Horizon: How mad are you?

Right, well, I’ve spent most of a whole 24 hours gathering my thoughts and sharpening pencils, and I’m now ready to give you my considered opinion on the first half of the two-part Horizon investigation into mental health, which was broadcast last night.  (Note: my opinion may not be considered.  Oh, and I haven’t actually sharpened any pencils.  That would be silly.  I’m typing this on a computer keyboard, for goodness’ sake.  What do you think this is?  The 1970s?)  The programme’s available on the iplayer if you missed it, and don’t want to feel left out.  There’s already a review at Mentally Interesting: The Secret Life of a Manic Depressive, Zarathustra has given his thoughts over at Mental Nurse, and I dare say there are lots of other reviews I haven’t spotted yet.

The basic premise behind the programme is this.  Ten people were sent to live for a week in Hever Castle.  (No, I’m not sure why they set it in a castle either, unless it was to give them some more interesting establishing shots for the narrator to talk over than there would have been if they’d set it in a Travelodge in Nuneaton.  To be fair, the time-lapse film of the dawn coming up over the moat was very pretty.)  Five of the ten people are certified mentalists, having been diagnosed with a psychiatric disorder.  The other five are certified normals, or rather ‘have no history of engagement with MH services,’ as the jargon would have it.  A team made up of a psychiatrist, a clinical psychologist, and an ultra-high-up mental nurse have to assess the ten subjects as they are put through a range of tests that should hopefully give insights into their mental state.  They only get to watch the subjects on TV, and every day they also get to have a five minute interview with a subject of their choice, but they are only allowed to ask questions relating to what they’ve seen – so no questions designed to establish the clinical history of the patients.

The team of MH professionals know that, amongst the group of ten, are one individual who has been diagnosed as anorexic, one who has been diagnosed with social anxiety, one who has been diagnosed with obsessive compulsive disorder (OCD), one who has been diagnosed with unipolar depression, one who has been diagnosed with bipolar disorder, and another who has been diagnosed with schizophrenia.  At certain points they have to choose two subjects, one of whom they think has a history of one of the five mental disorders, and one of whom they think has no history of mental ill-health.  On last night’s show, the panel correctly identified that Dan suffers from OCD, but wrongly identified Yasmin as having no history of any psychiatric disorder.

OK, so on with the review.

First of all, I have a fairly major problem with one of the fundamental premises of the show.  When the subjects were preparing for the stand-up comedy task, the narrator said in a voice-over that ‘one of these people suffers from social anxiety.’  Well, I’m sorry, but they don’t.  They’re in an unfamiliar situation, meeting an entirely new group of people, and doing it all under the gaze of cameras and a TV crew.  Anyone who was actually suffering from social anxiety wouldn’t even have been in the room, they’d have been a small blur of dust disappearing over the horizon.  What they actually mean is that one of these people has suffered from social anxiety in the past.

At one point one of the panel (I think the psychologist, but don’t hold me to that) said about one of the subjects, ‘well, all we can say is that she’s not suffering from a depressive episode at the moment.’  For me, that got straight to the heart of the problem with this programme.  All of the subjects taking part are not currently unwell.  Some of them may have been unwell in the past, some of them may be controlling their illness with medication, but all ten are currently in good health.  Essentially the panel are being asked to spot five healthy people who are mixed in with another five healthy people.  It’s not so much a question of looking for a needle in a haystack as it is looking for a needle in a box of identical needles.

Of course, this makes things very difficult for the panel, and they are forced to look at character traits that might be indicative of a particular MH problem.  So, for example, we saw them discussing the fact that one of the subjects, Stuart, enjoys extreme sports, and wondering whether this was risk-taking behaviour that might be associated with the manic phases of Bipolar disorder.  I can understand their logic, and in fact I noticed that Stuart also did things like lie down in the middle of the farmyard while everyone else was standing up, and remove items of clothing when everyone else stayed fully dressed, and you could maybe speculate whether this was the kind of disinhibited behaviour that might be associated with mania or hypomania.  The thing is, it’s literally impossible to tell.  Loads of people are ‘adrenaline junkies’ without being dangerous risk-takers, and some guys will take off their shirts at the drop of a hat without it meaning that they’re abnormally disinhibited.

I think lots of people would accept the idea that many symptoms of mental illness are closely related to normal character traits and behaviour.  (In fact, this is one of the key principles on which the experiment was founded.)  They only become symptoms of mental illness when they reach a sufficient intensity to start seriously interfering with ordinary life.  In other words, there’s a ‘normal range’ for character traits and behaviour patterns, and an ‘abnormal range’ (and a messy area in the middle where the transition happens).

Since all the participants in the experiment are currently healthy, that means that, by definition, all their behaviour and character traits are in the ‘normal range.’  Again, this makes it almost impossible for the panel.  They have to decide, without the benefit of a clinical history, whether someone who shows a particular pattern of behaviour sometimes experiences a drastic intensification of that behaviour, or whether they don’t.  There is no way for them to do this other than by guessing, so with each ‘diagnosis’ they have only a 50% chance of being right.

In fact, the situation the panel find themselves in is ludicrously contrived.  They have no background information on the subjects of the experiment, and they are prevented from asking questions to establish a clinical history.  As I’ve mentioned already, all the subjects are currently healthy, so there are no major symptoms in evidence.  The panel are also prevented from having all but the most limited interaction with the subjects, which means they cannot establish a subject’s mental state by gauging his or her reaction to particular questions.  Asking a psychiatrist to diagnose a patient in the face of all these obstacles is like asking a GP to carry out a physical examination blindfolded and with their hands tied behind their back.  You are more or less guaranteeing that you’re going to get the wrong result.  If, by some fluke, you do get the right result it will be just that – a fluke.

All this emphasis on the ‘normality’ of people who have previously had problems with mental illness is in lots of ways a good thing.  It dispels the idea that you can tell a mentalist from a non-mentalist just by looking.  It makes the point that, just because someone has been mentally ill once, that doesn’t mean they will always be ill (although, personally, I think that point gets made rather too often in TV programmes about MH, with the result that those people for whom mental illness is a chronic, long-term problem are effectively ignored).  Most importantly, it breaks down the idea that there is a clear line in the sand dividing the sane from the insane, and that must be of huge benefit in tackling stigma.

I think there are also some problems, though.  If I try to put myself in the shoes of someone who has no personal experience of mental ill-health and knew little about it before they sat down to watch the programme, it seems to me there’s a danger that it masks the seriousness of mental illness.  Depression is turned into being a bit of a pessimist; OCD into what you have if you feel like you want to wash your hands after you’ve been clearing up cow shit.  Social anxiety is feeling a bit nervous before you do your first ever stand-up routine in front of some total strangers at a pub.  Bipolar disorder is what you have if you enjoy extreme sports, and so on.

I think there’s really two problems here.  One is that an unsympathetic viewer might decide that, if that’s all there is to mental illness, then their mate Dave down the pub is right, and it’s all just a big con for getting money out of the government.  The other is that a nervous viewer might decide that they have a mental illness (or even a whole range of them) just because they possess some of the ‘suggestive’ behavioural and character traits.  Watching last night’s show, I could have diagnosed myself with OCD (fear of germs; try to wash my hands after contact with things like door handles and light switches that are likely to have been touched by someone else) and social anxiety (feel apprehensive in social situations; sometimes experience physical symptoms like heightened heart-rate and excessive sweating), even though I’ve never been formally diagnosed with either of them.

The programme did take steps to challenge this impression.  It included sections describing the symptoms of a particular illness as it came up for discussion, and these emphasised that psychiatric illnesses are not collections of trivial symptoms.  These sections also gave more concrete information for people who might have been inclined to worry that a couple of minor problems meant they had a serious mental illness.  So far we’ve only seen one sufferer speak about his experiences (Dan with his OCD), but if, once they’re outed, all the other mentalists speak about their past problems in the same way, then that will also be a good source of information about the realities of mental illness.

To sum it all up, I have mixed feelings about the programme.  As a piece of ‘social’ programming, I think it’s pretty good.  I think it will help to de-mystify mental illness, and hopefully clear up some of the fear and stigma associated with it.  I also think it strikes a reasonable balance between on the one hand pointing out that the mentally ill are not an entirely weird and different group of people, and on the other acknowledging that the issues they (we) face aren’t trivial either.

That said, as a piece of ‘science’ programming (and it’s worth remembering it went out as part of the Horizon “strand”), it’s pretty terrible.  Obviously I haven’t seen the second part yet, but it’s very hard to imagine that it will be possible to draw any conclusion from the ‘experiment’ except that when MH professionals aren’t allowed to use their usual diagnostic methods, it’s harder for them to make accurate diagnoses.  There’s a danger, I think, that a ‘general viewer’ will come away with the impression that psychiatric diagnosis (which is, I’d be the first to agree, not an exact science) is even more vague and uncertain than it actually is.  In the grand scheme of things I’m pretty relaxed about this, but I do worry that some anti-psychiatrists might use it as “evidence” in support of their campaigns.

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13 Responses to Horizon: How mad are you?

  1. Omaniblog says:

    Thank you very much. You’ve written a wonderful piece of descriptive analysis. I’ve not seen the programme but feel I’ve now got plenty to think about and imagine. I found your blog via Google Alert for ‘Mental health and depression, and hypomania. I’m trying to find out if I have hypomania. I hope you continue writing about part 2. And I look forward to reading some of your other stuff.

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  3. This really sums up most of what I was thinking about the programme. You’ve saved me a blog post anyhow!

  4. cellar_door says:

    I haven’t seen it, and am finding myself reluctant to watch it. A lot of the concerns you raise are ones I would have. It just seems a bit…tacky…

  5. aethelreadtheunread says:

    Thanks for the comments.

    Omaniblog – thanks. :o) I’m not sure whether i’ll write about part 2 or not – i guess it depends on whether or not something comes up in it that i find interesting. But i shall certainly keep in mind that you would like me to. :o)

    intothesystem – it’s kind of you to say that i’ve ‘saved you a post’ rather than ‘you stole my ideas’… ;o) I’d still be interested in reading what you think, btw.

    cellar_door – i know what you mean about being tacky, but it’s not too bad – they’re keeping the “Big Brother for Mentalists” side of things reasonably under control. But that said i doubt it would add anything to your understanding of mental illness – you don’t strike me as the kind of person who’d be inclined to see mental illness in every minor character quirk anyway. :o)

  6. Zoe says:

    Brilliant review. As always. I felt more or less the same. I will watch it, and I am not offended by it. But I hold no expectations of learning ANYTHING about mental illness from this programme that I didn’t already know.

  7. jdc325 says:

    Nice work Aethelred. I think you’ve made some really excellent points here.
    I hope the programme does break down the idea that there is a clear line in the sand dividing the sane from the insane, and that it is of huge benefit in tackling stigma as you’ve written.
    Re some of the negative points you raised: I thought the speculation on using character traits to predict MH disorders was daft for similar reasons to yours. It seemed to me there was a danger of normal human behaviour being ‘medicalised’.
    I didn’t really consider the danger that the show could have an effect in terms of masking the seriousness of very real, and very serious, psychiatric disorders but this does touch on something I’ve been interested in for a while. The self-referencing/”self-diagnosis” of mental health disorders trivialising genuine suffering. People claiming they are “a bit x” or that they have “a touch of y” – for example someone claiming to be depressed when in reality they are just sad or someone sweary casually claiming they have Tourette’s.

  8. Mick says:

    Disagreed with most of the negative stuff you’ve written about this programme. I watched this with my 13 Year old daughter and really enjoyed competing with the professionals (we’re beating them at the moment), talking openly with her about mental illness and how it is perceived. I thought that as a format it was interesting for all. I particularly don’t agree with your suggestion that it may trivialise mental health conditions. Dan’s description of parts of his life was heart breaking. 10 out f 10 from me.

  9. ‘(although, personally, I think that point gets made rather too often in TV programmes about MH, with the result that those people for whom mental illness is a chronic, long-term problem are effectively ignored)

    That’s because you and I are statistical outliers. The vast majority of sufferers do not go on to have life-long problems. You’re looking at 2-3% v. 25% of the population.

    I’m glad the program is pointing out that mentalists are not all unreliable, child-molesting, creepy weirdos who you wouldn’t want living next to a primary school, but ill ordinary people.

  10. aethelreadtheunread says:

    Thanks for the extra comments.

    Zoe – you’re too kind, thank you. :o)

    jdc325 – thanks for commenting. I didn’t mention it in the main body of the post, but i think one of the other potential difficulties with the panel attempting to diagnose from personality traits is that general viewers will come away with the idea that this is how psychiatric diagnosis is carried out, and that could lead to the ‘i have a touch of x’ thinking you talk about.

    Mick – i’m pleased you and your daughter found the programme interesting and informative. There’s a lot about it i liked too, even though my review concentrates more on the negative than the positive.

    DeeDee Ramona – i always wanted to stand out from the crowd, but somehow i never thought it would be like this… ;o) You’re right, of course, and there’s a lot to be said for the media taking an upbeat approach – i certainly wouldn’t want them to be reinforcing hopelessness, as that would be seriously counter-productive for a lot of people. It’s occured to me, as well, that i was being unfair to the programme – Dan talked about his OCD as being something he had to learn to cope with, rather than something he’s completely recovered from.

  11. erik says:

    very good comments. i’m surprised no one from the bbc has responded here. one of the programme-makers has responded to this blog (http://blogs.bmj.com/), saying it was well-supported by all the mental health charities. funny how only the college of psychiatry is credited at the end!

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