Tuesday, November 18, 2008

blurred boundaries, fine lines - how mad are you? (part 2)

go to blog on part 1

Related Post - Mental - a History of the Madhouse

Tonight BBC2 broadcast the second part of How Mad are You? This is a documentary which repeats, in a controlled environment, David Rosenhan's 1972 experiment whereby "pseudopatients" were admitted to a psychiatric ward - and each of them exited with a diagnosis of mental illness.
Horizon brought together a team of three mental health professionals to assess ten people, knowing that five of them had been diagnosed with a mental illness in the past, but not knowing which five.

Towards the end of the last programme, the team scored a hit when they correctly diagnosed Dan with OCD. Dan went on to explain that he felt proud to have OCD on the basis that your mental illness is part of you - our minds are inside any condition or situation that affects them.

It was to be the last correct call of the first programme. In the second, after an exercise that saw participants trying to shrink a "stretched" photo of themselves on a laptop to what they thought they really looked like, the team noted that, while most people overestimate their size by up to 10%, Alex had done so by 30%. When they asked her if she'd had an eating disorder she replied that she had, and later elucidated that it had nearly cost her her life - but there's always hope: she's been well for 12 years now.

There was much discussion among the professionals - Michael First, Professor of Clinical Psychiatry at Columbia University, psychiatric nurse Ian Hewlett, mental health advisor to the Royal college of Nursing and Richard Bentall, Professor of Clinical Psychology at Bangor University - on what constituted a basis for a diagnosis, and what was merely a part of the personality - as Bentall stated, scratch anybody and you'll find an "eccentricity".

A case in point was a test in which the "patients" had to guess from which unseen tub of different mixes of coloured beads an operator was choosing, one bead at a time. Beforehand we saw the team discussing the significance of the test: it might be useful in helping identify somebody who was prone to delusional thinking, who might make a prediction based upon a less than average amount of beads. Vicky called her choice after one bead was drawn. Ruby Wax - see bottom of page

The team thought this was very significant, but were cautious: they had wondered if Vicky might have been diagnosed with schizophrenia in the past, but Bentall and First urged caution on the grounds that to present a patient with this diagnosis was the psychiatric equivalent of a diagnosis of cancer.

Except, it isn't always. It's a daunting diagnosis, certainly, but on the BBC's Headroom site is an interview with Stuart (not the documentary's Stuart), who won a travel fellowship from the Winston Churchill Memorial Trust to travel to Everest Base Camp, a "journey of ups-and-downs" to represent his recovery from schizophrenia. Stuart said that the most important advice he could give Click to go to the Winston Churchill Memorial Trusthealth prefessionals was not to be afraid to give hope to people diagnosed with schizophrenia - "recovery and a meaningful life, while difficult, is possible".

Stuart related a tale of being dumped by a date because she had found out his diagnosis by googling him, and told him on the phone "I have to protect my children". His video was on the subject not of schizophrenia but stigma - as one of the taglines from the "time to change" anti-discrimination campaign states, "people found my cancer easier to deal with than my depression".

The team asked Vicky tentatively, "have you ever had a significant psychiatric problem of some kind or other?" she answered that she hadn't, and added "I've always been like this".

To cut a long story short, having been challenged to identify five mentally ill people out of ten the team correctly identified two, and two people were left with what the team had voiced fears over - doubts about what in their behaviour suggested they'd had a psychiatric diagnosis. Significantly (I think) Yasmin, who disclosed at the end of the documentary that she had been diagnosed with depression, had been initially identified by the team as the person least likely to have had a diagnosis. This said to me that mental illness isn't the end; as I've experienced in my own life, recovery is always a possibility.

In one sense it was positive that the team had a 60% failure rate - as Vicky stated, it showed "what a fine line there is" between appearing mentally ill and not; and indeed the programme's Stuart voiced relief at having recovered so much from the bipolar disorder that had cost his his relationship that he appeared "well" to a panel of three top mental health professionals. They themselves had commented how blurred the boundaries between diagnoses could be, to such an extent that at one point they considered "swapping" a participant's diagnosis from depression to bipolar disorder.

Beyond the fine lines and blurred boundaries, however, is the reality of many in-patient wards today. In the documentary, the team had access to DVD footage of the participants' tests, and of much of their day. In too many wards there is a rushed, hassled team, sometimes labouring under a hierarchical system (although this is changing), passing information across to each other and up the line to others who don't have time to see individuals for great amounts of time.

In some localities, ward closures mean that only the most ill people can get an in-patient place, which increases pressure on the staff - and it has to be said that dealing with a wardful of people which can contain some floridly psychotic patients, other very anxious people and still other deeply depressed individuals isn't the easiest working environment in the first place.

There is hope, however - self-help groups are flourishing, including in cyberspace, and groups like "time to change" are working to break down preconceptions and stigma. Hopefully their work will include the aforementioned phenomena as they exist among mental-health workers too, including advice on how to treat those who fall into the cracks between diagnostic categories, and how to be big enough to say something that can be hard to say: "got it wrong there".

The most positive thing about this 2-part documentay, I think, was that I wouldn't have picked anybody out from the 10 participants as having had a mental illness.

At one point Ian Hewlett stated that, the statistics on having a serious episode of mental illness being 1 in 4, "we're not talking about 'them', we're talking about us", upon which Richard Bentall disclosed that he'd suffered from depression earlier in his life. I can remember a time when having been sectioned (certified) would have militated against being accepted for training as a psychiatric nurse but now, thank God, this is no longer a bar.

Congratulations again to all the individuals involved in How Mad are You, participants and professionals alike, for their courage.

View the documentaries on BBC i-player until 23 December 2008:

How mad are you? - Part 1

How mad are you? - Part 2

You can also find many useful mental health resources with Ruby Wax at Ruby's Room.


  1. Hi Thanks for your positive comments on the Horizon documentary. I have avidly read all reviews about the programme as i was one of the 10 volunteers at Hever. Some reviews have completely missed the point of the programme and complained that it it trivalised mental illness. It did not, it has just opened up a discusion about it and has shown that peoplewho have been diagnosed are not two headed monsters. Since doing the programme so many people have come up to me and talked about traits in themselves that could be seen as OCD, depression and socail anxiety. It is so refreshing. The only thing that i disagree with you about is that Dan was the panel's only success. They also guessed me after the body image task. I was amazed that they were able to diagnose me as i have been well for 12 years but i still think for people suffering with annorexia now i can be a positive image as i do live a very full and happy life, all the programme proved was that my body image is still a bit screwed in times of stress. Alex

  2. I agree with Alex; the point is that attitudes and efforts toward diagnosis need to be worked on. Psychiatry and psychology are in their infancy - there's a long, long way to go. Assumptions that current knowledge is anywhere remotely near complete merely hinder progress.

  3. Alex - I've watched the documentary again and was shocked that I'd missed your diagnosis. I really do apologise for this, and have rewritten about a third of the post. I think you and everybody else were very brave - I don't think, being manic depressive, that I'd have had the guts to participate in such a study. But I predict that these two episodes will be part of the training régimes for doctors, psychiatrists, psychologists and psychiatric nurses for many years to come.

    Pam - I couldn't agree more. I think the original definition of psychiatry still stands - a blind man in a dark room looking for a black cat that isn't there.


  4. why would you ever put a fluro green background? It makes the content so much harder to read..


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