Wednesday, January 10, 2007

Sane in an Insane World

Another classic psychology study. David Rosehan published his famous 'On being sane in insane places' in Science, in 1972. Rosehan was interested in the ability of psychiatrists to make a distinction between those with a mental illness and those who are 'normal'. Since it is a basic requirement that psychiatrists get this particular distinction correct, Rosenhan's work was very important.

He sent 8 normal people to 12 different hospitals, in 5 different states in the US. Each presented with the complaint of hearing voices and all eight were admitted to the hospitals as psychiatric patients. After admission, these pseudopatients acted as normally as possible and no longer reported the voices. From Rosenhan:

Despite their public “show” of sanity, the pseudopatients were never detected. Admitted, except in one case, with a diagnosis of schizophrenia, each was discharged with a diagnosis of schizophrenia “in remission.” The label “in remission” should in no way be dismissed as a formality, for at no time during any hospitalization had any question been raised about any pseudopatient’s simulation. Nor are there any indications in the hospital records that the pseudopatient’s status was suspect.

Rather, the evidence is strong that, once labeled schizophrenic, the pseudopatient was stuck with that label. If the pseudopatient was to be discharged, he must naturally be “in remission”; but he was not sane, nor, in the institution’s view, had he ever been sane. The uniform failure to recognize sanity cannot be attributed to the quality of the hospitals, for, although there were considerable variations among them, several are considered excellent. Nor can it be alleged that there was simply not enough time to observe the pseudopatients. Length of hospitalization ranged from 7 to 52 days, with an average of 19 days.
So, Rosenhan found that when a normal person walked into a mental hospital claiming to hear voices, that they could spend up to 52 days being observed, despite exhibiting no further unusual behaviour. One of the strange findings of Rosehan's work is that despite the psychiatrists inability to discover the pseudopatients, the other patients were often quite good at realising that something was different about them:
It was quite common for the patients to “detect” the pseudopatient’s sanity. During the first three hospitalizations, when accurate counts were kept, 35 of a total of 118 patients on the admissions ward voiced their suspicions, some vigorously. “You’re not crazy. You’re a journalist, or a professor (referring to the continual note-taking).
Finally, after the experiment had finished, a number of hospitals declared that such mistakes could not occur at their institutions. Rosehan set up a test with one hospital, whereby he would send further pseudopatients along and try and fool their psychiatrists into admitting more normal people. During that period, 193 patients were admitted, with 41 identified as pseudopatients with a high degree of confidence by at least one member of staff, 23 were suspected by at least one psychiatrist and 19 were considered possibly sane by one member of staff and one psychiatrist. Importantly Rosenhan had not sent a single pseudopatient to the hospital, during the three-months! Rosenhan concluded:
But one thing is certain: any diagnostic process that lends itself too readily to massive errors of this sort cannot be a very reliable one.
Wasn't Rosenhan's research amazing? It showed that diagnosing a mental illness is not the science that psychiatry makes out, but is an interpretative process which is influenced by all manner of expectations. Psychiatry is one of those areas which attempts to help alleviate mental problems. The difficulty is that we know so little about how the mind works, that it is still just a best effort, grappling around in the dark.