Pseudo-patients in psychiatric hospitals

    In January 1973, the prestigious journal Science published a report on an unusual experiment which the American psychologist David L. Rosenhan of Stanford University had carried out with his assistants. He wanted to know how the staff of psychiatric hospitals treated their patients and how effective the doctors were in making psychiatric diagnoses. The article entitled “On Being Sane in Insane Places”, in which he gave a detailed description of the results of his experiment, is believed to be one of the most resounding articles in the field of psychology because it initiated along-lasting polemic about the validity of psychiatric diagnostics.

    Pretending to hear voices

    Rosenhan, four male and three female colleagues, of which three were psychologists and the others were a pediatrician, a psychiatrist, a painter and a housewife, decided to experience for themselves what it was like being admitted into a psychiatric hospital. For the purposes of the experiment they chose several hospitals in five different American states and tried to get admitted by simply appearing on their doorsteps.

    In all of the cases the experiment started in a similar way. The pseudo-patients would first call the hospital and set up an appointment to be examined. When they came to the reception they would complain of sometimes hearing voices. When asked what kind of voices these were, they would answer that they were mostly indistinct, but that some words were recognizable, among which “empty” and “hollow” would often appear. These very words were chosen deliberately because there was no report in the medical literature of the time on hallucinations dwelling on emptiness and the meaningless of life. The psychiatric profession had not yet written about the supposed existential psychosis which these “patients” had enacted. The men in the group heard male voices, and the women heard female voices, and in all cases none could link these inner phantoms to any familiar person.

    Except for their fake symptoms and the details of their profession, occupation and name they provided on arrival, everything else the group told the doctors was true. All questions concerning their personal history and other medical difficulties were answered truthfully. Once admitted into the hospital, moreover, the pseudo-patients behaved in a completely normal fashion. They no longer heard voices in their heads. They had sanguine conversations with both the patients and the staff and followed all instructions they were given except for swallowing the prescribed medication.

    Once you get a diagnosis, it’s hard to get rid of it

    After being admitted, seven were diagnosed with schizophrenia and, when they were discharged, received the diagnosis of schizophrenia in remission. Of course this did not mean that they were healthy, but simply that they were no longer very ill. One of them was diagnosed with manic depression. Even though the doctors treated them as if they were ill, other patients were quick to discover that there was nothing really wrong with them. The actual psychiatric patients would tell them: “You’re not crazy. You’re a journalist (or a professor, because they often took notes). You are only here to check the hospital’s work.”

    In several cases the pseudo-patients who were hospitalized experienced some anxiety, since none of them had expected that the hospital would be so eager to keep them. Because most of them had never visited a psychiatrist before, they also worried about being exposed as imposters and scorned. Members of the experiment had also been instructed to try and get themselves discharged. For this they would have to convince their doctors that there was nothing wrong with them. Indeed, except for the initial lie about hearing voices each of them had told in the hospital reception office, they had given staff no grounds for believing they were psychologically disturbed. However, each group member soon found out that the only way they would be released would be if they agreed with the doctors that they also believed they were mentally ill and then declare that they were feeling much better. The length of hospitalization for the fake patients ranged from 7 to 52 days, with an average period of 19 days spent in hospital.

    For their research they tried to write down as much of what they saw and heard as possible and, out of fear that the notes would be destroyed by the hospital staff, hid them in safe places each day. At first they made these notes in secret, expecting that they would not be allowed to continue; but when staff showed no particular interest in this activity, they began writing in their journals quite openly in the common social rooms. It turned out that taking notes was not deemed problematic, as hospital staff usually interpreted it as a compulsive disorder causing the patient to write everything down. Once they were labeled as schizophrenic, even the fakes’ most habitual and inconsequential activities were viewed as potentially pathological.

    During the entire period of the experiment the fake patients were prescribed a total of 2100 pills. Of these, only two were swallowed and all others ended up in pockets or being flushed down the toilet. Another interesting thing is that the fraudulent patients often discovered that the toilet bowl already contained medication left there by actual patients.

    Expecting pseudo-patients

    During their research the team observed two major common symptoms in people admitted to psychiatric hospitals, notwithstanding their individual illnesses: all suffered from a feeling of helplessness and a feeling of depersonalization. The staff talked about the patients as if they were not present in the same room or even invisible. On one occasion, for example, a nurse unbuttoned her uniform in front of the entire ward and readjusted her bra although many male patients were present. But this was not at all meant as an act of exhibitionism: the nurse simply did not regard the patients as physically and socially real people, in front of whom she would feel normally uncomfortable shifting her underwear.

    When doctors from other hospitals across the United States heard of this singular experiment they were naturally certain that nothing of the kind could happen in their wards. Rosenhan therefore arranged with one of the most prestigious hospitals to send them a couple more false patients over the following three months. Senior doctors in the hospital were convinced that they would have no problems in identifying the impostors. For the next few months, each new patient at the hospital was intentionally evaluated as a possible fraud. Out of 193 patients 41 were identified as false and another 42 were placed under suspicion. Of course the doctors were in for another shock, since Rosenhan had not in fact sent them a single false patient.

    The BBC repeats the experiment

    Recently, the popular BBC science program Horizon repeated the experiment. However, this time the volunteers did not try to get themselves admitted into hospitals; the experiment was carried out as a sort of reality show. They chose five typical psychiatric patients with the most common diagnoses: bipolar disorder, depression, eating disorder, obsessive-compulsive disorder and social anxiety disorder. All these people had been in treatment for quite a while, so they could not be instantly recognized as different to the five volunteers who had never experienced any difficulties with their mental health.

    Three experienced psychiatrists, experts on mental disorders, followed the group of ten for one week. Their task was to separate the ill from the healthy by observing them and performing tests. For an experienced diagnostician this should not be too difficult, but it soon turned out that this process of identification was a very demanding challenge. The specialists only succeeded in correctly identifying the two disorders that were most characteristic. The obsessive-compulsive disorder was exposed when they observed the patients cleaning a stable since one of the ten was much more meticulous in washing up thoroughly after the dirty work was done.

    The experts were also successful in diagnosing the eating disorder because one of the participants showed a 30% deviation in assessing her actual physical appearance. The patients were told to correct a deformed image of themselves using a computer program so that it would match their real image. Most of the participants in the experiment were able to correct their image more or less successfully: only a formerly anorexic patient, who had already been rehabilitated and now leads a completely normal family life as a mother of three, failed to make a realistic image of her body; she thought she was one third fatter than in reality.

    When it came to other diagnoses, the experts unfortunately failed. A once severely depressive patient was actually declared to be the healthiest of the group. It should probably be mentioned that all they had at their disposal while making the diagnoses was footage of the candidates performing the task they were given, and the chance to pose a couple of short questions. The diagnoses therefore had to be made on the basis of very limited information. Nevertheless, there does seem some truth to what philosophers, poets and ordinary people alike have been saying for time out of mind: it is often difficult to tell the sane from the mad, or to say who in the asylum should be patients and who should be doctors.