Sane in Insane Places

I have my first set of psychiatry didactics tomorrow, called "seminars" at this institution. I've been having trouble with my email, so today I finally received the reading material for tomorrow's talks. Some of it was pretty dry, but buried in the PDF's was an article which I'd imagine is required reading for all psychiatry residents (and if it's not, it should be):

On Being Sane in Insane Places
D. L. Rosenhan
[Science 1973;179:250–258]

35 years ago, this author posed the question, would psychiatrists recognize normal? We all think we can recognize abnormal out in the land of the normal, but would we see normal in the land of the abnormal? To answer his question, he and seven other volunteers became "pseudopatients": they "snuck" into psychiatric hospitals, using the key phrase "I'm hearing voices", and then tried to convince the staff they were sane to be let out. Other than the voices, none of the 8 fabricated symptoms or history; they told their own stories. (None of the pseudoopatients had any psychiatric diagnoses, and all were highly educated, high-functioning members of society). Once inside, they said "I'm fine, I have no symptoms anymore" and behaved as they would in any other situation.

So what happened to the pseudopatients? Did psychiatry recognize normal?

It turns out, some people were very good at detecting the sane: the insane. Or at least, the hospitalized patients in the psychiatric hospitals. Pseudopatients were often questioned as to whether they were journalists or professors (they took notes on the wards), but only by patients. Psychiatrists, nurses, and staff never questioned the admitting diagnosis of schizophrenia; even behavior that was normal was seen as pathological. If the patient was seen writing, it was "patient is engaging in writing behavior". When patients were discharged, they were diagnosed with "schizophrenia, in remission".

One hospital, hearing of the results, took offense. That could never happen here, they said. So a second experiment was arranged. The hospital was warned that in the next 3 months, one or more pseudopatients would be sent to try to gain admission. Psychiatrists and staff were asked to evaluate every patient on the ward and presented for admission, to see whether they might be faking their symptoms. Of 193 patients evaluated, 41 were suspected strongly by 1 psychiatrist of being fakers; 19 were suspected by 1 psychiatrist AND 1 staff. In fact, the author did not send any pseudopatients within the three months.

The author hypothesizes that barriers to recognizing sanity were multiple. 1) In medicine we prefer false positives to false negatives; it's better to overdiagnose cancer than underdiagnose it. He believes that this should not be true in psychiatry, because 2) Psychiatric diagnoses carry stigma, even among mental health professionals. He presented multiple studies of people treating others very differently in the psych ward than out in public. 3) The multi-tiered structure on the psych ward keeps psychiatrists, with the most training, furthest from the patients, and staff, with the least training, closest to patients. 4) All staff is somewhat segregated from the patient populations, hiding out in glass "cages" (in other hospitals I've been in, they're called the "control towers"). Interaction with patients is limited. 5) Not many mental health professionals recognize the dehumanizing forces at play within a psych ward. He makes the obvious next step: if these "sane" people went undetected, then how many "sane" people are even now locked into psych wards, saddled with diagnoses that will keep them labelled for life?

I had many feelings about this article. First, I was rather amused that the author pulled this off, and showed up the doubting hospital. Second, I was horrified that this used to happen. Third, I was appalled that this probably still happens every day. Fourth, I vowed to reread this article frequently during my training, lest I forget.

I will say that in my experience last year, we admitted several patients to the pediatric ward at the insistence of parents/law enforcement, etc, only to discharge them the next day or within 2 days because they were fine. Often our history at admission was from the parent or other family; even when it conflicted with the patient's words, sometimes the kid would get admitted anyway (especially if a warrant was involved). Then, with the parents out of the room, we could usually get a good story of what was going on. So, why did we believe the parents more than the kid? Was it the fact that a kid is a minor, and the parent is in charge? Or was it that the kid was accused of being a psych patient, and therefore we didn't trust their story initially? I'm not sure.

This article is over 30 years old, and I hope that things have improved dramatically. I also hope I can help things continue to improve. I'm a little unsettled, though, which is an odd place to be the night before I start attending lectures in this field. I will take hope from the fact that I'll be receiving lectures from an attending discerning enough to have us read this article in the first place.


Added 7/8 at 2054: I just posted a sequel to this post, written after my lecture today on this article. Check it out here.