Ethics of Diagnosis

Every time a psychiatrist diagnoses someone with a mental disorder, one thing is certain - life for that person will never be the same.  Hopefully, the patient will receive the help they need - either therapy or drugs, or a combination of the two - that will enable them to lead a full, happy life.  Less hopefully, the label of "mentally ill" might hang over that person like a dark cloud, affecting their employment, relationships, or even their very sense of self.
Think Critically

On the 24th of March, 2015, a young co-pilot named Andreas Lubitz deliberately crashed the Germanwings plane he was flying into the French Alps, killing himself and all 149 people on board.  A later investigation found that Andreas had suffered from severe depression, and had been taking medication for his illness.  You can read more about this tragic event here

In response to this incident, a politician proposes a new law.  According to this law, any person who is responsible for the safety of others - such as pilots, doctors, police officers, and so forth - will be required to disclose all history of mental health treatment.  Employers will then have the right to review the mental health records of these people, and terminate the employment of anyone who might pose a threat to the safety of others.

  • You are arguing in favor of the proposed law.  Think of three arguments why people in positions of responsibility should be required to disclose their mental health records

  • You are arguing against the proposed law. Think of three arguments why people in positions of responsibility should not be required to to disclose their mental health records


Ethics of mental health

The story of the depressed pilot reveals how complex the ethics of mental health can be.  On the one hand, you will likely sympathize with victims' families, who might be outraged that the safety of their loved ones was placed in the hands of a very mentally unstable young man.  On the other hand, you might also wonder at the consequences if everyone with mental health issues was excluded from important jobs.  Who would seek help from a psychiatrist if it could mean the end of their career?

Ethical issues in the diagnosis of mental illness include the following:

  • Stigmatization.  Being called "mentally ill" can have profound consequences for how others perceive and respond to you.  Despite efforts to increase understanding and tolerance, many people still perceive mentally ill people to be dangerous, unpredictable, or beyond hope.  Historically, mentally ill people were often forced to receive treatment against their will, or were even locked away in psychiatric facilities.  Employers may be wary of hiring people with mental health issues, friends might seek greater distance, and potential romantic partners may be frightened away.  Imagine you have just started dating someone new - and it is revealed that your date was once hospitalized for hearing voices.  Would you be brave enough to see that person again?

  • Stickiness of labels.  One of the consequences of diagnosis is that it is very difficult to completely shed the label of being mentally ill.  For instance, many former alcoholics - and the leading therapy group Alcoholics Anonymous - believe that if you were ever hooked on booze, you'll forever be at risk of relapsing and becoming addicted again, even after just one sip of alcohol.  In other words - once mentally ill, always mentally ill.  Once someone is diagnosed with a disorder, it is likely that that label will hang above their heads - fairly or not - for the rest of their lives.

  • Confirmation bias.  Imagine that your friend calls you at 11pm.  She is walking home alone after a light night shift at work, and is very worried that a stranger appears to be following her.  How would you respond?  You would probably feel very concerned for your friend's safety, and might even offer to call the police or pick her up immediately.  Now, imagine the situation is exactly the same, except that this particular friend has recently been diagnosed with chronic anxiety.  How would you respond now?  Perhaps you might completely dismiss her concerns, thinking that "her anxiety is just acting up again".  Once someone has been labeled as mentally ill, there is a tendency to see evidence of their mental illness in all of their actions.  Even relatively normal behavior - like forgetting one's keys, having a bad argument with a friend, or crying in bed after a particularly hard day - might be perceived in a completely different light if you know that person is "mentally ill".

In the 1970's, a research named Rosenhan carried out an investigation into the experience of being labeled mentally ill, and his study remains one of the most fascinating and memorable in the history of Psychology.  Read about Rosenhan's study below.


Research: Rosenhan

Aim:  To investigate the experience of being labeled mentally ill, and the ethical issues that are raised by psychiatric diagnosis

Procedure

  • 8 healthy adults were recruited to take part in the experiment.  They all checked themselves into mental hospitals, claiming (falsely) that they heard voices saying words like "empty", "dull", and "thud"

  • After being admitted, the "pseudo-patients" acted normally, and reported that the voices had stopped.  During therapy sessions, the patients answered truthfully about their life

Results

  • All participants were diagnosed with schizophrenia, admitted to hospital, and forced to take psychiatric medication

  • Patients were kept in the mental hospital in average of 19 days (in one case, 52 days) despite showing no symptoms of mental disorders after being admitted

  • At no point did doctors or nurses suspect that the patients did not, in fact, suffer from a mental disorder.  In fact, hospital staff interpreted many examples of normal behavior as signs of mental illness, demonstrating confirmation bias.  For example, when patients came to the cafeteria early for lunch (there was nothing else to do), hospital staff labeled this as "oral-acquisitive symptoms", or when a patient took notes in a diary, this was labeled as "writing behavior"

  • When participants were released, they were diagnosed with "schizophrenia in remission" rather than being considered as cured

Conclusion

  • Once a person is diagnosed with a mental disorder, others tend to dehumanize you, misinterpret your behavior, and forever label you as mentally ill

Evaluation

  • This study took place in real mental health hospitals, involving actual psychiatric doctors and hospital staff, so ecological validity is high

  • The study raised ethical concerns of its own, as participants lied to doctors and hospital staff.  Furthermore, the "pseudo-patients" used doctors' time and medical resources that might have better been used to treat actual patients

  • Some have criticized Rosenhan's interpretation of the study.  Psychiatry relies heavily on self-report of symptoms, and psychiatrists don't expect people to fake symptoms, therefore perhaps this study is not a fair critique of psychiatry.  According to Rosenhan, however, if psychiatrists can't tell the difference between real and fake patients after several weeks of observation, this suggests there is something wrong with psychiatry
Is Rosenhan relevant today?

When Rosenhan's study was published, in the early 1970's, the public reaction was overwhelming.  America was in the midst of a counter-culture revolution, and Rosenhan's study fit the narrative of a psychiatric establishment that was dehumanizing, out of touch, and incompetent.

On the other hand, a great deal has changed in psychiatry since the time that Rosenhan's study was published.  Consider the following points:

  • In the 1970's, a large proportion of mentall ill people were kept in mental health facilities, which became notorious for poor conditions and mistreatment of patients.  Nowadays, most people diagnosed with mental illness remain in their homes and communities, and are encouraged to integrate in society to the greatest extent possible

  • At the time of Rosenhan, knowledge of mental illness was still in its infancy, and certainly far less developed than it is nowadays.  The current DSM V has far more detail on specific disorders and symptoms than the DSM II version that was used at the time of Rosenhan's study

  • Psychiatry has developed better methods of diagnosis, such as structured interviews, which check for specific symptoms.  These methods of diagnosis had still yet to be developed in the early 1970's

On the other hand, Rosenhan's study is not the one investigating how labeling and confirmation bias can skew perceptions of behavior.  For another example of how important labels can be, read the study below.

Research: Langer & Abelson

Aim:  Investigate how stigma, labels and confirmation bias affects perceptions of the mentally ill

Procedure

  • The participants in this study were two groups of clinical psychologists.  The first group were analytic psychologists, who tend to view mental illness as a consequence of internal conflicts and childhood trauma.  The second group were behavioral psychologists, who tend to focus more on identifying and changing negative patterns of behavior, in the here and now

  • Participants watched a video of a man being interviewed about his feeling and experiences concerning his past work

  • Half of the participants were told that the man was a "job applicant", while the other half were told that the man was a "patient".  The label given to the man was the independent variable in this study

  • Participants then rated the man according to how "disturbed" or "well-adjusted" he was.  The rating of the man's mental health was the dependent variable in this study

Results

  • The behavioral psychologists tended to rate the man as fairly normal, regardless of the label

  • The analytic psychologists, on the other hand, rated the man as significantly more disturbed when they were told that he was a "patient"

  • Same man who was described as “realistic”, “unassertive”, “attractive”, “innovative” became “tight, defensive”, “dependent, passive aggressive” and had a “conflict over homosexuality” when labeled a patient

Conclusion

  • In some cases, being labeled as "mentally ill" can cause psychologists to perceive evidence of mental illness where none exists, showing the power of labels and confirmation bias

  • Analytic psychologists may be more likely to be influenced by labels, since they regard mental illness as an internal struggle which may be difficult to see, whereas behavioral psychologists focus more on obvious signs of abnormal behavior

Evaluation

  • This study is a well-designed experiment demonstrating a clear causal relationship between the label assigned to the man and how psychologists described him

  • Since the study involved real psychologists using their clinical judgment, ecological validity is high.  The study has relevance for understanding how psychologists may perceive patients in the real world of treatment

  • This study, like Rosenhan's, took place in the 1970's, and so the results may be different today.  In particular, analytic psychology as become much less common nowadays, as it has come under a great deal of criticism for its unreliability and lack of evidence
IB Psych Matters

Over the past 20 years, there has been an explosion in diagnosis for Attention Deficit Hyperactivity Disorder (ADHD) in the United States, particularly amongst young boys.  Many psychologists assert that ADHD is a real disorder, and failing to treat people with ADHD can lead to lower academic attainment, behavioral problems, and even depression.  On the other hand, some critics have expressed concern that many boys are being diagnosed with ADHD simply because they would rather run around and play, instead of sitting through boring classes all day in school.

Read this article on ADHD, and consider the following:

  • Why do you think younger students in a classroom are more likely to receive a diagnosis of ADHD compared to older students in the same class?

  • What role has the pharmaceutical industry played in the diagnosis of ADHD?  What ethical questions does this raise?

  • Imagine you are a 10-year old boy, who has just received a diagnosis of ADHD.  How do you think stigma, labeling and the stickiness of labels might affect you?  Make reference to the results of Langer and Abelson's research study in your answer


Checklist

  • I can discuss ethical issues relevant to clinical diagnosis, including stigmatization, the stickiness of labels, and confirmation bias

  • I can discuss the aim, procedure, findings and conclusion of Rosenhan's study, as well as evaluating the research
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  • I can discuss the aim, procedure, findings and conclusion of Langer & Abelson's study, as well as evaluating the research

  • I can critically evaluate the relevance of research carried out in the 1970's to the ethics of diagnosis in the 21st century, discussing the extent to which the findings of Rosenhan and Langer & Abelson still apply today

Quiz Yourself!

1.  Mark, an 11 year boy, has come under increased attention from school administrators, who suspect he may have ADHD.  Since then, his Math teacher has noticed that he often fidgets and moves around in his chair, and sometimes interrupts the class with inappropriate comments, all of which may be symptoms of ADHD.  This is an example of which ethical issue:

(a) Stickiness of labels

(b) Stigma

(c) Confirmation bias

(d) Overdiagnosis



2.  In Rosenhan's experiment, after the "pseudo-patients" were admitted to psychiatric hospitals, they ____

(a) reported hearing voices, such as "dull" and "thud"

(b) discussed traumatic events from their childhood

(c) refused to take psychiatric medication

(d) acted completely normal



3.  Which of the following statements in NOT accurate regarding changes in psychiatry since the 1970's?


(a) The DSM III has been updated twice, and the current edition is the DSM V

(b) More reliable criteria for diagnosis, such as structured interviews, has been developed

(c) Most patients are no longer admitted to psychiatric facilities

(d) Diagnosis is mainly based upon objective biological markers, rather than reports of symptoms




4.  In Langer & Abelson's study, what difference was observed between analytic and behavioral psychologists?

(a) Analytic psychologists were more likely to rate the "patient" in the video as disturbed

(b) Behavioral psychologists were more likely to rate the "patient" in the video as disturbed

(c) Analytic psychologists were more likely to rate the "job applicant" in the video as disturbed

(d) Behavioral psychologists were more likely to rate the "job applicant" in the video as disturbed



5.  Which finding from Rosenhan's research illustrates the "stickiness of labels"?

(a) Pseudo-patients were forced to take psychiatric medication

(b) Nurses reported that pseudo-patients were engaging in abnormal behavior, such as waiting in line for lunch far before lunchtime and writing compulsively

(c) None of the doctors or nurses suspected that the pseudo-patients were not actually ill

(d) The pseudo-patients were discharged with a diagnosis of "schizophrenia in remission" rather than pronounced "cured"


Answers

1 - C, 2 - D, 3 - D, 4 - A, 5 - D