‘How Mad Are You?’ is a two part 2008 BBC Horizon/Discovery Channel Co-Production produced and directed by Rob Liddell. The program explores the relationship between character traits and mental illness and considers the social implications of inaccurate diagnosis of the latter. Ten volunteers, five of whom have been previously diagnosed with psychiatric disorders, are observed and interviewed by a panel of three mental health experts who then venture their diagnoses. The experts include a psychiatrist, a professor of clinical psychology, and a psychiatric nurse. The volunteers and experts have no prior knowledge about one another, and were brought together for this one week study.
Part One introduces the three experts and ten volunteers and explains that the goal of the study is to attempt to recognize six forms of mental illness: depression, social anxiety disorder, schizophrenia, obsessive-compulsive disorder, bipolar disorder and the eating disorders anorexia and bulimia. The panel of experts has one week of observation to identify whether or not any of the volunteers has one of these illnesses. Before beginning, the panelists discuss the insufficient time for a proper psychiatric diagnosis but appear willing to accept the challenge and lend their expertise to the study.
The ten volunteers complete a variety of tasks designed to determine symptoms of mental illness. The first task is to perform a stand up comedy routine in front of a small audience in a pub. Several of the volunteers have difficulty with this task but for the panel the results are inconclusive. As part of the study the panel makes daily predictions as to which volunteers may later be diagnosed with one or another of the six mental disorders. The second task involves problem solving skills and it utilizes the Wisconsin card sorting test for determining bipolar disorder, schizophrenia and obsessive compulsive disorder (OCD). The results are also inconclusive but the panel begins to focus attention on one of the volunteers. The third task involves cleaning up after farm animals, after which the panel is allowed to interview one volunteer. This interview yields the first clear indication that one of the volunteers may be suffering from OCD. The interview is followed by an explanation of OCD and a set of short interviews in which the volunteers are asked about their perceptions of one another.
By the end of the fourth task, designed to detect depression, the panel found that their observations contradicted earlier predictions, with the narrator noting ‘greater confusion is not what the panel was hoping for.’ As the panel will attempt their first diagnosis after the next task, they discuss their observations so far, which is made more complicated because none of the volunteers indicates the classic signs of depression. This segment is followed by background information about depression.
After the fifth task, a paintball team competition designed to display leadership and teamwork, the panel selects a single volunteer for an extended interview. They are then asked to make their first diagnosis by identifying one volunteer that they think has a mental disorder and one that appears to be normal. This segment is significant because although the conditions are not optimal for a proper psychiatric diagnosis, psychiatry is a profession and as such is expected by society to produce results. The panel takes this seriously and compares notes on the ten volunteers, because, as the narrator suggests, ‘one person here might be about to discover their mental illness marks them out from the group,’ while another person ‘could be burdened with a label of a disorder they don’t actually have.’
Part Two opens with a map orienteering task that involves running, teamwork, leadership skills and problem solving, returning to the question of whether or not difficulty with such tasks would be due to mental disorder or simply related to character traits. This again raises the point that diagnoses in this study are based only on observation and interviews over a short period of time, not on the usual clinical procedures. However, the experience remains valuable for what it can reveal about the social implications of labeling and in particular the related problem of social stigma. In fact, the issue of social stigma as the result of diagnosis (correct or incorrect) seemed to be of prime importance to some of the volunteers, while the panel of experts took risks that are potentially present for any mental health professional, that there are social implications of identifying people with disorders, for failing to recognize mental disorders, and in labeling someone with a disorder that they do not have.
Designed to test perception of self with others, one of the most interesting tasks utilizes a computer simulation to illicit paranoid reaction, featuring a virtual reality environment that simulates being on a train among strangers. All characters on the virtual train were programmed to be neutral, but volunteers were asked if any stood out or seemed to be looking at them, which was expected to help determine if any volunteers were imagining that they were being watched. This task raised questions about social exclusion versus paranoid delusion, and was followed by information on schizophrenia. The final task considered decision making by observing if any volunteers jumped to conclusions when asked from which jar different colored marbles had been drawn after being shown jars with differing amounts of each color, even though all marbles were actually drawn in the same sequence from a tray, not from the jars initially shown to the subjects. This raises valuable questions about the experimental method, because various responses were evaluated with averages and norms ultimately determining the basis for a diagnosis, as it is with most other medical professions.
Although it appears to unfairly burden the experts who are asked to diagnose with insufficient data, the program makes the broader point that if the experts cannot tell who has a mental illness and who does not through observation then certainly the public ought to refrain from making any such judgments. Perceptions and observations, whether from experts or the public, are not enough to be sure about mental illness, which often takes long term systematic evaluation to determine. At the same time there are very real and potentially damaging social implications of labeling people with a mental illness, because those who are labeled may then become stigmatized while those who are undiagnosed may be reluctant to seek help if they feel revealing their disorder will stigmatize them.
‘How Mad Are You’ originally aired on the BBC and affiliate stations in November 2008, and is occasionally available for viewing on various viral media sites. The Rosenhan study, ‘On Being Sane In Insane Places,’ was originally published in the journal Science in January 1973 and is available online, and the quote from Rob Liddell is from his article ‘How Mad Are You?’ on the BBC News website, in its 18 November 2008 Magazine section.
[This review is by Yusef Progler and was originally published in the Journal of Research in Medical Sciences, vol. 14, no. 5, 2009.]