If sanity and insanity exist, how shall we know them?

The question above, the many others like it, and the thoughts it inspires have bothered philosophers, physiatrists, lawyers, poets and angsty teenagers for centuries. There are the questions of cultural relativity, moral ambiguity and just what makes something normal that produce books, films and papers all trying to tackle the subject in various ways. Some, such as R.D Laing’s works, have made their mark and are always references when dealing with this controversial topic – but many are brushed aside or laughed at by those professionals seeking neat and clear definitions.

On being sane in insane places1 is the name of a paper written in 1973 by Dr. David L. Rosenhan, in which he tries to deal with the question of just what makes a person insane in somewhat empirical terms. The specific aspect of the question he was most intrigued with is yet another that can be found in some form in all cultures and all human thought – nature vs. nurture. Are the characteristics that make a person become classified as ‘insane’ held within them, or can they be found in the situations and surroundings in which they are presented?

Rosenhan devised an experiment that was meant to test the hypothesis that psychiatrists cannot accurately tell the difference between sane and insane people. In proving this hypothesis he hoped to address some of the issues in psychiatry that bothered him the most – the classifying of people with mental disorders as ill, the context (psychiatric hospitals) in which they find themselves and the 'stickiness of psychological labels’.

Preparing the experiment

The basic premise of the experiment was to get a number of ordinary people and have them attempt to gain admission into a psychiatric hospital. The idea here obviously being that the psychiatrists should reliably be able to tell that these people were not really mentally ill.

8 people were selected for the experiment:

1 20 year old psychology graduate student

3 psychologists

1 paediatrician

1 psychiatrist

1 painter

1 housewife

12 different hospitals in the United States were chosen as the places to try and gain entry to. The hospitals were a mixture of old, new, research, teaching, government funded and privately owned – but all with a good, solid reputation.

Beginning the experiment

Each of the pseudo-patients was told to phone up one of the hospitals and arrange a meeting with one of the psychiatrists there. They were instructed that the only symptom they should complain of was that of hearing a voice. These auditory hallucinations would be of the same sex as the patient and what they heard would be indistinct although all would say they could make out the words 'hollow', 'dull' and 'thud'. These words were chosen because of their similarity to common existential symptoms and because there was no case of them being reported before in any psychiatric literature. Other than this the patients were to behave exactly as they normally would and to be honest with any questions they were asked. This meant that they talked about their own lives exactly as they were, that is, pretty normal, the only exception to this was those who were in the psychiatric field were asked to choose another profession as they might other-wise receive different treatment from the doctors at the hospital.

Every single one was admitted with a diagnosis of schizophrenia, except one who was diagnosed with manic-depression.

Inside the hospitals

The pseudo-patients were instructed that should they gain entry into the hospital they were to stop showing any symptoms immediately and behave exactly as normal. Just as in the case when a patient gets committed for real, they had no idea when they would be released; it was up to them to get out – basically by proving to the doctors that they were fine. On the ward they were to be the models of cooperativeness and politeness and were to be totally asymptomatic. Each patient was to write down in a note-book the way that they were treated by the staff and other patients, as well as details of their medication and general ward life.

During this time the patient was allowed to see 'visitors’, and these friends or family members were asked to note if they saw any changes in manner, behaviour or thought in the people they knew. All of the patients were eventually discharged with a diagnosis of 'schizophrenia/manic-depression in remission’. The length of stay was between 7 and 52 days – with an average of 19.

Phase two

Once this part of the study had been completed a number of times at all 12 of the chosen hospitals, the next stage began. For this part of the experiment, several other hospitals were chosen and the doctors and staff were shown the results of the previous study. Without exception they all insisted that this could never happen at their hospital and that the results must be false. They were then told that during the next three months there would be some more of these pseudo-patients coming to their hospitals to try and gain entry. During this period all doctors and staff should keep a note of the new patients and record which, if any, they thought were faking it.

This, however, was all part of a further act. Rosenhan was not in fact sending any pseudo-patients to their hospitals. However during that time, 41 of the 193 patients who were admitted at the various hospitals were 'confidently judged to be pseudo-patients' by the doctors and staff.

Now – although this experiment was not as shocking in the way of some other studies which have now almost passed into popular fiction – it none the less raised quite a fuss in the psychiatric circles as well as raising some interesting questions for everyday life.

Being sane today

One of the main counter-points today is the fact that at the time of the study it was the DSM-II that was in use. In the later versions now in use, the criteria are much stricter and much more specific – very much due to studies such as these - which highlighted the inadequacies in the previous models and methods. Today, patients complaining of the same symptoms as those used in the original study would be highly unlikely to be admitted. That makes it no less interesting to wonder what would happen today if the study were to be repeated with the requisite symptoms in place…

Another factor is that most patients in psychiatric hospitals nowadays are their by their own admission, involuntary admissions are far less common today than they were in the time of Rosenhan’s study. However there are many recent studies done that still show a remarkable difference between diagnoses – for example, even in the early 90’s the same patient was twice as likely to be diagnosed as schizophrenic in America than he would be in Britain.4

Although for every study done there will be others to counter the claims made previously, Rosenhan’s still makes an interesting case. If mental health professionals cannot distinguish between the mentally ill and the healthy, the question of whether they can distinguish between different types of mental illness seems premature and, perhaps, even pointless.5 And the effects of having ones behaviour and thoughts judged based on preconceived notions is something that just about everyone can relate to in some form or another, a universal desire to be understood, yet a constant feeling of being misjudged, misplaced and misinterpreted.

Cite:



Paper was first published in Science, 179, pp. 250-8

All paragraphs within quotes are from the original paper Neisser (1973) Kety (1974) WHO (1973), US-UK Diagnostic Project Lilienfeld (1995)

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