Saturday, 14 June 2014

On Being Sane in Insane Places

Throughout history, there has been a fascination with attempting to classify abnormal behaviour in the medical world. In the 1950s, the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) was released, reflecting the popular outlook towards categorisation and classification. This manual contained common criteria for all known mental disorders at the time, and since there have been a further 4 more updated versions published. 

However, over time viewpoints began to change; perhaps due to the release of popular media such as One Flew Over the Cuckoo’s Nest (published 1962 by Ken Kesey), a book that ends with the main character's ultimate sacrifice in a mental institution as a result of bad behaviour. By the 1960s, the anti-psychiatry movement had started. Many psychiatrists began to criticise the hard medical approach to abnormality, and some went as far as to try mock the entire system.

Still from the film version of the book "One Flew Over the Cuckoo's Nest" -
a story that changed attitudes towards mental health institutions dramatically

This attitude was exemplified in the Rosenhan Experiment.

David Rosenhan was a psychiatrist in the 1970s, and also a critic of his field. He devised as two-fold experiment that completely turned psychiatry on its head.

The first part of the experiment consisted of eight pseudopatients (fake patients - mentally healthy people) including Rosenhan attempting to gain admission into different psychiatric hospitals across the US in 1973. No hospital staff were informed. The pseudopatients simply called the hospital for an appointment and reported (fake) auditory hallucinations, consisting only of the words “hollow”, “thump” and “empty”. These symptoms were chosen due to their dissimilarity with any other listed mental condition in the current DSM. Apart from the descriptions of the 3 words, everything else the pseudopatients reported was entirely true – their family history, relationships, previous life events etc.

David Rosenhan 
Following their appointments, all eight were admitted to psychiatric hospitals immediately, despite being mentally healthy. Interestingly, 7 were diagnosed with schizophrenia and 1 with manic-depressive psychosis. Once admitted, all the fake patients were told by Rosenhan to stop exhibiting any of their previous symptoms and act as they ordinarily would. However, throughout the experiment none of the pseudopatients were identified as imposters by hospital staff, although 35 out of 118 psychiatric patients in the various hospitals involved noted a suspicion the pseudopatients were sane – with some even suggesting they may be journalists. Instead, some of the note-taking by the pseudopatients was reported by hospital staff as pathological “writing behaviour”.

The length of time that the pseudopatients stayed ranged from 7 to 52 days – and all were discharged on the basis of their “conditions” being “in remission”. Their discharge depended on convincing the staff they were sane. During their stay, the pseudopatients were altogether given a total of 2,100 medication tablets (only two of which were swallowed, the rest pocketed or flushed away down the toilet). Some pseudopatients noted that when they went to flush their tablets, they found some already there - some of the actual psychiatric patients had already flushed theirs too. Some pseudopatients reported that sadly there was a real consensus that you could have an easy life if you didn't create too much of a fuss - similar to the attitudes reflected in the fictional characters in Kesey's book.

Nellie Bly
This experiment in part is “inspired” by the work Nellie Bly, a female newspaper reporter from the 1880s. Bly feigned insanity, and was committed to an insane asylum. Whilst there, Bly investigated and reported on counts of brutality and neglect from the staff towards patients. Her reports were eventually published in 1887 into “Ten Days in a Mad-House”. Unsurprisingly, Bly’s book did not go unnoticed, and actually led a grand jury to conduct their own investigation of the asylum. Upon being proven right, Bly’s book resulted in a large increase in the budget of the Department of Public Charities and Corrections. Although the aim of Bly's investigation was to report on the conditions of a mental health institution at the time, her articles also showed it was almost easier to gain access inside by posing as a patient than her real identity.

The second part of Rosenhan’s experiment followed as a result of the extreme discontent from the mental health institutions involved in the first part. One institution was extremely bothered by the results, and so Rosenhan then proposed he would carry out a new experiment – over the course of 3 months more pseudopatients would attempt to be admitted into their hospital. Again, the pseudopatient's identities would be kept secret and the staff members would try to catch Rosenhan out by rating each patient on their likelihood of being clinically sane during preliminary testing.

Over the course of the 3 months, the results showed that out of 193 patients judged, 41 were confidently assumed as pseudopatients, 23 were suspected by 1 psychiatrist and 19 were suspected by both a psychiatrist and staff member.  In reality, Rosenhan had not sent a single pseudopatient over the 3 months.

It is important to remember however, that a large proportion of psychiatric diagnoses rely on the patient’s account.  In the uproar that followed the publication of Rosenhan's experiment, some argued that the psychiatrists were just doing their job by diagnosing the symptoms they were given, and perhaps should not have assumed the patients presented were fake. Rosenhan’s retort to this was that should you present yourself with a physical symptom (such as an ulcer), you may be primarily diagnosed, but if doctors continue to believe you have an ulcer in the weeks after despite no other symptoms, there is a problem.

As I am discovering to be more true the more I learn about neuroscience, you can never be entirely certain when it comes to the mind and brain! It is a sobering thought that an industry of institutions given such a high reputation back then was able to make such a huge mistake. Since the 1970s however, much has changed in both the field of psychiatry and the general public's attitude towards mental health. It is no longer the norm (fortunately) to lock away family members who may not be classed as “clinically sane”, and thankfully the findings of both Bly and Rosenhan’s investigations have had huge implications within the medical world. Rosenhan’s findings alone hugely accelerated the deinstitutionalisation movement, which aimed to reform mental institutions and replace long-stay psychiatric hospitals with community mental health services.

What do you think? 

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