Are psychiatric diagnoses really reliable?

 "One Flew Over the Cuckoo's Nest" tells the story of Mike Murphy (Jack Nicholson), in order to escape the forced labor in prison, pretending to be mentally abnormal and being sent to a mental hospital. severe impact.

In 1975, American director Milos Forman's Oscar-winning film "One Flew Over the Cuckoo's Nest" brought a strong psychological impact to audiences all over the world, showing the dark side of the mysterious and terrifying mental hospital. However, the plot of "One Flew Over the Cuckoo's Nest" is staged over and over again in real life. In fact, when the tragedy of "Flying Over the Cuckoo's Asylum" occurs, we have to ask whether there are legal and institutional flaws in the identification, admission and management of mental illness, or whether there is a "human intervention" in the diagnosis of mental illness itself Is there a problem too?

"Crazy" Psychologist - Rosenhan

David Rosenhan is an American psychologist who was a professor of law and psychology at Stanford University. What Rosenhan is really known to the world is his almost crazy "Rosenhan Experiment", because this experiment challenged the validity of psychiatric diagnosis and shook the foundation of psychiatry.

The "Rosenhan Experiment" is like this: In 1972, the United States was mired in the "quagmire" of the Vietnam War and could not extricate itself. At the time, Rosenhan had just completed a double major in psychology and law, and had won a faculty position at Stanford University with honors. Although he did not travel to Vietnam, he found that many people used mental illness as an excuse to avoid drafting. The adventurous Rosenhan asks: Is the diagnosis of mental illness a fake? To what extent is it fake?

In order to verify his conjecture, Rosenhan had a whim and was ready to take a risk and make a daring experiment. So he took out his phone book, called his 8 friends, explained his plan to them, and hoped that they could participate in the experiment. Among his friends are 3 psychologists, 1 graduate student, 1 pediatrician, 1 psychiatrist, 1 painter, 1 housewife, and Rosenhan himself, a total of 9 people. Rosenhan asked everyone to pretend to be a mental patient, and pretending to be a mental patient is not an easy task. To ensure the success of the experiment, Rosenhan and his friends did their homework. They plan on not bathing, shaving, and brushing their teeth for five days in a row, leaving themselves so unkempt that people want to hide when they see it. That's not enough, Rosenhan also checked a lot of psychiatric literature and found a symptom related to "auditory hallucinations", that is, the ear always hears "bang, bang, bang" sounds. Rosenhan not only asked everyone to memorize symptoms, but also to practice how to talk to a psychiatrist. And if the doctor says that hospitalization is needed, as long as everyone is admitted to the ward, they will immediately say that the symptoms of auditory hallucinations disappear and they feel good. At the same time, Rosenhan also taught his friends how to pretend to take medicine: first hide the pill under the tongue, wait for the doctor and nurse to leave, immediately go to the toilet and spit it into the toilet and flush it.

After a few days of "training", Rosenhan and his buddies have managed to turn themselves into a "sloppy king." Afterwards, Rosenhan selected 8 mental illness hospitals. Among these hospitals, some are beautiful in appearance and well-equipped inside; while others are public hospitals with poor equipment, the aisles are filled with the smell of urine, and the walls Full of graffiti. Then Rosenhan hit the road with his friends.

Crabs in the fish basket: easy to get in, hard to get out

On this day, the weather in Pennsylvania, the United States, was exceptionally good. The blue sky was shining with silver light, as if heralding the arrival of a great moment. Rosenhan came to a public psychiatric hospital in Pennsylvania, registered first, and then was taken into a small white consulting room. A doctor received Rosenhan and followed the admission procedure to inquire about his condition. Rosenhan answered skillfully according to what he had rehearsed before. When Rosenhan said that he heard the sound of "bang, bang, bang", the doctor repeatedly confirmed with Rosenhan. After confirming, the doctor pondered for a long time, and then decided to hospitalize Rosenhan. Rosenhan was then taken into a room, told to undress, put a thermometer in his mouth, and put a black band around his arm to measure his blood pressure and pulse. While Rosenhan's measurements were perfectly normal, it was no longer important. Immediately afterwards, Rosenhan was led down a long corridor. When passing through the corridor, Rosenhan saw all kinds of patients in the ward. Their faces were pale and their eyes were dull, as if the world around them did not exist. Afterwards, Rosenhan was taken to his bed, changed into hospital clothes, and asked to take medication by a nurse.

According to the previous experimental design, Rosenhan spit out all the medicine. He then went to the doctor, said he couldn't hear the "bang, bang, bang" anymore and asked when he could be discharged. And the doctor just smiled at him as if he didn't exist at all. When Rosenhan again loudly asked the doctor when he could be discharged from the hospital, the doctor replied with great disdain: "When you are healed." Because he had been diagnosed with paranoid schizophrenia by doctors, he had to be hospitalized. In the following time, Rosenhan was very cooperative. He took the medicine three times a day, and then went to the toilet to vomit. Of course, his other friends did the same. will not care.

Finally, when it was time to be discharged from the hospital, Rosenhan immediately contacted the other friends and waited for the safe return of all the friends. Afterwards, Rosenhan arranged for everyone to review the entire process and details of the experiment together. To the surprise of Rosenhan and his friends, all 9 people were diagnosed as "ill", 8 of them were diagnosed with schizophrenia, and one was diagnosed with "manic-depressive psychosis". The nine people were hospitalized for an average of 19 days, with the longest being 52 days and the shortest being 7 days. In addition, Rosenhan also found that when everyone was hospitalized, the medical staff did not realize that they were actually cheating, and they all interpreted their normal speech and behavior as "sick" behavior.

The rude nurses, indifferent nurses, and uncaring doctors in "Flying Over the Cuckoo's Nest" build a "perfect" environment for the mentally ill

Photo of David Rosenhan himself.

Drop a 'blockbuster' on the psychiatric community

After the experiment, Rosenhan wrote down his entire experimental plan and what he and his friends had personally experienced in the mental hospital with an uneasy and excited mood. ", and the paper was published in the famous "Science" magazine, which was like a blockbuster that shook the entire psychiatric community in an instant. In his paper, he argues that the diagnosis of mental illness is not based on the patient's internal conditions, but is controlled by external situations, so all diagnostic processes are bound to be full of such errors, and the results are unreliable.

Rosenhan's conclusion aroused strong protests and unanimous opposition from many American psychiatrists. Most psychiatrists emphasized that they made a premise before making a diagnosis, that is, "the patient will report the condition honestly", so the diagnosis of mental illness It is also based on "honesty". And Spitzer, the most famous psychiatrist in the United States, also strongly criticized Rosenhan's experiment. This Dr. Spitzer has a lot of background. It was under his leadership and promotion that the first set of rigorous psychiatric diagnosis standards in the United States, the Diagnostic and Statistical Manual of Mental Disorders (DSM), came into being; and in Spitzer. Thanks to the efforts of doctors, the American psychiatric diagnosis excluded homosexuality from the category of mental illness, laying the foundation for the legalization of same-sex marriage in the United States. And he wrote a special article in the Journal of Abnormal Psychology in 1975, fighting back against Rosenhan's findings. Spitzer directly pointed out that Rosenhan's paper did not provide detailed information on the patient's demeanor and speech at the time, and Rosenhan refused to provide the original information on the grounds of confidentiality of the information and to avoid damaging the reputation of individual medical institutions. His experiments are not credible.

Shortly after Rosenhan's research paper was published, a mental hospital pointed out that Rosenhan had been "artificially screened" when selecting psychiatric hospitals in the experiment, and accused Rosenhan of selecting those with inadequate facilities and professional level of doctors. Not enough public hospitals, and confidently sent a gauntlet to Rosenhan, saying: "In the next three months, let Rosenhan send fake patients to his own hospital anytime, anywhere, and the professional doctors of the hospital. I'll find out right away."

Rosenhan was born unconvinced and resolutely accepted the challenge, and said that he would assign a number of fake patients to the hospital for treatment in the next three months. If the medical staff of the hospital could identify these fake patients, the hospital would win. Soon, three months later, the hospital released its report and confidently declared that it had found 41 fake patients sent by Rosenhan. However, Rosenhan said that in fact, he did not send anyone, and the hospital did misdiagnose.

At this point, the whole event is over. Rosenhan has already slapped the American psychiatric community in the face of both positive and negative aspects. However, the influence of Rosenhan's experiment did not end. It can be said that his experiment affected the development of psychiatry in the future. So, what is the reason for such a high misdiagnosis rate of mental illness? And what makes a psychiatric hospital as scary as a prison?

Scientific progress and humanistic care

In fact, the problem that Rosenhan found in the diagnosis of mental illness may be understood in two ways:

On the one hand, it was limited by historical conditions, when more precise scientific research tools had not yet appeared. Dr. Spitzer firmly believes that mental diseases are essentially the same as lung diseases and liver diseases. They are all lesions of human tissue. One day, mental diseases will be explained by the function of brain tissue and nerve synapses. In fact, Dr. Spitzer was right. With the advancement of science and technology, especially the advent of technologies such as nuclear magnetic resonance and genetic testing, coupled with the advent of the information age, scientists can not only use more advanced instruments to collect data, but also use computers to organize and analyze data. This makes it possible to further explore the spiritual and psychological world of human beings. For example, genetic research has shown that the glucocorticoid receptor is a stress coping gene. The mother's kissing and touching will promote the secretion of the glucocorticoid receptor enzyme in the newborn. High levels of the enzyme can enhance the child's future stress resistance.

On the other hand, there is insufficient humanistic care, especially the poor doctor-patient relationship. Rosenhan and his colleagues have found a common phenomenon: in psychiatric hospitals, there is very little communication between patients and doctors. Especially these "fake patients", when they try to communicate with the doctor, the doctor is always perfunctory, especially when the patient is ready to describe the feelings, the doctor does not listen or care at all. The same is true of the medical staff in the hospital, who completely treat these patients as "non-existent". Rosenhan discovered during her hospital stay that female nurses would unbutton their uniforms and adjust their bras in a lounge full of male patients. And the female nurse did this not to tease the patient, but she did not treat the mentally ill patient as a "human" at all. If what Rosenhan says is true, it's not hard to see why psychiatric diagnoses can go wrong.

To answer this question, we must first understand this philosophical proposition: what is a human being? In Rosenhan's doctor, the man is the machine, and the doctor is the machine repairer, repairing wherever it breaks. Mental illness is a problem with the brain, just like repairing a machine. In fact, the human body may have some similarities with the machine, but the human spirit and psychological world are far from the machine. This is because humans have something unique - emotional experience. If two people have emotional experience with each other, it means that the two people have a relationship, and relationship is the basis for both parties to know and understand each other. If there is no relationship between the doctor and the patient, it means that it is impossible for the doctor to fully understand the patient under the condition that the scientific instruments are not advanced enough.

Rogers, a master of American-based psychotherapy, believes that "experience is the foundation of knowing a person." When one person's experience is experienced by another person, a channel of "relationship" is established between two people. And if you want to experience the experience of others, the premise is that you can give the other person sincerity and acceptance, and pay unconditionally positive attention to achieve a state of "empathy" between two people. Only in this way can you truly understand a person. In real life, when we understand a person, we tend to pay attention to what the person said, that is, the person's thoughts and knowledge experience, and often ignore the experience. Because thought is logical and there are traces to follow, while experience is continuous, it is not easy to control like flowing water. Rogers believed that thought is the mirror image of experience, just as we must look in a mirror to see our own face. The image in this mirror is the mirror image, but the mirror image is not real after all. Therefore, to understand a person, it is far from enough to only use thought and logic, and his experience must not be ignored. However, the psychiatric diagnosis at that time had neither advanced equipment nor good relationships to support it. Therefore, if the diagnosis is made only by the static diagnostic criteria of mental illness and the rational knowledge of doctors, misdiagnosis is inevitable.