On Being Sane in Insane places
A very interesting experiment was done by Dr. David Rosenhan, which still, after all these years, has its impact on how we perceive psychiatry and mental institutions. Rosenhan, in his 9 pages long paper in Science (1973) started by stating, “If sanity and insanity exist, how shall we know them?”
His experiment aimed at determining the validity of psychiatric diagnoses. It was divided into 2 parts. 1st part included 3 women and 5 men who were to be pseudopatients. They were healthy individuals and had no history of any mental illness. Rosenhan himself also volunteered along with others. All of these volunteers or associates briefly faked having auditory hallucinations. This was in an attempt to get hospitalized in 12 different psychiatric hospitals across 5 different states. They said that the voices weren’t clear but they think it was from the same sex and they often heard words like, “thud”, “empty” and “hollow”. They were all admitted and were diagnosed with Psychotic Disorder. One patient, however, was diagnosed with manic-depression with psychosis.
During admission intake, the pseudopatients faked their names and profession but all other biographical details given were true. After they were admitted, they behaved normally and reported to the doctors that they were absolutely fine. They also told them that they weren’t experiencing auditory hallucinations as well. However, the staff forced them to believe that they were still experiencing them and had put them on antipsychotics (which the pseudopatients never took). The inpatients present in the same ward were suspicious that the associates were faking. But the staff took even simple behaviors as diagnostic symptoms. Such as, when one of the pseudopatients was writing on his notepad about the observations he had made in there, was reported by a staff nurse as having ‘writing behavior’.They were ill-treated and abused both physically and verbally, patients were tied up and there was a severe invasion of privacy by the staff members. They were not allowed to even get discharged. They were admitted on average for about 19 days, without exhibiting any symptoms of psychosis. The days they were admitted for ranged from 7 to 52 days. Only one patient got the diagnosis of Schizophrenia (in remission) during discharge, to which Rosenhan concluded that “Mental Illness is perceived as an irreversible condition creating a life long stigma rather than a curable illness”.
After Rosenhan informed the hospitals and doctors in charge that the associates were all a part of the experiment and none of those 8 patients had any hallucinations or mental illness of any kind. This agitated the doctors and they challenged him to send pseudopatients now and they would identify them correctly this time. 193 patients went to those hospitals out of which 41 were confirmed to be imposters and a further 42 were considered suspects by the doctors. Rosenhan, then informed that he had not sent any pseudopatients, and all of those 193 who reached these hospitals were ordinary patients. This concluded the 2nd part of his experiment.
Through this experiment, Rohensan concluded that "any diagnostic process that lends itself too readily to massive errors of this sort cannot be a very reliable one". He explained, “it was clear that we cannot distinguish the sane from insane in psychiatric hospitals”. He also talked about how these institutions practiced dehumanization, invasion of privacy, and abuse of the patients. He primarily critiqued the validity of the psychiatric diagnoses.
This experiment has been criticized extensively by many scientists and psychiatrists and called it “pseudoscience”. They argued that if a patient is malingering, it is very hard to notice since psychiatric evaluation is often based on the history the patient provides. One of the arguments that were made was that if a person drinks a pile of blood and then vomits blood, goes to an emergency ward, would it be the physician’s fault that they give him/her a diagnosis of perforated peptic ulcer? To this argument, Rosenhan replied that if after admission the patient shows no signs of a peptic ulcer, he would be released rather than being told that they still have it and give extra medicines for the same.
This study by Rosenhan is a very old study and mental healthcare systems have improved significantly since then. More private institutions have opened up and the government assigns a relatively higher budget for the government hospitals. These days, an intensive case history is taken before admission from both the patient and their family or whoever they live with. The intake of patients for psychiatric wards has reduced by a huge number and only those who have severe psychosis or are suicidal are generally admitted. The infrastructure is better and outdated therapy models are rejected. ECTs are more humane than before. Insulin therapy has been discontinued. But when it comes to the dehumanization of patients who are admitted in psychiatric hospitals, especially government-run, is very much there, although lesser than before. But because the stigma sticks even after higher levels of awareness about mental health, these problems will be around. The study also makes a point that the diagnostic criteria are not reliable as they are pretty vague, which given the rate of misdiagnosis, stand relatively true even now.
One of the recommendations given by Roenhan was that community mental health facilities should be inculcated which concentrates on specific problems and behavior rather than the labeling of diagnosis. Community mental health facilities are rising in number but still not enough of them are present when compared to the need for it. Institutionalising happens even now. Even when we have come this far in the field of psychiatry, we haven’t come far enough if we still are concerned more about the labels and not the patients.
Rosenhan’s experiment was pretty bold and radical in its approach but he did give us a peek into the reality of the diagnostic system and how vague the criteria for them are and also how dehumanizing the institutionalism can be for the people who are supposed to be looked after.
The mental health care system needs to get better, faster than it is now.