Pseudo-Schizophrenia: How to Fool a Psychiatrist
It’s easier than you’d think —and this crack team has perfected the art.
The year is 1973, and, across America, eight secret agents spring into action.
Not “secret agents” in the ordinary sense of the world, though.
There is a psychology student, three trained psychologists, and a psychiatrist — as well as a pediatrician, a painter, and a housewife. An eclectic bunch, to be sure.
And they didn’t really “spring into action”, so much, either. It was slightly more relaxed than that.
Instead, these eight individuals checked themselves in to psychiatric hospitals on the grounds that they were hearing voices.
(In reality, none of them were. They were all lying — but to make a point, as we shall see.)
All of them were admitted to hospital — seven with a diagnosis of shizophrenia, and one with a diagnosis of manic depressive psychosis.
After being admitted to hospital, they immediately claimed to feel fine and to no longer hear voices in their head, and instead busied themselves with diarising their experiences in notepads they brought with them.
The idea was simple: see how long it takes to get released as an outwardly mentally healthy person, and document what happens along the way.
The results were shocking: on average, each “pseudopatient” was in hospital for 19 days, one of whom was kept for seven-and-a-half weeks from initial admission.
During their stay, many documented invasions of privacy, verbal abuse from staff, and random searches of their possessions. They felt dehumanised, bored, and lonely. It was not, on the whole, pleasant.
Eventually, all were discharged without major incident — and then the leader of the team, David Rosenhan of Stanford University, published an account of the experience in the journal Science.
The world of psychiatry was shocked. In weeks, On Being Sane in Insane Places had become something like the unofficial scientific equivalent of a New York Times best-seller. It split the field in two — those who thought the experiment was a cunning piece of critical investigation into psychiatry from the bottom-up, and those who thought that it was a silly, pretentious game, designed to make professionals look like fools without really learning anything of importance in the process.
In an almost-so-good-it’s-cruel aftermath, Rosenhan subsequently one-upped his first experiment. He was, in essence, dared by one particular psychiatric hospital to send a number of pseudopatients to them, on the grounds that they were utterly confident in the ability of their psychiatrists to distinguish between an actor and a genuine patient. Rosenhan agreed to the trial.
Over the following months, the hospital identified dozens of patients (of nearly 200 admitted to the institution) that they strongly suspected were pseudopatients.
Imagine their surprise when Rosenhan turned around, months later, and told them that he had sent no pseudopatients at all. Every single suspected pseudopatient was, in reality, a legitimate patient. As far as Rosenhan knew, anyway.
That’s all very well and good, you might think. But what exactly is the point?
Let me explain that in Rosenhan’s words:
“It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals. The hospital itself imposes a special environment in which the meanings of behavior can easily be misunderstood. The consequences to patients hospitalized in such an environment — the powerlessness, depersonalization, segregation, mortification, and self-labeling — seem undoubtedly countertherapeutic.”
In On Being Sane in Insane Places, Rosenhan illuminates better than ever before the glaring issues at the heart of psychiatry. As the quote above points out, the very nature of the hospital is such that even the perfectly sane can be easily misinterpreted as insane.
For instance, the journalling behaviours of the pseudopatients, including Rosenhan himself, were thought to be obsessive, compulsive, and related to their apparent schizophrenia — despite the fact that they were literally just writing in their diary.
Rosenhan’s inspiration for the experiment, reportedly, was found in attending a lecture by a prominent antipsychiatrist of the day. Antipsychiatry, if you aren’t familiar, is a broad movement that criticses contemporary psychiatry.
Issues range from difficulty in classifying poorly-understood disorders and diseases (Is depression one thing, or many? How about autism?), in frequent involtuntary incarceration when it is not needed, in willy-nilly interpretations of behaviours and thought processes, in the frequent interjection of a psychiatrist’s values or society’s values, and so on.
Another complaint — striking at the very core of psychiatry — is the idea that psychiatry should not focus on what is wrong with the patient, but what is wrong with society such that the patient cannot comfortably exist and function. This flips psychiatry on its head, from introspective to outward-looking in orientation; from medical and pharmaceutical to social and political.
Rosenhan wanted to see to what extent these issues in psychiatry were observable, or whether they were merely theoretical nit-picking. Were disorders like schizophrenia really well-defined enough to be impenetrable to impostors, easily identifiable when legitimate, and discernible from the illegitimate? Would psychiatrists and mental health staff at these hospitals be able to tell the sane from the insane? Would they treat individuals appropriately?
Just as philosophical criticisms of psychiatry flow from Rosenhan’s writings like a tapped tree, pychiatristts, philosophers, and psychologists defending the field have had no shortage of ammunition to fire back.
The philosopher Rachel Cooper, for instance, sets up this thought experiment:
“Suppose that Henry is driving along with his young son. Together they label the objects that they pass: “There’s a cow”, “There’s a tractor”, “There’s a barn”. In the normal course of events we have no doubt that Henry here displays knowledge. For instance, he knows that there is a barn. We take Henry to be a reliable barn-detector because he can distinguish barns from relevant look-alikes; he knows that the object is not a house, or a windmill, or a church — it is a barn. But now let us change the scenario somewhat. Suppose that Henry and his son enter new territory. Unknown to them they drive into Fake Barn Land, a place where under-employed philosophers have constructed dozens of papier-mâché barn facades. When viewed from the road these look like barns, but they are not barns; they are just barn facades, held up with scaffolding at the back. Henry and his son continue their game: “There’s a horse”, “There’s a windmill”, “There’s a barn”. This time, however, we do not think that Henry knows that he is seeing a barn. There are multiple fake barns around. He could so easily be tricked that his barn beliefs are no longer secure. In Fake Barn Land he is no longer a reliable barn-detector.”
The idea, of course, is that psychiatrists don’t need to be able to tell whether or not a schizophrenic or other mentally-ill patient is pretending — because they almost invariably are not. The “experiment” by Rosenhan has taken them on an unwitting drive through Fake Barn Land, where the ordinarily-useful skills of psychiatrists are made to seem ridiculous and imperfect. There is really no merit, by this artgument, in Rosenhan’s experiments: all they have done is introduced a novel situation (in bad faith, one might add) with which psychiatry is not acquainted and with which it need not be acquainted.
There is certainly something to be said for this argument. However, I don’t think that it quite dismisses all of Rosenhan’s concerns.
For instance, why was one patient, who presented with exactly the same singular symptom, given a different diagnosis to the other seven? Why did the hospitals hold them for such variable lengths of time? How was their mental health assesssed throughout by professionals? And why did the patients feel so dehumanised during the ordeal?
These are problems within instutitional psychiatry that cannot be swatted under the carpet by a few niggles in experimental design. Rather, they are representative of problems in how society identifies and deals with the mentally ill — and they are, as such, issues that we must address.