The Problem of Diagnosis

The sociological model of mental illness gains credibility when we look at re- search on the problems with psychiatric diagnosis. These problems became a po- litical embarrassment for psychiatrists (medical doctors who specialize in treating mental illness) after a famous experiment by psychologist David Rosenhan. Rosenhan and seven of his assistants had presented themselves to 12 mental hos- pitals and complained of hearing voices but otherwise acted normally. The hos- pitals diagnosed all eight “pseudopatients” as mentally ill and admitted them for treatment. After they were admitted, all behaved normally, leading 30% of the other patients to identify them as frauds. The staff, however, never noticed anything unusual about these pseudopatients. It took an average of 19 days for them to win their release, with their symptoms declared “in remission.”

When these results were published, psychiatrists objected vociferously that the results were some sort of fluke. In response, Rosenhan agreed to send pseudopa- tients to another hospital and challenged the staff at that hospital to identify the pseudopatients. During the three months of the experiment, the staff identified 42% of their new patients as pseudopatients even though Rosenhan really had not sent any!

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These two experiments vividly demonstrate the subjective nature of psychi- atric diagnosis and its susceptibility to social expectations. Within the context of a mental hospital, staff members quite reasonably assume patients are ill and inter- pret everything patients do accordingly. When, for example, one bored pseudopa- tient began taking notes, a worker officially recorded this “note-taking behavior” as a symptom. Conversely, when staff members expected to find pseudopatients, they interpreted similar behaviors as signs of mental health.

The problems with diagnosis are particularly acute when therapists and pa- tients lack a shared culture. With the rise in immigration to the United States over the past generation, doctors increasingly must diagnose and treat patients whose symptoms don’t even appear in Western textbooks. For exam- ple, a common symptom of psychological problems in Japan is a debilitating fear that one’s body will embarrass someone else, while a common symptom among Malaysian men is intense fear that their penises will recede into the body and somehow kill them. The American Psychiatric Association (APA) now offers all its members materials designed to help them consider cultural and ethnic factors in their work and require training programs to cover cross-cultural issues.


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