The following piece is part of the Quest’s new series featuring final projects of Minerva students. This piece was written for Minerva’s Cognitive Neuroscience course, by Alex Sanchez, Minerva Class of 2020.  To view more final projects, click here. If you are a Minerva student and would like to have your final project published,  fill out this form


Introduction

Increasingly the way mental illness is diagnosed and treated in the Western world is skewing towards pathologization, which can have the potential of creating more of a social separation between those who are perceived as typical and those who are perceived as disordered. To address this issue, I propose a two-pronged experimental study focusing on reconceptualizing diagnosis through an inclusive and dimensional classification system and reforming treatment to address underlying social stigma, and hypothesize that such changes in current standards lead to improved patient outcomes.

Historical Background

A brief history of mental illness diagnosis and treatment is necessary to understand its modern pitfalls. For hundreds of years, mental illness was explained through supernatural or religious causes like demonic possession, resulting in primitive treatment practices such as trepanning. It wasn’t until the 20th century with the rise of psychodynamics and behaviorism that mental disorders began to be viewed as unique disease entities. This concept was further solidified with the introduction of the Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952, sparked by a need for a categorization of disorders of veterans from WWII in order to treat them more effectively (Jutras, 2017). It is important to note then that the way that we conceptualize mental disorders today is rooted not primarily out of scientific discovery but out of necessity . This set the stage for the beginning of criticisms of the DSM and diagnosis that question diagnostic validity that might occur at the expense of practicality and streamlined use.

A famous experiment that sought to address this reliability was the Rosenhan experiment, published in 1973 under the title On Being Sane in Insane Places (Rosenhan, 1973). David Rosenhan sent a group of “pseudopatients” to different psychiatric hospitals around the country under the instructions that they were to feign auditory hallucinations. They were all admitted and diagnosed with psychiatric disorders, but afterwards they acted normally and told staff they felt fine. However, they were all forced to admit to having a mental illness and were forced to take antipsychotic drugs if they wanted to be released. Almost all were diagnosed with schizophrenia in remission before release, at an average stay time of 19 days.

After the experiment was made public, an offended psychiatric asylum staff challenged Rosenhan to send pseudopatients to its facility, and 41 out of 250 new patients were identified by the asylum as potential pseudopatients in the following weeks. In actuality, Rosenhan hadn’t sent any pseudopatients at all.

This led Rosenhan to conclude that “any diagnostic process that lends itself too readily to massive errors of this sort cannot be a very reliable one … it is clear that we cannot distinguish the sane from the insane in psychiatric hospitals” (Rosenhan, 1973, pg. 257). Although critics argued that a psychiatric diagnosis relies largely on patient reports and that faking symptoms no more highlights problems with psychiatric diagnosis than lying about other medical symptoms, nonetheless the study highlighted the danger of labeling and dehumanization in psychiatric facilities.

It also accelerated the movement of deinstitutionalization that started in the latter 20th century with the goal of discharging patients from mental hospitals. The movement itself was sparked by the rise of antipsychotic drugs and the possibility for reduced medical expenses from more home-based care instead of running psychiatric facilities. Deinstitution was an incredibly large scale social experiment, as represented by the graph below which represents its onset in the 1950s with the introduction of the first antipsychotic drugs (“Deinstitutionalization – Special Reports, 2018).

(“Deinstitutionalization – Special Reports, 2018)

The movement sparked community-based mental healthcare in place of institutionalized care, through the creation of community health centers and smaller supervised residential homes for the mentally ill. Deinstitutionalization and community care initiatives led to improvements of patient satisfaction, friendships, and adaptive behaviors, but it also led to deficits in vaccine screenings and medical checks. Additionally, many patients under community care initiatives reported poverty, poor physical health and loneliness. In general, the deinstitutionalization movement was mostly beneficial for Americans with moderate disabilities but was far less successful for those with Serious Mental Illness (SMI) (Pollack, 2013).

However, deinstitutionalization didn’t only affect patients. The rapid migration of patients from psychiatric facilities to their homes often placed immense stress and burden on caregivers who lacked the resources and medical knowledge to provide proper care, which also negatively affected the mentally ill patients in turn. These outcomes highlight the mixed results of a movement that although sound in theory, in practice led to mixed results (“Deinstitutionalization – Special Reports, 2018).

Mental Illness Today

The way mental illness is diagnosed and treated today in the Western world follows the path of categorical diagnosis, medical/psychodynamic interventions, and community based care that was established throughout the 20th century. As mental illness is further solidified within standards of classification and treatment through emerging research, it seems like the issue is being tackled in a consistently productive way, despite some drawbacks. However, there are underlying assumptions related to mental illness that are mostly unquestioned and deserve better scrutiny.

For one part, critics of the DSM argue that there is danger in representing mental illness through a categorical classification system that differentiates disorders based not on degree but in kind. Known as threshold psychiatry or dichotomous classification, this creates single cut-offs that separate the abnormal from the normal, even though health is more realistically reflected by a continuum. As a result, lack of one symptom can lead to a change in diagnosis from present to absent and can leave a large proportion of people with symptoms that do not reach the threshold undiagnosed and untreated, even if they suffer from impairment. This classification system can also lead to a divide that justifies unequal treatment and poorer living standards for a powerless group assumed to be disabled, crazy or violent in the eyes of an empowered group assumed to be healthy, normal and capable (Craddock, 2007).

Perhaps most importantly, this categorization system can lead not only to stigma towards the mentally ill but also self-fulfilling prophecies where self-identity and behavior of a patient might be influenced by the terms to classify them. Certain expectations are implicitly placed on these individuals and over tie they might change their behaviors to fulfill them. This is the viewpoint of modified labeling theory, which posits that such expectations can cause patients to withdraw from society. Those labeled as disordered are constantly rejected by society is apparently minor ways, but those actions add up and can drastically alter self -labels, damaging their quality of life and exacerbating present symptoms. Hence the self-fulfilling prophecy (Maisel, 2011).

Current Paradigm

In the views of others, these exacerbated symptoms only serve to reinforce negative preconceptions of mental illness, creating a vicious cycle of diagnosis, stigma and self-labeling. This reinforcing system, coupled with all of the setbacks of diagnosis and treatment previously mentioned, has contributed to a mental illness crisis that seems to be largely unquestioned and unnoticed today.

Below is a gif of the simulation I created of this system. Click here to access an interactive version (use Safari instead of Chrome, the simulation runs better there).

Legend
  • “+” symbol: Direct relationship
  • “-” symbol: inverse relationship
  • Red: Negative quality 
  • Yellow: Neutral quality (can have both negative and positive effects)
  • Green: positive quality
Instructions
  • Press “play”
  • Hover over “Labeling” and click the “^” arrow once
  • Observe what occurs (Here is a gif of the process for clarification)
  • You can speed up the simulation by dragging the circle on the bottom
  • Try different combinations of increasing/reducing certain nodes to see its effects
Summary of Effects

“Labeling” represents the current way mental illness is diagnosed, based on a system that labels disorders categorically. Labeling leads to “Differences” between those considered normal and those considered abnormal or disordered. This has the potential positive effect of matching a patient to a more effective and appropriate treatment, but it can also lead to inappropriate treatment if individual differences are not taken into account beyond just the diagnostic criteria. Additionally, this way of categorizing differences could lead to societal stigma previously mentioned. This results in the self-fulfilling prophecy and feedback loop between stigma, self-labeling, and differences, where the effects of self-labeling reinforce the normal/abnormal dichotomy. Self-labeling can also exacerbate symptoms, and treatment for these symptoms is often ineffective because it isn’t addressing the underlying stigma as a causal factor.

Updated Paradigm Proposal

Based on this complex system and on the negative effects of mental illness diagnosis/treatment mentioned previously, I propose an updated paradigm which can be accessed here. Below is a gif of the simulation:

Legend
  • Mostly the same as the previous simulation
  • Blue: proposed intervention
Instructions
  • Press “play”
  • Hover over “Dimensional Classification and click the “^” arrow once
  • Quickly click the “^” arrow once of the other blue nodes
  • Observe what occurs (Here is an updated gif of the proposed intervention)
  • Try different combinations of increasing/reducing certain nodes to see its effects
Explanation of Interventions
  • Dimensional Classification: This contrasts with a categorical classification of mental illness like the DSM, instead plotting wellness and symptoms across a spectrum. In such a classification differences between abnormal and normal people is minimized, because I dichotomy does not arise which can lead to stereotyping and stigma. The fallback of a dimensional classification is that it might occur at the expense of lessening appropriate treatment that would have arisen from a more categorical classification of illness (Farreras, n.d.).
  • Integration: As mentioned previously, movements like deinstitutionalization and community care were formed partially with the intent of increasing integration of people with mental illness in order to combat stigma and reduce symptoms through a supportive community environment. However, their pitfalls call for the need for an updated standard for integration, not only formal but social. A good example to follow might be the current mainstreaming program in special education, which places special ed children with non-disabled peers during certain class times based skills (Wang, 2009). It results in a hybrid between specialized care and inclusionary practices, which can be applied to the way mental illness is treated by focusing on community care while also increasing resources for caregivers and standardizing mental health checkups so as to not allow any individuals to fall into the cracks unseen by professionals . Within the paradigm proposal integration would help to reduce mental illness stigma by focusing on social cohesion between those with and without mental illness while also more effectively treating symptoms through participation in social behavior.
  • Morita Therapy: Morita therapy is a relatively new form of therapy founded in Japan which in this paradigm proposal would seek to reduce symptoms that arise from self-labeling behavior. Unlike Western conceptions of therapy, Morita therapists believe that symptom combat interferes with the natural recovery process and leads to worsening of symptoms. The aim is not to cure undesired symptoms but to teach patients how to live with, rather than be unpleasant with, unpleasant emotions that arise from these symptoms. Within the updated paradigm, Morita would help patients to reduce their own self-labeling behavior by helping them understand that such symptoms can be lived with and do not have to define the individual. This would help to reduce the prevalence of the symptoms themselves (Sugg, 2016).
  • Bias Training: Lastly, bias training for professionals working with people with mental illness could help to reduce institutional stigma that exists within the psychiatric community. Psychiatric workers could be trained to be more aware of the social psychology of their facilities and its effects on patients (Rosenhan, 1973), and to practice power-sharing that could be used to question if mental illness prejudices have been expressed when communication between a caregiver and patient breaks down (Kalinowski, 2018). This would help to combat the implicit ways that caregivers reinforce perceptions of disability in patients, and lead to more effective patient outcomes as a result.

Conclusion

It is clear that this proposal is more of an ideal rather than a practical experiment that can be easily tested. However, it is vital that the current mental health crisis is first viewed from a broad perspective in order to understand what the end goal should be. Once the intended society-wide outcomes and the nodes within the system that are susceptible to positive change are made clear, then one can move forward and think about ways to test and measure the outcomes of each of the interventions. Although this visualization might make the issue of mental health seem too daunting and complex, it is through this very complexity that there is hope, for it allows for change through multiple avenues that all contribute to the increased livelihood of those who need it most.