On the troubling trail of psychiatry’s pseudopatients stunt

December 12, 2019 4:40 AM

From 1969 to 1972, an extraordinary experiment played out in 12 psychiatric institutions across 5 US states. Eight healthy people — including David Rosenhan, a social psychologist at Stanford University in California, who ran the experiment — convinced psychiatrists that they needed to be committed to mental hospitals. The ensuing paper, published in Science in 1973 ^{(free access)}, opens with the words: “If sanity and insanity exist, how shall we know them?” It claimed that the psychiatric establishment was unable to distinguish between the two. Rosenhan’s study had far-reaching and much-needed effects on psychiatric care in the United States and elsewhere. By the 1980s, most psychology textbooks were quoting it. However, Susannah Cahalan’s investigation of the social-psychology experiment in her book The Great Pretender finds inconsistencies that appear to indicate it was all an unelaborate fraud.
posted by Blasdelb (32 comments total)

Q&A with Susannah Cahalan on CSPAN (57:17)
Journalist Susannah Cahalan talked about her book, The Great Pretender: The Undercover Mission That Changed Our Understanding of Madness, about a 1973 experiment, led by Stanford psychologist David Rosenhan, conducted to test the legitimacy of psychiatric hospitals in America. For the experiment, Professor Rosenhan and seven other healthy individuals checked themselves into mental asylums claiming that they were experiencing hallucinations. Once inside, they acted normally and told doctors the hallucinations had subsided, but they were not allowed to leave until they admitted to having a mental illness and agreeing to take antipsychotic drugs to treat their conditions. Ms. Cahalan discussed the experiment and the impact the resulting study, “On Being Sane in Insane Places,” had on the psychiatric profession.
posted by Blasdelb at 4:42 AM on December 12, 2019 [2 favorites]

is this where we talk about social psychiatry being a fake field because i am down for that
posted by Reclusive Novelist Thomas Pynchon at 4:52 AM on December 12, 2019 [3 favorites]

I read about this a month or so ago and I'm just dying to read the book, but I asked for it for Christmas so now I have to wait for Christmas and I'm extremely impatient. Now I can listen to that Q&A to tide me over - thank you!
posted by Stacey at 5:09 AM on December 12, 2019

Nitpick: It's social psychology, not social psychiatry. (I also don't agree that it's a "fake field", but it's definitely had some problems.)

Thanks for this, Blasdelb. I'll definitely be giving the CSPAN interview a listen.
posted by nangar at 5:41 AM on December 12, 2019 [7 favorites]

I’m trying to find the article I read about this, but I was unimpressed by the strength of her evidence that it was all a fraud. She couldn’t find all of the pseudopatients, but she did find some, and it’s not clear to me that her inability to find the others is strong evidence that they weren’t there. She found one whose experiences weren’t used in the study, possibly because he thought the institution had a positive effect, but even he was misdiagnosed as schizophrenic, which doesn’t seem to contravene the main point of the study.

The evidence in the book may be much stronger than it was in the article I read, but I was unconvinced.
posted by LizardBreath at 5:50 AM on December 12, 2019 [7 favorites]

At this point, journalist should only be reporting cases were famous social psychology experiments aren’t frauds.
posted by vorpal bunny at 6:10 AM on December 12, 2019 [5 favorites]

The idea that people are faking mental illness for personal gain or to get out of jail is such a destructive belief. I'm sure there are people who fake mental illness sometimes but it's not a strategy that works well for people (and probably points to a need for other supports.)

With the possible exception of trying to stay out of jail for a really serious crime, I can't see too many long-term benefits. Occasionally, people have tried to tell me that I can't possibly be multiple or have PTSD because, I guess, I'm too functional, and on the Internet in my 20s when I was in the first flush of it myself, some people said I was making it up for attention...I can officially let people know that there is no magic rainbow pot of positive attention that you get for suffering from a mental illness or experiencing neurodiversity. At the point at which you are "getting attention" you probably need some kind of help or therapy because the translation for that is that something is visibly wrong. If I were to go on disability, which I definitely don't need but am glad is there for those who do, it is not like I would be living high on the hog. There's no discounts on all-inclusive vacations. The drugs that you take to address mental illness are not fun to take. Being in hospital is not fun either, as far as I have heard.

So basically...even if people could fake mental illness and therefore get inappropriate care...what is it they end up with, a free trip to a mental ward and stigma on their charts for the rest of their lives??? Like, what was that point again? That it's tricky to diagnose mental illness and that the criteria for it shifts around in the DSM-whatever? That's because being human is tricky! Yeesh.
posted by warriorqueen at 6:32 AM on December 12, 2019 [12 favorites]

Nitpick: It's social psychology, not social psychiatry.

What would social psychiatry be? Drugging the water supply with meds, I suppose.
posted by thelonius at 6:35 AM on December 12, 2019 [7 favorites]

"The evidence in the book may be much stronger than it was in the article I read, but I was unconvinced."

The absence of evidence is indeed absolutely not evidence of absence to a degree that is very much not intuitive, but I think a lot of what is most damning is just the sheer number of positive demonstrations of falsification that piled up in what became her investigation. For example, she was able to conclusively demonstrate that Rosenhan could not have had a writ of habeas corpus prepared for each of the entering pseudopatients or an attorney who was kept “on call” during every hospitalization like he claimed in the published paper. Even if the other patients were in fact in at least some way real, the degree to which he falsified the experience of the one patient that Cahalan was able to find goes way past what could be justified by anonymization in even the most generous possible interpretation and is itself unambiguously research fraud perpetrated to improve the narrative.

We don't need to rely on how profoundly implausible it is that, even with full access to all of Rosenhan's papers including 200 pages of drafts for his book manuscript, she was still not able to hunt real pseudopatients down or that none of them are coming forward today. We can still be able to be confident that the portrayals are likely fictitious because the one portrayal she was able to track down was and fictional portrayals somehow based on real pseudopatients would still be fiction rather than a scientific report.
posted by Blasdelb at 6:38 AM on December 12, 2019 [8 favorites]

Social psychiatry, because pills aren't always the solution...
posted by bluefrog at 6:41 AM on December 12, 2019 [2 favorites]

Only evidence I saw in that article is that someone wrote a book. Good for them.

Look, I work in mental health and psychiatry is a very subtle, ethereal thing. Proving or disproving anything in a profession where one is talking about conditions that are really just sets of observable behavioral phenomena and expressed symptoms is gonna be a hard go. It seems the approach here is insane or sane, true or untrue, and that isn't really how this works at all. I read that study a long time ago, and have come to see it as a truism of sorts... take a good look at someone through the lens of education or authority granted by a degree or title and we can begin to see all sorts of things that aren't really there. I learned from that study to be very careful when making assumptions about people, whether they are "sick" or not or even more importantly whether or not they can recover and that has been most helpful.
posted by cybrcamper at 6:43 AM on December 12, 2019 [11 favorites]

i was taught this as being true at an ivy league university six months ago
posted by lazaruslong at 7:35 AM on December 12, 2019 [3 favorites]

It seems the approach here is insane or sane, true or untrue, and that isn't really how this works at all.

In the very beginnings of western science, one was often required to swear an oath before God as on your honor as a Catholic gentleman attesting to the good faith and honesty of your reports before they would be published, and obviously the specifics have changed but the basic concept remains intact. Science still inherently relies on the idea of a deeply sacred trust, which absolutely must be sacrosanct if the scientific enterprise is to have any hope of offering something of value to humanity.

Both the many frauds like this one and the astonishing levels of statistical illiteracy that at best approach fraud that were recently ubiquitous in the field of Social Psychology, and which the field is still grappling with, cannot be handwaved away as parables. Certainly, the lines between sanity and insanity are much fuzzier than can be easily captured by experimentally rigorous analysis, but the scientific enterprise has enough of a challenge sifting through 'valid or invalid' without having to worry about sifting through good faith and intentional lies. The extraordinary challenge inherent to performing science on the mind is only more reason to insist on ferreting out bullshitters.

There were plenty of venues in which he could have invented the truthy just-so-story that you want this to have been and be honest about it, this was after all the golden age of science fiction. However, Rosenhan stole the legitimacy that came with making factual claims without accepting the responsibility inherent to claiming things that were factually true. When this legitimacy is appropriated whole fields that are critical to our self-understanding become dominated by bullshit biotruths, people die horrific deaths, and the careers of eager replicators get derailed into tragedy. How many of the things that you learned in school as experimentally valid results are really just bullshit pulled out of the asses of mediocre white men for momentary fame? Do you even care?
posted by Blasdelb at 7:39 AM on December 12, 2019 [10 favorites]

For example, she was able to conclusively demonstrate that Rosenhan could not have had a writ of habeas corpus prepared for each of the entering pseudopatients or an attorney who was kept “on call” during every hospitalization like he claimed in the published paper.

As I said, I haven't read the book. But I don't understand how you could demonstrate that -- I really can't picture what the facts would be that would establish that there weren't papers ready to file on behalf of each of the pseudopatients. I don't mean to say that I'm sure she can't have proved that, but it seems really difficult to prove and I can't picture how she would have.
posted by LizardBreath at 7:44 AM on December 12, 2019 [1 favorite]

A lot of this comes about because of the enmeshment between "psychiatry" as a medical specialty and "psychiatry" as an instrument of social policy. Today, insanity is a legal construct and not a psychiatric diagnosis or symptom. This was much less true in years past.

As an endeavour psychiatry is necessary, tortuous and grimly paradoxical. What is dispensed is not sanity, but madness. The healing art consists in finding a kind of madness that the patient – and neighbours and family – can live with.
posted by meehawl at 7:54 AM on December 12, 2019 [1 favorite]

I find the review to be something of a nothingburger. It admits that Rosenhahn's experiment was beneficial to the application of psychiatric care, then implies that it was all a fraud, then ends saying that well, maybe it wasn't, but WHO KNOWS ?!?!?!. Like, way to sell me on not reading the book.

Also there is no way in hell anyone could get me to voluntarily check myself into a mental institution. No way no how.
posted by grumpybear69 at 8:10 AM on December 12, 2019 [4 favorites]

I've taught this using a snippet of a video interview with Rosenhan (which I've almost memorized by now). Something jumped out at me.

The Nature article, says the patients had the same symptom of hearing voices:

All eight, including Rosenhan, reported the same symptom to different doctors: that they heard voices uttering “thud, empty, hollow”, denoting existential doom

Rosenhan's 1973 Science article says "empty", "hollow" and "thud" (p. 251)

However in Discovering Psychology, Volume 21, an interview with Rosenhan (date: from the 1980s?) he clearly says: '...and the voices said "empty", "dull", "thud"'

It seems odd that the signature symptom would change.
posted by soylent00FF00 at 8:19 AM on December 12, 2019 [2 favorites]

I visited a friend in the VA hospital many years ago, on the psychiatric ward, and yeah, it was scary. Hospitals are a little creepy already and ones that lock the doors behind you....no thanks.

I tried to explain to the doctors that some of the crazy sounding stuff he was talking about (Budapest, playing in the grandmaster chess tournament) was 100% real, but they didn't seem to care. That dude was bipolar as fuck and he showed up at my door, back from Budapest, not having slept for days and physically injured and raving about the KGB trying to kill him and I didn't know what to do except take him to the VA. They let him go after a few days at least.
posted by thelonius at 8:21 AM on December 12, 2019 [2 favorites]

We don't need to rely on how profoundly implausible it is that, even with full access to all of Rosenhan's papers including 200 pages of drafts for his book manuscript, she was still not able to hunt real pseudopatients down or that none of them are coming forward today.

This was an experiment conducted 50 years ago; the first three of the pseudopatients were then a "recently retired psychiatrist", his wife and sister (presumably of similar age). The 1973 paper describes the pseudopatients as "a psychology graduate student in his 20’s. The remaining seven were older and 'established.'" The pseudopatient that she did track down is described as a former graduate student, which could mean he was the youngest of the participants by enough of a margin to be notable, and would still be in his mid-to-late 70s.

I can come up with a pretty good alternative hypothesis why a retired person, plausibly in their mid-60s in 1969, is not coming forward today 50 years later and it's not because he's busy celebrating his 116th birthday.
posted by Homeboy Trouble at 8:29 AM on December 12, 2019 [24 favorites]

A short version (by Calahan) in the NY Post: Stanford professor who changed America with just one study was also a liar.
posted by Mr.Know-it-some at 9:32 AM on December 12, 2019 [1 favorite]

Also there is no way in hell anyone could get me to voluntarily check myself into a mental institution. No way no how.

a friend recently did just this. The voluntary part was a decision offered her by the police. Either voluntarily check herself into the psyche ward and commit to a course of treatment ... or go to jail, face criminal charges (she'd been repeatedly disturbing the piece, wreaking havoc etc).

The key point (new to me) is that an involuntary commitment to the psyche ward is less binding. Once you're no longer exhibiting the particular systems that got you arrested, you're free to go. In my friend's case, this had already happened twice. Thus the option for voluntary check-in ... and minimum three week stay.

She's doing way better now.
posted by philip-random at 9:35 AM on December 12, 2019 [3 favorites]

Reading the NY Post article Calahan wrote, her claims seem very hedged:

The only other participant I discovered, Harry Lando, had a vastly different take. Lando had summed up his 19-day hospitalization at the US Public Health Service Hospital in San Francisco in one word: “positive.”

Even though he too was misdiagnosed with schizophrenia, Lando felt it was a healing environment that helped people get better.

“The hospital seemed to have a calming effect. Someone might come in agitated and then fairly quickly they would tend to calm down. It was a benign environment,” Lando, now a psychology professor at the University of Minnesota, recalled in an interview.

But instead of incorporating Lando into the study, Rosenhan dropped him from it.

Lando felt it was pretty obvious what had happened, and I agree: His data — the overall positive experience of his hospitalization — didn’t match Rosenhan’s thesis that institutions are uncaring, ineffective and even harmful places, and so they were discarded.

“Rosenhan was interested in diagnosis, and that’s fine, but you’ve got to respect and accept the data, even if the data are not supportive of your preconceptions,” Lando told me.

Rosenhan, I began to realize, may have been the ultimate unreliable narrator. And I believe it’s possible some of the other pseudopatients he mentioned in his study never existed at all.

So, she found one psuedopatient whose data was used, another whose data wasn't used but who was misdiagnosed, so not squarely contradicting the findings of the study, and she thinks that it's possible that some of the other patients were invented. If she's calling Rosenhan a liar, shouldn't she have a firm opinion about whether and how many of the patients weren't real?
posted by LizardBreath at 9:52 AM on December 12, 2019 [8 favorites]

symptoms
posted by philip-random at 10:29 AM on December 12, 2019

And I don't mean to say that I'm sure Rosenhan wasn't a huge fraud, many exciting results like that from that era do seem to be either fraudulent or at the least very poorly founded. But the conclusions Calahan has drawn seem very strong, while the strength of her evidence for them seems really unclear.
posted by LizardBreath at 11:18 AM on December 12, 2019 [4 favorites]

I also don't want to leave the impression that Rosenhan is necessarily a good actor or that his science is good, even though I did point out above that it's plausible nobody else in the study is alive to come forward today. But another point:

For example, she was able to conclusively demonstrate that Rosenhan could not have had a writ of habeas corpus prepared for each of the entering pseudopatients or an attorney who was kept “on call” during every hospitalization like he claimed in the published paper.

This evidence is equally consistent with Rosenhan doing the study, but lying about taking expensive safety precautions. I don't know a lot about researcher attitudes of the day, but my impression is that this sort of "fib" was not uncommon, especially since telling someone they had lawyers on call would make them more likely to sign up to be committed.

For instance, the Stanford Prison Experiment (done by a colleague in the same psych department, same timeframe) told participants during recruitment that they could leave at any time, but then denied them this during the experiment. The 'guards' were coached more than was implied in the paper, I believe. This doesn't mean the experiment didn't happen, just that researchers were hella unethical back then.
posted by Homeboy Trouble at 11:55 AM on December 12, 2019 [9 favorites]

What would social psychiatry be? Drugging the water supply with meds, I suppose.

Oh, is that what you want?!?

Because that’s how you get Reavers!
posted by mikelieman at 12:03 PM on December 12, 2019 [11 favorites]

This study was a milestone in what amounted almost to a crusade against mental hospitals:

The movement for deinstitutionalisation moved to the forefront in various countries during the 1950s and 1960s with the advent of chlorpromazine and other antipsychotic drugs.

A key text in the development of deinstitutionalisation was Asylums: Essays on the Social Situation of Mental Patients and Other Inmates, a 1961 book by sociologist Erving Goffman.[3][4][5] The book is one of the first sociological examinations of the social situation of mental patients, the hospital.[6] Based on his participant observation field work, the book details Goffman's theory of the "total institution" (principally in the example he gives, as the title of the book indicates, mental institutions) and the process by which it takes efforts to maintain predictable and regular behavior on the part of both "guard" and "captor," suggesting that many of the features of such institutions serve the ritual function of ensuring that both classes of people know their function and social role, in other words of "institutionalizing" them.

Franco Basaglia, a leading Italian psychiatrist who inspired and was the architect of the psychiatric reform in Italy, also defined mental hospital as an oppressive, locked and total institution in which prison-like, punitive rules are applied, in order to gradually eliminate its own contents, and patients, doctors and nurses are all subjected (at different levels) to the same process of institutionalism.[7] Other critics went further and campaigned against all involuntary psychiatric treatment. In 1970, Goffman worked with Thomas Szasz and George Alexander to found the American Association for the Abolition of Involuntary Mental Hospitalisation (AAAIMH), who proposed abolishing all involuntary psychiatric intervention, particularly involuntary commitment, against individuals.[8][9][10] The association provided legal help to psychiatric patients and published a journal, The Abolitionist,[11] until it was dissolved in 1980.[11][12]

On the popular culture front, One Flew Over the Cuckoo's Nest was published in 1962 and made into a movie in 1975.

All this seems way too complex for a straightforward cui bono? test, but there's no doubt that Big Pharma didn't exactly suffer a setback from deinstitutionalization.
posted by jamjam at 12:32 PM on December 12, 2019 [3 favorites]

The key point (new to me) is that an involuntary commitment to the psyche ward is less binding. Once you're no longer exhibiting the particular systems that got you arrested, you're free to go. In my friend's case, this had already happened twice. Thus the option for voluntary check-in ... and minimum three week stay.

It may be different because the cops were involved in that case, but when I was admitted against my will at 19 years old, I was given a choice whether to say it was voluntary or involuntary. If I said it was voluntary then I could get out earlier, whereas involuntary meant I had to be there at least 10 days IIRC. Probably a regional thing too; I was in Texas.

Though I guess grumpbear69 meant just voluntarily in the broader sense and not in the weird Catch-22 checkbox-on-the-form bullshit sense.
posted by fleacircus at 3:48 PM on December 12, 2019

Rosenhan's 1973 Science article says "empty", "hollow" and "thud" (p. 251)
However in Discovering Psychology, Volume 21, an interview with Rosenhan (date: from the 1980s?) he clearly says: '...and the voices said "empty", "dull", "thud"'
It seems odd that the signature symptom would change.

It doesn't seem odd that participants would have a handful of similar words to use in descriptions; they may not have decided on "use these three words - exactly these words and no others."

I didn't know what to do except take him to the VA. They let him go after a few days at least.

Part of the changes in institutional psychology over the last few decades, is "throw out anyone who's not overtly dangerous to themselves or others, because the insurance company won't cover an extended stay that's just focused on behavioral modification aimed at better quality of life."

In the late 60s, the approach was different. In many places, it was "Keep them inside until they are ready to fully integrate into normal society."
posted by ErisLordFreedom at 3:58 PM on December 12, 2019 [2 favorites]

So basically...even if people could fake mental illness and therefore get inappropriate care...what is it they end up with, a free trip to a mental ward and stigma on their charts for the rest of their lives???

The issue is more: if the doctors can't even detect the unquestionably sane, how can we trust their judgment on who is and isn't sane? It's an attempt (obviously flawed) to introduce a control into the system.

All this seems way too complex for a straightforward cui bono? test, but there's no doubt that Big Pharma didn't exactly suffer a setback from deinstitutionalization.

Large psychiatric institutions commonly being hellholes was not a Hollywood fiction. Also, it's not as if they didn't use psychiatric drugs in vast quantities themselves. (That is, releasing someone from a mental institution was unlikely to increase their psychiatric drug treatment, just strip away the non-drug components. Not many people ill enough to be in a mental hospital wouldn't be being treated with psychiatric drugs there.)
posted by praemunire at 10:03 PM on December 12, 2019 [4 favorites]

It doesn't seem odd that participants would have a handful of similar words to use in descriptions; they may not have decided on "use these three words - exactly these words and no others."

You are probably right. However, the full quote from the video is

"Between 1969 and 1972 a group of colleagues and I gained admission to psychiatric hospitals by simulating, by faking, a single symptom, which was we said that we heard voices, and and the voices said "empty, dull, thud". The moment we were admitted to the hospital, we abandoned our symptom and behaved the way we usually behave."

(emphasis mine)

This clearly claims there was only a single symptom and suggests to me it was identical across subjects, which would be a sensible experimental design. It's very close to the 1973 paper's description.

Memory and fame are weird, but it still seems a little weird to me that he gets it wrong in later retellings.

It's like Bart Simpson saying his famous catchphrase is "Ay cucaracha" ;-)
posted by soylent00FF00 at 8:32 AM on December 14, 2019

About 40% through Cahalan's book now--thus far, it's only marginally about the study and a quest to validate or debunk it. It's more a look at the illness model of mental health, largely schizoaffective disorders.

I'm enjoying it. YMMV It seems well-researched; it's certainly written in an engaging and thoughtful manner by a person who directly and clearly acknowledges that her knowledge of psychiatry and psychiatric hospitals is through a traumatic brain illness and misdiagnosis.

Both the narrow subject (the study) and the broader one (mental health care as one indicator of social attitudes to mental disorder) are interesting and dense. I feel she treats them as such.
posted by crush at 6:11 AM on December 16, 2019 [1 favorite]