On being sane in insane places

Psychologists seek to understand behaviour and sometimes to classify behaviour.  However, research into the mentally ill suggests that what we see depends as much on who is doing the looking.

We tend to talk about 'mental illness' as if it there was something objective about it as having a physical ailment such a broken leg. Rosenhan wanted to know whether medical professions recognise insanity as well and as reliably as they would recognise a physical illness.

The first experiment involved 8 observers, termed 'pseudo-patients', who complained of hearing voices in the head in order to try to get admitted to one of 12 actual psychiatric hospitals in different parts of the USA. The pseudo-patient (using a fake identity) would explain that the voices were unclear, but seemed to be saying 'empty', 'hollow', and 'thud'.

All but one were admitted to a psychiatric ward with a diagnosis of schizophrenia.  Immediately upon admission to the psychiatric ward, the pseudo-patient stopped showing any signs of the disorder.

Apart from an initial nervousness about the situation, the pseudo-patients behaved 'normally' once admitted.  They chatted to other patients, followed instructions (apart from taking medicine, which was flushed down the toilet).  They initially took notes secretly, but as it became apparent that nobody cared, they did it more openly.  Much of their behaviour such as note-taking and queuing for the lunch room was treated as signs as their disorder, in examples of what Rosenhan called 'the stickiness of psychiatric labels'.  In other words, once you have a diagnosis of mental illness, ordinary behaviour may be seen as symptoms of your 'disorder'.

When asked by staff how they were feeling, pseudo-patients reported that their symptoms had gone.  Despite their public 'show' of sanity, the pseudo-patients were never detected. They were kept in hospital for an average of 18 days, with the longest stay being 52 days.

Did staff realise that a mistake had been made?

Not at all.  Pseudo-patients were discharged with a diagnosis of schizophrenia 'in remission'.  This means that the patient was thought to still have the disorder, but that the symptoms had temporarily died down.  In contrast, fellow patients and their visitors voiced their suspicions, for example by suggesting that the a patient was actually a journalist, checking up on the hospital.

A follow up study, hospitals were told that pseudo-patients would be checking in with them soon, but in fact none came forward.  In this case, staff mistakenly identified real patients as fakes!

For Rosenhan, all of this showed a worrying inability of psychiatric professionals to distinguish between the sane and the insane.  He asked, 'if sanity and insanity exist, how shall we know them?'  He was concerned that categorization of mental illness is, at best, useless and, at that it was worst, harmful and misleading.

Above all, the study showed the role of labelling.  Once labelled schizophrenic, a pseudo-patient's behaviours tended to be interpreted to fit with this label.   Other explanations of ordinary behaviours such as note-taking were overlooked. Rosenhan's study has been influential in prompting improvements to the diagnostic manual DSM, and better treatment of psychiatric patients.

Beyond Psychology, labelling has an influence in many areas of life - from the job applicant who is dressed as a punk to the 'sulky' teenager to the person in a relationship who is judged by their past mistakes.

Stereotypes and prejudice link to a similar set of processes, with people seeing what they expect to see.