
Rosenhan and Spitzer agree on some aspects and disagree on others. Spitzer agrees that psychiatric diagnosis can only be made on the observed, but Rosenhan exemplifies that fact that observation can be based on a falsity rather than something that really exists. He also states the idea of remission as being the absence of symptoms, which does not mean that it cannot recur or that the symptoms really existed in the first place. Psychiatry, psychology and sociology have always been contested as ‘true’ sciences and in this case it is evident exactly how they gained the label of ‘pseudo-science.