November 3, 2015 • 42 mins
How do we know precisely what constitutes "normality" or mental illness? And if there is a difference, can anybody detect it? Even professionals? In this episode of Stuff to Blow Your Mind, Robert and Joe explore the groundbreaking 1973 study that saw eight otherwise-healthy "pseudopatients" admitted to 12 different psychiatric facilities and diagnosed with mental illness.
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Episode Transcript
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Speaker 1 (00:03):
Welcome to stuff to Blow your Mind from house stop
works dot com. Hey, who wasn't disposed to blow your mind?
My name is Robert Lamb and I'm Joe McCormick. So, Robert,
I've got a scenario for you. Throw it at me.
Imagine you are on a jury. Okay, so you have
(00:25):
been picked. You're not one of the people who got
sent home early and normally get out of it. Yeah,
but you're there on the jury and you're hearing the
trial of a man who ran a muck in a
bowling alley and so he went nuts. He took his
bowling shoes off, he started throwing bowling balls at people,
and fortunately no one was killed, but several people were
seriously injured. And now this man is standing trial for
(00:48):
his bowling ball rampage. And at trial, the man's attorney
attempts to mount a defense based on the insanity plea,
the claim that the accused did commit the acts in question,
but is not responsible for his actions because his mental
state prevents him from understanding them. Uh. And then the
(01:09):
prosecution brings out an expert witness who is a highly
respected and very confident sounding forensic psychiatrist who testifies that
he has interviewed the defendant and found that the defendant
shows all the normal signs of a person in perfect
command of his actions. But then the defense brings forth
another highly respected and confident sounding forensic psychiatrist who testifies
(01:33):
exactly the opposite, that the defendant symptoms are consistent with
those of a person who is disconnected from reality and
cannot tell right from wrong. If you have no psychiatric
expertise yourself, how are you supposed to tell which one
of these expert witnesses is correct. This is the problem
that one encounters with a number of these trials, right,
(01:55):
because it ultimately comes down to a who can either
who can make the better case for insanity or insanity,
or if they both kind of make equally pressing cases,
then it comes down to something as simple as a
as a character judgment on the part on your part
of the accused. Yeah, now, I might say that it's
possibly true that this scenario I've come up with it's
(02:18):
kind of contrived. It might be worth saying that apparently
less than one percent of defendants in US cases plead insanity,
and then for those that do enter such a plea,
the rates of success are low, so pleading insanity typically
doesn't get you very far in the US legal system.
But the example does raise a few questions about how
(02:39):
we deal with concepts of mental uh, let's say, mental
normality and mental abnormality, as as the lay public understands them.
Throughout this episode, we're gonna be using the words sane
and insane to give a sense of the way that
they're used in the milieu of the experiment we're going
to talk ab out in this episode. But every time
(03:01):
you hear those words, you should imagine that we're putting
some huge, big finger quotes around them, because, as we
discussed at the end, these are probably not the most
useful terms or concepts for describing or helping people in
the real world, but they still are salient concepts too
many people. Like if you take the average person and
(03:23):
ask them if they think the difference between sane and
insane is a real, actual thing and they can tell
the difference, they'll say, yeah, right, yeah, I mean, we
we encountered this all the time, right The just the
basic idea that I'm here on this side of the wall,
and then there are people inside the hospital, there are
people receiving care, there are people that are incarcerated. That's
(03:46):
the insane side of the wall, and there's a bearer
between us. It's kind of a Sneeches and star Belt.
He'd sneeches approach to mental health. You can easily divide
everybody into one of two categories. Either those that have
it all thegether and are seeing everything straight and have
an acceptable understanding of reality, and in those who do not. Yeah,
(04:07):
And so today we want to talk about a landmark
experiment in the history of psychology, one that's been written
about and talked about a lot for years, often celebrated.
It's highly cited, and it concerns the question of how
do we know precisely what constitutes normality or mental illness?
(04:29):
And if there is a difference between sanity and insanity,
can anybody tell the difference? Even professionals, Yeah, especially professionals
that because this uh, I mean, that's what this whole
experiment hinges on is is how do our professionals, how
do our mental health professionals judge uh and and evaluate
(04:50):
individuals that are entering the system. Yeah. So the experiment
in question was carried out by the Stanford professor and
psychologist David Rosenhan, who lived from nineteen twenty nine to
two thousand twelve, And I found this in an obituary
of him, that his education path seemed to be interestingly varied.
So he got a BA in mathematics in nineteen fifty
(05:12):
one from Yeshiva College, and then and then a master's
in economics, and then a PhD in psychology from Colombia,
and then he went on to sort of branch into
two different fields and work on unifying concepts between them.
So he's a professor of law and of psychology. And
according to his Stanford obituary which I read, he he
(05:33):
was sort of known for applying psychology to legal practices
like jury selection and jury consultation. And he held various
honors during his lifetime, like being the head of the
A p A and and stuff like that. So he
was very respected psychologist and jurist, one might say. But
in nineteen seventy three, rosen Hand published in the journal
(05:57):
Science a piece that was old on being sane in
insane places. And it begins with this question that we
talked about a minute ago. If sanity and insanity exist,
how shall we know them? That's what he says. Yeah,
He presents this quite nicely, and as we were discussing
prior to to the recording session here, the whole paper
(06:20):
is just so well written. It's so accessible to uh to,
to the average leader, to the average reader, it's not
it's not you know, lost in a bunch of psycho babble. Yeah,
you can find this paper online and I do highly
recommend reading it as it is. It is not just
clear and very interesting, it's a great piece of writing.
But so Rosenhan opens by pointing out the same thing
(06:42):
we did at the beginning of our podcast. He says
that it's common in murder trials where the defendant sanity
is under dispute, for perfectly respectable psychiatrists to testify in
direct contradiction of one another about the mental state of
the accused. And I actually went and read a couple
of articles about what happens when somebody tries to enter
(07:05):
an insanity polae in court, like how can the the
experts try to figure out whether they are faking it
or not? And there are various methods they have, But
one of the things that struck me about the way
that forensic psychiatrists go about trying to evaluate the mental
state of a person accused of a crime is they're
(07:25):
trying to see if the person fits a known diagnosis.
So they're trying to say, here the known symptoms of
schizophrenia or here the known symptoms of x known state
of psychosis as described in the literature, and can the
defendant match the description that I have here? And if
(07:48):
they just present sort of like an odd collection of symptoms,
it's generally ruled that they're probably faking right there. They're
they're just putting together things that seem to them like
they qualify as crazy, right, And one of the big
ones that often shows up is someone will be they'll
be trying to defend the accused by saying that they
(08:09):
are insane, and then the prosecution will point out something
something in their actions that is clearly premeditated and uh,
thus uh disputing any idea that this was just a
spontaneous manifestation. Oh yeah. There are often very various features
of the crime itself that make it clear that the
(08:31):
person was in a fairly lucid state when they committed that,
like if they try to destroy evidence and you know,
do smart, clear thinking ways of avoiding responsibility for the crime.
But anyway to investigate this question. If sanity and insanity exist,
how shall we know them? David Rosenhan staged an experiment
(08:53):
that's one of the most interesting I've ever come across
in the history of psychology, and it was essentially an
under cover sting operation to determine what it takes to
convince a mental health facility that a person is insane,
and then what it takes to convince them that that
same person is sane. Indeed, so this took place between
(09:15):
nine seventy two, So they're there as we'll discuss, uh,
their various locations that are employee. Here you have eight
same people and they're gained a secret admission to twelve
different hospitals. So we're talking three women, five men, um
one of the psychology graduate student in his twenties. The
(09:36):
remaining seven were older and quote unquote established. So among
them you have three psychologists, a pediatrician, a psychiatrist, a painter,
and a housewife. And uh oh, and then also rosen himself.
Rosenhan himself is involved here to Yeah, he was one
of the mental health professionals, and the mental health professionals
gave false professions in their biographies. They were describing themselves
(10:01):
to the these mental hospitals basically for fear of being
treated differently than other patients. And that makes sense to me,
because if if you want to know how the hospital treats,
you know, the average person who walks up, you don't
want to say hi, I'm a psychiatrist. I know, they
might sort of be on their guard when they're dealing
with you. And likewise, they went in under false names
(10:22):
as you might expect. Yes, Rosenhan himself was one of
the patients, um though he was not a fully clandestined
one as the other one as the other people were.
He Rosenhan himself was the first of these pseudo patients
as they're called, and his presence was quote known to
the hospital administration and the chief psychologist and so far
as he says, I can tell to them alone. So
(10:46):
he was known, but nobody else was known, and he
was only known to a couple of people at the
hospital and nobody else there. Yeah, there has I mean,
obviously you would have to have some sort of arrangement
employ here. You can't just They couldn't have carried out
this experiment by just doing cold blind calls on various institutions, right,
but no nobody else was known to anybody, which just him.
(11:06):
And so the eight patients that they went to twelve
different hospitals. So obviously some of them were admitted more
than once, and they went to twelve different hospitals in
the sample, and they were trying to cover a broad
range of the different kinds of mental facilities that you
could go to. So they were in five different states
on the east and west coast, and the hospitals were
a varying condition. Some were old and shabby, as they said,
(11:29):
and some were newer. They had different levels of funding,
different patients to staff ratios, and only one of the
twelve hospitals was a private hospital and that made an
interesting difference in how the diagnoses were treated. Later. But
how did the so called pseudo patients get admission to
the hospital. It was a pretty simple trick, and they
(11:50):
all did exactly the same thing. Yeah, they all show
up and uh claim that they are hearing voices, that
they're experiencing auditory hallucinations, Yes, which of course is is
is often a key symptom of schizophrenia, right, And so
when they were asked about what the voices said, the
participant would say that the voice was an unfamiliar voice
of the same sex as the pseudo patient and that
(12:13):
they were generally difficult to understand, but that they had
said the words quote, empty, hollow, and thud, and I
was like, wow, what an interesting combination of words. What
would a psychiatrist make of that? But Rosenhunt explains that
these words were chosen because they sort of went both ways,
and number one, they formed an easy association with concepts
(12:36):
of existential anxiety, like you could imagine somebody having thoughts
like my life is empty. I'm so you know, existence
is so hollow? Should I kill myself and land on
the floor with a thud? But they never said any
of that explicitly, just empty, hollow and thud. Those were
the only words, empty hollow, that that would be a
great name for like a nineties goth act. Oh yeah, yeah, yeah,
(13:00):
I love it. That's a that's a tattoo already on somebody.
But anyway, they also picked these because this type of
psychosis described in these terms did not match any in
the medical literature at the time. So this didn't match
an existing diagnosis that could be found. Okay, so it's
a little more abstract than just it was less on
(13:21):
the nose. If someone is showing up and saying, oh, well,
I have this symptom, the symptom in this system, and
they go, oh, those symptoms are exactly what I have
on the paper here. More, it leaves the uh, the
individual making the diagnosis, room for at least the illusion
of discovery. R So, as you would expect, the people
who showed up at the hospitals faking these symptoms were
(13:43):
immediately detected and sent home. Oh no, wait, that's not
the case. In fact, all twelve times they were admitted
to the hospitals, with eleven out of the twelve times
they were diagnosed with schizophrenia, and then interestingly, one out
of the twelve times they were diagnosed with manic depressive psychosis,
(14:04):
which Rosenhan. Rosenhan points out that the manic depressive psychosis
had at the least of the time a more favorable
prognosis than schizophrenia, so that this was a condition that
you were more likely to recover from. Things looked better
for you had a better outlook, and for whatever reason,
this one different diagnosis. The better diagnosis took place at
(14:26):
the one private hospital in the study, but note that
it's not necessarily a more accurate diagnosis because these people
were all faking and all said the same thing. It's
just the diagnosis that tended to turn out better for
the patient. Okay, So this is adding possibly an interesting
layer of class bias into what they found these hospitals
(14:49):
behave like. So they were admitted, they were put into
these hospitals, and then what did they do. Did they
continue to pretend that, oh, I'm hearing these voices that
at step, of course, is to sort of straighten up
and said and uh and resume their normal behavior, claim
that their symptoms are completely gone. But it's important to
(15:09):
note they're not coming clean either. They're not saying actually surprised.
This is all part of a study, right, They're just saying, oh,
I feel fine now, I'm not experiencing those auditory hallucinations
that I was talking about earlier. Right. They immediately resumed
normal behavior, claim their symptoms were entirely gone and they
were on their best behavior. So they were very good patients. Uh,
(15:31):
at least they tried to be, and they self reported
that they were good patients. They were described by the
nursing reports kept at the facilities as quote friendly, cooperative,
and exhibited no abnormal indications. So according to the reports,
they didn't do anything weird or disruptive. Uh that they
seemed perfectly well behaved and normal. But nobody caught on.
(15:56):
Well maybe not nobody. None of the people who should
have caught on caught on. The the hospital staff uh
and psychologist, psychiatrists, the attendants, the nurses. Nobody caught onto
the fact that these people were faking, but some of
the other patients did. In fact, that was fairly common.
(16:17):
So during the course of the of three different hospitalization records,
participants recorded that out of a hundred and eighteen fellow
patients on the admissions ward, thirty five of them quote
voiced their suspicions somewhat vigorously. You're not crazy, you're a
journalist or a professor, referring to the continual note taking
(16:38):
you're checking up on the hospital. So the other patients
were detecting what was going on with these people, but
the hospital staff was not. Huh, that's fascinating. So how
did the staff respond. They forced the studio pay since
first of all, to admit to having a mental illness
and made him agree to take antipsychotic drugs as a
(17:00):
condition of their release. So there they said, Okay, you're
doing better. You're you're not having you're not experiencing these
auditory hallucinations anymore. UM, to sign this and then agree
to this a particular drug treatment, and you can go
on your way. Okay. So how long did that take?
Was that just like two or three days before they
(17:20):
did that? Between let's see whether the length of the
hospital stays or between seven and fifty two days. So
an average day of nine average day of nineteen days.
So this one overnight, Yeah, a week confined to the
hospital was the shortest. Somebody was in there for fifty
two days. In fact, that might have been rosen Hunt himself.
I'm not sure, but there was a point where he said,
I didn't know how long I was going to be
(17:42):
in there, but I thought it would be a few days.
I didn't expect it to be two months. Um. But yeah,
an average day of nineteen days in the hospital with
no symptoms whatsoever while they're there, and then a note
on all of those anti psychotic drugs that they were
required to take as a condition of their release. Um.
The report says that the pseudo patients were administered more
(18:05):
than two thousand pills. It was like pills over the
course of this including the drugs uh, I don't even
know if I'm not familiar with these, elavil, stella, zine, composine, thorazine,
I know those, uh, to name a few of them.
And then Rosenhan points out in this note that quote
such a variety of medications should have been administered to
(18:27):
patients presenting identical symptoms is itself worthy of note? It
kind of makes you wonder about the extent to which,
at least at the time, some of the drugs prescribed
for psychological diagnoses were I don't know, perhaps somewhat arbitrary,
but anyway, that they didn't take the pills, so only
(18:48):
two pills over the course of the entire experiment were swallowed.
The rest they pocketed deposited in the toilet. And then
they also said that they noticed some of the real
patients doing the same thing, because I mean, and they
had to actually consume two of them in order to
set the precedent that they were taking them. Because that's
because that's a common reaction to being administered all these pills,
(19:09):
right that you can start start refusing to take them
or secret them away. Yeah, well, at least they for
whoever took those two pills, I guess. I mean the
fact that they could get away with not taking the
pills for so long, I mean almost nobody took the
pills and then they didn't get caught. I think that's
interesting also key to the experiment, of course, that they're
(19:29):
not taking all these pills and then because then you
would have to factor in, well to what effect is
this massive drug intake affecting their behavior and therefore, uh,
their reception by the staff. Right, So you had all
these diagnoses, you had these schizophrenia diagnosis, but then people
they reported their symptoms were gone and eventually were released,
(19:50):
though sometimes after a kind of a long stay in
the hospital that I that I know in many cases
was not pleasant for these people. Yeah, and they were
all diagnosed with schizophrenia quote in remission before their release.
And this is a really key point because Rosenhn is
careful to point out the distinction between in remission and
sane It's suggesting sort of the categorization of schizophrenia in
(20:14):
remission retains a level of categorical stigma that's associated with
the fact that the patient is still considered fundamentally an
insane person. They're just not showing symptoms right now. Like,
once you have been deemed insane, it almost seems as
if the hospital will not consider you sane again. Yeah,
(20:36):
it's it's it's as if it's affected your sort of
baseline sanity score, and it's it's forever going to be
a little lower, no matter what your particular manifestation level
is going to be. Yeah, though then again, I mean
even that might be more progressive than what was actually
displayed in practice in the hospital, because I don't know,
(20:56):
it seems kind of cruel to think of sanity on
a like sliding scale of numbers, like a like a
D one role. But what we have here doesn't even
seem like the sliding scale. You're just either in the
club or you're not. You're in the normal sane person club,
or you are outside that club and you don't get
to get in. You either have the star or you don't. Now,
I do want to mention as well that that in
(21:19):
in the paper, Rosenhan also comments on the conditions that
that they encountered, then he himself encountered a part of Yeah,
just talking about like the language that was used, the
attitude that was used against the patients, as well as
just the feeling of powerlessness that that that he felt
(21:39):
inside these institutions. And uh and therefore the ramifications that
that that those conditions would have upon any individual that's
placed in their care, especially someone who might have some
level of of actual mental illness. But one of the
main takeaways of this, at least the first half of
this experiment, and we'll get to the very interesting second
(21:59):
half in a moment um, is what they called called
the uniform failure to recognize sanity. And Rosenhan points out
on the paper that that shouldn't be attributed to these
just being like bad hospitals, because they went for a
whole range of them. They went from you know, they
went to some shabby hospitals, but then also to some
(22:20):
very nice hospitals, and it just seemed like, you know,
once you were there and you presented a few symptoms,
they said, okay, yes you are insane. You know, given
all of this, I can imagine if I was running
a hospital at the time of rosen Hans's experiment, I
would I would respond with, well, you know what that
(22:41):
could ever happened. Here, it never happened. Here's one thing
for these other institutions to fail to to to see
through this scheme and to properly diagnose these pseudo patients.
But you try that mess with me, buddy, and I'm
going to spot your pseudo patients and kick them right
out the door. Give me your best shot. And in fact,
there was there was one hospital that did exactly that.
(23:01):
There was a hospital administration that took issue with rosen
Hans findings and they put a challenge to him. They
were like, okay, okay, hold on a second, you send
us your pseudo patients and we will rout them out.
And what did Rosahn do? He agreed, he so he said,
I'll send you send them, I'll send them on beyond
your guard. And so they were on their guard. In
(23:24):
the following weeks, out of one new patients that the
staff identified, forty one as potential pseudo patients, with twenty
three receiving suspicion from at least one psychiatrist and nineteen
of these receiving suspicion from one psychiatrist and one other
staff member. So they were and they they upped their security.
(23:46):
They were ready for it, and they were pointing out
pseudo patients left and right, calling out of the woodwork.
Uh so how many did rosen Han actually send zero?
He sent nobody right. So this is an interesting because
now we have two different types of classical errors that
are being attributed to a psychiatric diagnosis in these hospitals.
(24:10):
We have the type two error, which is the false positive.
You have somebody who comes in, uh, fakes a very
simple simple symptom, resumes normal behavior and is not detected
as a sane person. So that's a that's a false
positive identification of mental illness. Then in the second half
we've got tons of false negatives. People showing up with
(24:30):
actual complaints saying I have a mental illness, I need help,
and the hospital saying you faker. It's like a game
of Werewolf where you don't have an individual with the
werewolf roll. Uh do, you just end up making accusations
left and right. Okay, So what conclusions can we draw
from this experiment? Now? Remember, as we said, this was
(24:52):
back in nineteen seventy three, published in seventy three, took
place between sixty nine and seventy two, So, uh, it's
not a direct common terry on the current day. Yeah,
so this was back then, and we can at least
hope that things are to some extent largely informed by
this study better today, but at least back then. The
(25:13):
takeaways where that the diagnostic process for distinguishing sanity and
insanity is not reliable. It has shown massive errors, just
complete failure to identify correctly people's mental state going both ways,
the type one error and the type two error. Uh.
The other takeaway that I sort of get from this
(25:35):
is that sane and insane do not seem to be
helpful designations to begin with, but rather the sort of
arbitrary and likely harmful ones. They might be a completely
artificial distinction. Now, that doesn't mean that mental illness isn't
real and that you can't experience, you know, true suffering
(25:56):
and symptoms from afflictions that affect the mind and the psyche.
These are definitely real things, and that's acknowledged by rosen
Han in the study. But it's more that these catch
all categories that fundamentally designate a person as sane or
insane just don't make sense and they don't really work.
So I think the study provides a powerful example of
(26:17):
white might be best to find different ways of talking
about mental illness. Thus some you know, saying like Ted
has a mental illness rather than Ted is a mentally
ill person. Yeah, and this is very much an issue
still today, just in our attempts to try and talk
about mental illness and deal with it. And of course
(26:38):
this has been in the news a lot recently, uh,
in response to the gun violence in America. Totally, I
know what you mean. Whenever there's another mass shooting in America,
one of the narratives that pops up in the media
is whether or not we need to do something in quotes,
do something about mental illness to stop things like this
(26:59):
from happening. Now. I think there probably are a lot
of ways we could improve how we treat and care
for people with mental illnesses. But I think sometimes I
worry that a subset of the people advocating this narrative
of do something about mental illness are less focused on
specific ways we could improve treatment and more focused on,
in a kind of vague and general way, just increasing
(27:22):
stigma even more, which is unfounded. I mean, most people
who have a mental illness of one kind or another
are not dangerous and do not commit acts of violence.
But it's just this idea that you know that having
a mental illness makes you sort of a tainted person,
you're just automatically suspect. And that's certainly a major theme
(27:44):
in rosen Hans's experiment. Yes, absolutely that. The third main
takeaway that I wanted to introduce was, and I wanted
to quote rosen Hans's own words because I can't put
it any better. Quote. Having once been labeled schizophrenic, there
is nothing the pseudo patient can do to overcome the tag.
The tag profoundly colors others perceptions of him and his
(28:05):
behavior unquote. So instead of observing a person's behaviors to
determine mental illness, the observers use the diagnosis of mental
illness to interpret the behaviors. So the context seems to
rule how observations of behavior are interpreted. Sitting in a
coffee shop writing in a journal is considered by most
(28:28):
people normal behavior. Sitting in a mental institution with a
diagnosis of schizophrenia writing in a journal is considered pathological
writing behavior. The behavior is the same, but they're using
the diagnosis to to interpret the meaning of what the
person's actions are, and the same thing is reported by
Rosen Han in some of the therapy sessions and the
(28:50):
notes that were taken on those. So a person can
talk about the relationships in their life and say, um,
you know, my wife and I rarely argue. Every now
and then we get angry with one another, but most
of the time we have a very loving relationship. Okay,
so that sounds perfectly normal. But if you're trying to
look at this with a kind of with an eye
(29:12):
for instability and and you know, problems in one's personal life,
you can just latch onto the part where you said, well,
every now and then we get angry and argue, and say,
you know has issues with angry arguments at home, and
that becomes a part of this psychological diagnosis. I mean,
everybody gets angry with people that they love every now
(29:33):
and then. It happened, it's totally normal. Now to just
to put this in a certain uh in the framework
of the time and sort of in the timeline of
American um psychiatric care, I found this pretty helpful. So,
according to American psychiatrist Alan Francis, who was a chair
on the task force that created the American Psychiatric Association's
(29:54):
Diagnostic and Statistics Manual four or the d s M
four UM in war Uh. He said that the predominant
post war, post World War two model and psychiatry was
psychoanalytic with an extremely confident focus on treatment. So it's
out there, we can treat it, and we can treat
it well. That was kind of according to Francis, that
(30:15):
was we know what we're doing here. Step back, Yeah,
let the professionals handle it. The institutions can handle it.
But then of course came rosen Han's experiment, and along
with some other revelations, it really took the wind out
of everyone's sales, right, exposing the unreliability of psychiatric diagnosis.
And I can imagine if you worked in the field
of psychiatry or psychology at the time, this would come
(30:36):
as a huge blow to you. Yeah. Indeed. Uh. In
his book Saving Normal and Insiders Revolt against Out of
Controlled Psychiatric Diagnosis ds M five, Big Pharma and the
Medicalization of Ordinary Life, Francis writes that before d s
M three, which very much previous edition, yeah, but but
still comes after rosen Hans experiments UM, he said that
(31:00):
psychiatry was quote pure art forms, something brilliant, sometimes brilliant
usually idiosyncratic and always chaotic. Yeah, I mean, I have
heard this charge before. H And I don't want to
make judgments against psychiatry or psychology. I mean, I don't
have any relevant expertise that can let me stand in
(31:20):
judgment of them. But I've definitely heard people make the
accusation than in some ways, especially historically, psychology is more
of an art than a science. I could see where
one could make a case for that. Yeah. And then
of course another feature of it is that seemingly, at
this time at least, there is a lot that it
seems to grow out of an expert's intuitions, you know,
(31:43):
like that you can't it's difficult to do very accurate,
unbiased quantitative measurements of a person's psychological state. So you
I mean, I guess you can derive sort of standard
batteries like of of question errors and and psychological tests.
But still in the field, I think you're going to
(32:04):
have a lot of intuition coming into play. You're having
an expert who knows something about the field, has read
the medical literature, knows what the standard diagnoses and the
descriptions of them are, and then sort of looks at
what he or she sees and gets a feeling or
intuition about what's going on here. Then then again, I
(32:25):
think you could probably also say sometimes medical doctors, you know,
somatic illness doctors, would do the same thing, say, you know,
I'm just kind of looking at your symptoms and getting
a feel for the fact that you've probably just have
some virus infect viral infection of the upper respiratory system. Well,
you know, that actually leads me to one of the
big criticisms that was leveled against rosen Hans experiment at
(32:46):
the time, um and uh. And one of the individuals
doing this was the Columbia psychiatrist and DASM three chair
Robert Spitzer, And that is that psychiatric diagnosis relies on
the patient honestly reporting what they feel, and rosen Hans
experiment would seem to bend, if not break that right
(33:07):
because each pseudo patient story is a lie. And and
let's not forget that a healthy person can still enter
a hospital emergency room complain of non existent pain and
received treatment. That might be a useful criticism, But then again,
I think a lot of the point of rosen Han's
experiment was about the hospital not catching on over time,
(33:29):
So I can maybe understand the original admission to the hospital,
especially if the hospital is strapped for time, they can't
spend a lot of time with the patient. Um, but
they didn't have complex, fake psychological personas that were designed
cleverly to trick the psychologist. They just said empty, hollow thud,
(33:50):
heard a voice said it. That's it. They get in
and then they completely all symptoms went away, normal behavior,
and then they couldn't get out for a long time. Yeah.
And and to your point, they're judging the individual who
is no longer claiming to have any kind of auditory hallucinations.
They are diagnosing them as something other than saying yes
(34:13):
absolutely and again playing on that that really problematic distinction,
the overall categorical distinction between sane and insane. But I
think this is a really strong indication that it is
not good for us to use these categories of sane
person and insane person. Just a fact I want to
mention is that according to the U s National Institute
(34:36):
of Mental Health in there were an estimated forty three
point eight million adults aged eighteen or older in the
United States with any mental illness. So that's just any
mental illness of all the kinds recognized in the past year,
and this represented eighteen point five of all US adults.
(34:56):
So there's a huge chunk of people in any given country.
But we have the stats here for the United States
that at any given time will experience a mental illness.
But this doesn't mean they've always had it. It doesn't
mean they always will have it. It doesn't mean they're
a bad or suspect person for having it. I mean,
we don't think that about people who have illnesses of
(35:19):
the body. We don't label somebody who has a somatic
body illness as a sick person who from thereafter is
known as a person who has been sick. Yeah. I
mean it's like we end up treating the human mind
as this fixed state that is not susceptible to change
and influence. Yeah, it's almost as if we're importing a
(35:40):
kind of magical thinking. They're too, Like the having a
mental illness is in a very unfair way treated like
being in a state of sin or being in uh,
having some kind of magical taint to you that makes
people afraid of you. This is a thing that was
described in the part of the report where rosen Han
talks about the conditions inside the hospital, which is a
very also a very salient part of the report and
(36:02):
another great reason you should read it. But one of
the things he talks about is the lack of contact
between the staff and the patients, like that there's just
really very little interaction, and that sometimes it's as if
people who don't claim to suffer from a mental illness
were afraid that they could catch it by being near
(36:24):
or interacting with the people who did have a mental illness.
There was like a like an aversion that drove them away.
And this was partially explaining the lack of interaction between
the staff and the patients. Yeah, and I can definitely
imagine an unwillingness to have to look at and think
about this thing that we UH often have an inability
(36:46):
to to talk about and to to even quantify in
a in a meaningful sense. There was one last paragraph
I wanted to read from rosen Hans studied because I
just found it absolutely fascinating. I wonder what you thought
about this, Robert, but let me read it first. The
quote is conceivably when the origins of and stimuli that
(37:08):
give rise to a behavior are remote or unknown or
when the behavior strikes us as immutable, trait labels regarding
the behavior arise the trait labels like insane that we
were talking about. When, on the other hand, the origins
and stimuli are known and available, discourse is limited to
the behavior itself. Thus, I may hallucinate because I am sleeping,
(37:33):
or I may hallucinate because I have ingested a peculiar drug.
These are termed sleep induced hallucinations or dreams or drug
induced hallucinations, respectively. But when the stimuli to my hallucinations
are unknown, that is called craziness or schizophrenia. As if
that inference were somehow as illuminating as the others. I
(37:55):
thought that was absolutely fascinating because it almost uh tracks
this this problem we have in dealing with mental illness
as a function of our lack of understanding. Like, like,
we think we're very advanced or much more advanced than
we used to be in fields like psychiatry and psychology
because we're I guess we're a lot better than we
(38:17):
used to be. I mean, we no longer think people
have demons in them. Uh, we understand that that there
are conditions that can affect the mind, that can cause
people suffering and distress or cause people abnormal behavior, and
that there are hopefully physical or or at least like
you know, talk based ways of treating those and helping
get people get relief and and fix the problem that's
(38:40):
affecting them. But we're still very imprecise with psychology, aren't we.
I mean, it's not like in many ways of treating
body illnesses where we've come up with extremely just laser
targeted ways of fixing the problems that arise. If you
get a broken bone, you know, you can get a
surgery or a splint put on. You know, there there
(39:00):
are ways of fixing it that we're pretty sure are
gonna work and aren't gonna have too many weird side effects.
And you can do the same thing with say antibiotics
or other you know, drug treatments that we have for
body illnesses. And there is just a fundamental lack of
precision and lack of technological advancement we have in treating
(39:21):
illnesses that affect the mind. Yeah, and it it definitely
reminds me of content that looked at in the past,
just talking about like what is in the same way
we're talking about what is saying and what is insane,
um and and as flawed as those categories are, But
then you know what is what is an actual experience
of reality versus a skewed experience of reality, especially when
(39:42):
you start thinking of any human perception of reality is
essentially flawed. It's imperfect, it's based, it's it's not it's
not one for one, you know, So, so how do
you start There is no objective Yeah, there is no
objective reality. All reality is a subjective reality, and the
individual on the other side of the glass, their experience
(40:05):
of of subjective reality is just different. So then how
do you treat it? How do you quantify it? Uh?
You end up falling back on these false terms. Yeah, absolutely,
And I think that point Rosenhan makes uh still largely
applies today. Even though we may have come somewhere since
since the nineteen seventies, we still are at this place
(40:26):
where the fact that we don't understand the origins of
of of somebody's problem makes us treat it with less
compassion than we should. And so, if there's one takeaway
from today's episode, try to ditch the concepts of sane
and insane. And I know they're deeply ground into us,
but I say, do your best to chuck them out.
(40:48):
I mean, when you encounter somebody who has a mental
illness and has symptoms, think about what can be done
to help the person's symptoms or there or alleviate the
problems in their direct experience, rather than saying, this is
an insane person. Yeah, or even if you just go
back your daily life, it's so easy to fall into
the mindset of just walking down the street and going
(41:09):
that person saying that one's that one's insane, that one's crazy,
that one's crazy, that one maybe a little crazy, that
one's sane. Uh. But but again that's just falling upon
this this this this false dichotomy of a mental experience. Yeah.
So anyway, I think that's a very fascinating paper, but
really highly recommended. You can find it online. There are
copies you can find you can read the whole text
(41:30):
for will make sure to link to it as well
on the landing page for this episode. So fantastic in
the in the history of psychology and science, and really
in the history of human empathy. I think. Yeah. All right,
So in the meantime, check us out at stuff to
Blow your mind dot com. That's where you'll find all
the episodes, various videos, blog post links out to social
(41:52):
media accounts like Twitter and Facebook. Will Blow the Mind
on both of those and I tumbling. We're stuff to
blow your mind. And if you want to write us
and let us know your feet back about today's episode
or what you thought about the topic of the categories
of sanity and insanity and how we diagnose them, you
can email us at will the Mind at how stuff
works dot com for more on this and thousands of
(42:22):
other topics. Is it how stuff works dot com. Remember
Welcome to stuff to Blow your Mind from house stop
works dot com. Hey, who wasn't disposed to blow your mind?
My name is Robert Lamb and I'm Joe McCormick. So, Robert,
I've got a scenario for you. Throw it at me.
Imagine you are on a jury. Okay, so you have
(00:25):
been picked. You're not one of the people who got
sent home early and normally get out of it. Yeah,
but you're there on the jury and you're hearing the
trial of a man who ran a muck in a
bowling alley and so he went nuts. He took his
bowling shoes off, he started throwing bowling balls at people,
and fortunately no one was killed, but several people were
seriously injured. And now this man is standing trial for
(00:48):
his bowling ball rampage. And at trial, the man's attorney
attempts to mount a defense based on the insanity plea,
the claim that the accused did commit the acts in question,
but is not responsible for his actions because his mental
state prevents him from understanding them. Uh. And then the
(01:09):
prosecution brings out an expert witness who is a highly
respected and very confident sounding forensic psychiatrist who testifies that
he has interviewed the defendant and found that the defendant
shows all the normal signs of a person in perfect
command of his actions. But then the defense brings forth
another highly respected and confident sounding forensic psychiatrist who testifies
(01:33):
exactly the opposite, that the defendant symptoms are consistent with
those of a person who is disconnected from reality and
cannot tell right from wrong. If you have no psychiatric
expertise yourself, how are you supposed to tell which one
of these expert witnesses is correct. This is the problem
that one encounters with a number of these trials, right,
(01:55):
because it ultimately comes down to a who can either
who can make the better case for insanity or insanity,
or if they both kind of make equally pressing cases,
then it comes down to something as simple as a
as a character judgment on the part on your part
of the accused. Yeah, now, I might say that it's
possibly true that this scenario I've come up with it's
(02:18):
kind of contrived. It might be worth saying that apparently
less than one percent of defendants in US cases plead insanity,
and then for those that do enter such a plea,
the rates of success are low, so pleading insanity typically
doesn't get you very far in the US legal system.
But the example does raise a few questions about how
(02:39):
we deal with concepts of mental uh, let's say, mental
normality and mental abnormality, as as the lay public understands them.
Throughout this episode, we're gonna be using the words sane
and insane to give a sense of the way that
they're used in the milieu of the experiment we're going
to talk ab out in this episode. But every time
(03:01):
you hear those words, you should imagine that we're putting
some huge, big finger quotes around them, because, as we
discussed at the end, these are probably not the most
useful terms or concepts for describing or helping people in
the real world, but they still are salient concepts too
many people. Like if you take the average person and
(03:23):
ask them if they think the difference between sane and
insane is a real, actual thing and they can tell
the difference, they'll say, yeah, right, yeah, I mean, we
we encountered this all the time, right The just the
basic idea that I'm here on this side of the wall,
and then there are people inside the hospital, there are
people receiving care, there are people that are incarcerated. That's
(03:46):
the insane side of the wall, and there's a bearer
between us. It's kind of a Sneeches and star Belt.
He'd sneeches approach to mental health. You can easily divide
everybody into one of two categories. Either those that have
it all thegether and are seeing everything straight and have
an acceptable understanding of reality, and in those who do not. Yeah,
(04:07):
And so today we want to talk about a landmark
experiment in the history of psychology, one that's been written
about and talked about a lot for years, often celebrated.
It's highly cited, and it concerns the question of how
do we know precisely what constitutes normality or mental illness?
(04:29):
And if there is a difference between sanity and insanity,
can anybody tell the difference? Even professionals, Yeah, especially professionals
that because this uh, I mean, that's what this whole
experiment hinges on is is how do our professionals, how
do our mental health professionals judge uh and and evaluate
(04:50):
individuals that are entering the system. Yeah. So the experiment
in question was carried out by the Stanford professor and
psychologist David Rosenhan, who lived from nineteen twenty nine to
two thousand twelve, And I found this in an obituary
of him, that his education path seemed to be interestingly varied.
So he got a BA in mathematics in nineteen fifty
(05:12):
one from Yeshiva College, and then and then a master's
in economics, and then a PhD in psychology from Colombia,
and then he went on to sort of branch into
two different fields and work on unifying concepts between them.
So he's a professor of law and of psychology. And
according to his Stanford obituary which I read, he he
(05:33):
was sort of known for applying psychology to legal practices
like jury selection and jury consultation. And he held various
honors during his lifetime, like being the head of the
A p A and and stuff like that. So he
was very respected psychologist and jurist, one might say. But
in nineteen seventy three, rosen Hand published in the journal
(05:57):
Science a piece that was old on being sane in
insane places. And it begins with this question that we
talked about a minute ago. If sanity and insanity exist,
how shall we know them? That's what he says. Yeah,
He presents this quite nicely, and as we were discussing
prior to to the recording session here, the whole paper
(06:20):
is just so well written. It's so accessible to uh to,
to the average leader, to the average reader, it's not
it's not you know, lost in a bunch of psycho babble. Yeah,
you can find this paper online and I do highly
recommend reading it as it is. It is not just
clear and very interesting, it's a great piece of writing.
But so Rosenhan opens by pointing out the same thing
(06:42):
we did at the beginning of our podcast. He says
that it's common in murder trials where the defendant sanity
is under dispute, for perfectly respectable psychiatrists to testify in
direct contradiction of one another about the mental state of
the accused. And I actually went and read a couple
of articles about what happens when somebody tries to enter
(07:05):
an insanity polae in court, like how can the the
experts try to figure out whether they are faking it
or not? And there are various methods they have, But
one of the things that struck me about the way
that forensic psychiatrists go about trying to evaluate the mental
state of a person accused of a crime is they're
(07:25):
trying to see if the person fits a known diagnosis.
So they're trying to say, here the known symptoms of
schizophrenia or here the known symptoms of x known state
of psychosis as described in the literature, and can the
defendant match the description that I have here? And if
(07:48):
they just present sort of like an odd collection of symptoms,
it's generally ruled that they're probably faking right there. They're
they're just putting together things that seem to them like
they qualify as crazy, right, And one of the big
ones that often shows up is someone will be they'll
be trying to defend the accused by saying that they
(08:09):
are insane, and then the prosecution will point out something
something in their actions that is clearly premeditated and uh,
thus uh disputing any idea that this was just a
spontaneous manifestation. Oh yeah. There are often very various features
of the crime itself that make it clear that the
(08:31):
person was in a fairly lucid state when they committed that,
like if they try to destroy evidence and you know,
do smart, clear thinking ways of avoiding responsibility for the crime.
But anyway to investigate this question. If sanity and insanity exist,
how shall we know them? David Rosenhan staged an experiment
(08:53):
that's one of the most interesting I've ever come across
in the history of psychology, and it was essentially an
under cover sting operation to determine what it takes to
convince a mental health facility that a person is insane,
and then what it takes to convince them that that
same person is sane. Indeed, so this took place between
(09:15):
nine seventy two, So they're there as we'll discuss, uh,
their various locations that are employee. Here you have eight
same people and they're gained a secret admission to twelve
different hospitals. So we're talking three women, five men, um
one of the psychology graduate student in his twenties. The
(09:36):
remaining seven were older and quote unquote established. So among
them you have three psychologists, a pediatrician, a psychiatrist, a painter,
and a housewife. And uh oh, and then also rosen himself.
Rosenhan himself is involved here to Yeah, he was one
of the mental health professionals, and the mental health professionals
gave false professions in their biographies. They were describing themselves
(10:01):
to the these mental hospitals basically for fear of being
treated differently than other patients. And that makes sense to me,
because if if you want to know how the hospital treats,
you know, the average person who walks up, you don't
want to say hi, I'm a psychiatrist. I know, they
might sort of be on their guard when they're dealing
with you. And likewise, they went in under false names
(10:22):
as you might expect. Yes, Rosenhan himself was one of
the patients, um though he was not a fully clandestined
one as the other one as the other people were.
He Rosenhan himself was the first of these pseudo patients
as they're called, and his presence was quote known to
the hospital administration and the chief psychologist and so far
as he says, I can tell to them alone. So
(10:46):
he was known, but nobody else was known, and he
was only known to a couple of people at the
hospital and nobody else there. Yeah, there has I mean,
obviously you would have to have some sort of arrangement
employ here. You can't just They couldn't have carried out
this experiment by just doing cold blind calls on various institutions, right,
but no nobody else was known to anybody, which just him.
(11:06):
And so the eight patients that they went to twelve
different hospitals. So obviously some of them were admitted more
than once, and they went to twelve different hospitals in
the sample, and they were trying to cover a broad
range of the different kinds of mental facilities that you
could go to. So they were in five different states
on the east and west coast, and the hospitals were
a varying condition. Some were old and shabby, as they said,
(11:29):
and some were newer. They had different levels of funding,
different patients to staff ratios, and only one of the
twelve hospitals was a private hospital and that made an
interesting difference in how the diagnoses were treated. Later. But
how did the so called pseudo patients get admission to
the hospital. It was a pretty simple trick, and they
(11:50):
all did exactly the same thing. Yeah, they all show
up and uh claim that they are hearing voices, that
they're experiencing auditory hallucinations, Yes, which of course is is
is often a key symptom of schizophrenia, right, And so
when they were asked about what the voices said, the
participant would say that the voice was an unfamiliar voice
of the same sex as the pseudo patient and that
(12:13):
they were generally difficult to understand, but that they had
said the words quote, empty, hollow, and thud, and I
was like, wow, what an interesting combination of words. What
would a psychiatrist make of that? But Rosenhunt explains that
these words were chosen because they sort of went both ways,
and number one, they formed an easy association with concepts
(12:36):
of existential anxiety, like you could imagine somebody having thoughts
like my life is empty. I'm so you know, existence
is so hollow? Should I kill myself and land on
the floor with a thud? But they never said any
of that explicitly, just empty, hollow and thud. Those were
the only words, empty hollow, that that would be a
great name for like a nineties goth act. Oh yeah, yeah, yeah,
(13:00):
I love it. That's a that's a tattoo already on somebody.
But anyway, they also picked these because this type of
psychosis described in these terms did not match any in
the medical literature at the time. So this didn't match
an existing diagnosis that could be found. Okay, so it's
a little more abstract than just it was less on
(13:21):
the nose. If someone is showing up and saying, oh, well,
I have this symptom, the symptom in this system, and
they go, oh, those symptoms are exactly what I have
on the paper here. More, it leaves the uh, the
individual making the diagnosis, room for at least the illusion
of discovery. R So, as you would expect, the people
who showed up at the hospitals faking these symptoms were
(13:43):
immediately detected and sent home. Oh no, wait, that's not
the case. In fact, all twelve times they were admitted
to the hospitals, with eleven out of the twelve times
they were diagnosed with schizophrenia, and then interestingly, one out
of the twelve times they were diagnosed with manic depressive psychosis,
(14:04):
which Rosenhan. Rosenhan points out that the manic depressive psychosis
had at the least of the time a more favorable
prognosis than schizophrenia, so that this was a condition that
you were more likely to recover from. Things looked better
for you had a better outlook, and for whatever reason,
this one different diagnosis. The better diagnosis took place at
(14:26):
the one private hospital in the study, but note that
it's not necessarily a more accurate diagnosis because these people
were all faking and all said the same thing. It's
just the diagnosis that tended to turn out better for
the patient. Okay, So this is adding possibly an interesting
layer of class bias into what they found these hospitals
(14:49):
behave like. So they were admitted, they were put into
these hospitals, and then what did they do. Did they
continue to pretend that, oh, I'm hearing these voices that
at step, of course, is to sort of straighten up
and said and uh and resume their normal behavior, claim
that their symptoms are completely gone. But it's important to
(15:09):
note they're not coming clean either. They're not saying actually surprised.
This is all part of a study, right, They're just saying, oh,
I feel fine now, I'm not experiencing those auditory hallucinations
that I was talking about earlier. Right. They immediately resumed
normal behavior, claim their symptoms were entirely gone and they
were on their best behavior. So they were very good patients. Uh,
(15:31):
at least they tried to be, and they self reported
that they were good patients. They were described by the
nursing reports kept at the facilities as quote friendly, cooperative,
and exhibited no abnormal indications. So according to the reports,
they didn't do anything weird or disruptive. Uh that they
seemed perfectly well behaved and normal. But nobody caught on.
(15:56):
Well maybe not nobody. None of the people who should
have caught on caught on. The the hospital staff uh
and psychologist, psychiatrists, the attendants, the nurses. Nobody caught onto
the fact that these people were faking, but some of
the other patients did. In fact, that was fairly common.
(16:17):
So during the course of the of three different hospitalization records,
participants recorded that out of a hundred and eighteen fellow
patients on the admissions ward, thirty five of them quote
voiced their suspicions somewhat vigorously. You're not crazy, you're a
journalist or a professor, referring to the continual note taking
(16:38):
you're checking up on the hospital. So the other patients
were detecting what was going on with these people, but
the hospital staff was not. Huh, that's fascinating. So how
did the staff respond. They forced the studio pay since
first of all, to admit to having a mental illness
and made him agree to take antipsychotic drugs as a
(17:00):
condition of their release. So there they said, Okay, you're
doing better. You're you're not having you're not experiencing these
auditory hallucinations anymore. UM, to sign this and then agree
to this a particular drug treatment, and you can go
on your way. Okay. So how long did that take?
Was that just like two or three days before they
(17:20):
did that? Between let's see whether the length of the
hospital stays or between seven and fifty two days. So
an average day of nine average day of nineteen days.
So this one overnight, Yeah, a week confined to the
hospital was the shortest. Somebody was in there for fifty
two days. In fact, that might have been rosen Hunt himself.
I'm not sure, but there was a point where he said,
I didn't know how long I was going to be
(17:42):
in there, but I thought it would be a few days.
I didn't expect it to be two months. Um. But yeah,
an average day of nineteen days in the hospital with
no symptoms whatsoever while they're there, and then a note
on all of those anti psychotic drugs that they were
required to take as a condition of their release. Um.
The report says that the pseudo patients were administered more
(18:05):
than two thousand pills. It was like pills over the
course of this including the drugs uh, I don't even
know if I'm not familiar with these, elavil, stella, zine, composine, thorazine,
I know those, uh, to name a few of them.
And then Rosenhan points out in this note that quote
such a variety of medications should have been administered to
(18:27):
patients presenting identical symptoms is itself worthy of note? It
kind of makes you wonder about the extent to which,
at least at the time, some of the drugs prescribed
for psychological diagnoses were I don't know, perhaps somewhat arbitrary,
but anyway, that they didn't take the pills, so only
(18:48):
two pills over the course of the entire experiment were swallowed.
The rest they pocketed deposited in the toilet. And then
they also said that they noticed some of the real
patients doing the same thing, because I mean, and they
had to actually consume two of them in order to
set the precedent that they were taking them. Because that's
because that's a common reaction to being administered all these pills,
(19:09):
right that you can start start refusing to take them
or secret them away. Yeah, well, at least they for
whoever took those two pills, I guess. I mean the
fact that they could get away with not taking the
pills for so long, I mean almost nobody took the
pills and then they didn't get caught. I think that's
interesting also key to the experiment, of course, that they're
(19:29):
not taking all these pills and then because then you
would have to factor in, well to what effect is
this massive drug intake affecting their behavior and therefore, uh,
their reception by the staff. Right, So you had all
these diagnoses, you had these schizophrenia diagnosis, but then people
they reported their symptoms were gone and eventually were released,
(19:50):
though sometimes after a kind of a long stay in
the hospital that I that I know in many cases
was not pleasant for these people. Yeah, and they were
all diagnosed with schizophrenia quote in remission before their release.
And this is a really key point because Rosenhn is
careful to point out the distinction between in remission and
sane It's suggesting sort of the categorization of schizophrenia in
(20:14):
remission retains a level of categorical stigma that's associated with
the fact that the patient is still considered fundamentally an
insane person. They're just not showing symptoms right now. Like,
once you have been deemed insane, it almost seems as
if the hospital will not consider you sane again. Yeah,
(20:36):
it's it's it's as if it's affected your sort of
baseline sanity score, and it's it's forever going to be
a little lower, no matter what your particular manifestation level
is going to be. Yeah, though then again, I mean
even that might be more progressive than what was actually
displayed in practice in the hospital, because I don't know,
(20:56):
it seems kind of cruel to think of sanity on
a like sliding scale of numbers, like a like a
D one role. But what we have here doesn't even
seem like the sliding scale. You're just either in the
club or you're not. You're in the normal sane person club,
or you are outside that club and you don't get
to get in. You either have the star or you don't. Now,
I do want to mention as well that that in
(21:19):
in the paper, Rosenhan also comments on the conditions that
that they encountered, then he himself encountered a part of Yeah,
just talking about like the language that was used, the
attitude that was used against the patients, as well as
just the feeling of powerlessness that that that he felt
(21:39):
inside these institutions. And uh and therefore the ramifications that
that that those conditions would have upon any individual that's
placed in their care, especially someone who might have some
level of of actual mental illness. But one of the
main takeaways of this, at least the first half of
this experiment, and we'll get to the very interesting second
(21:59):
half in a moment um, is what they called called
the uniform failure to recognize sanity. And Rosenhan points out
on the paper that that shouldn't be attributed to these
just being like bad hospitals, because they went for a
whole range of them. They went from you know, they
went to some shabby hospitals, but then also to some
(22:20):
very nice hospitals, and it just seemed like, you know,
once you were there and you presented a few symptoms,
they said, okay, yes you are insane. You know, given
all of this, I can imagine if I was running
a hospital at the time of rosen Hans's experiment, I
would I would respond with, well, you know what that
(22:41):
could ever happened. Here, it never happened. Here's one thing
for these other institutions to fail to to to see
through this scheme and to properly diagnose these pseudo patients.
But you try that mess with me, buddy, and I'm
going to spot your pseudo patients and kick them right
out the door. Give me your best shot. And in fact,
there was there was one hospital that did exactly that.
(23:01):
There was a hospital administration that took issue with rosen
Hans findings and they put a challenge to him. They
were like, okay, okay, hold on a second, you send
us your pseudo patients and we will rout them out.
And what did Rosahn do? He agreed, he so he said,
I'll send you send them, I'll send them on beyond
your guard. And so they were on their guard. In
(23:24):
the following weeks, out of one new patients that the
staff identified, forty one as potential pseudo patients, with twenty
three receiving suspicion from at least one psychiatrist and nineteen
of these receiving suspicion from one psychiatrist and one other
staff member. So they were and they they upped their security.
(23:46):
They were ready for it, and they were pointing out
pseudo patients left and right, calling out of the woodwork.
Uh so how many did rosen Han actually send zero?
He sent nobody right. So this is an interesting because
now we have two different types of classical errors that
are being attributed to a psychiatric diagnosis in these hospitals.
(24:10):
We have the type two error, which is the false positive.
You have somebody who comes in, uh, fakes a very
simple simple symptom, resumes normal behavior and is not detected
as a sane person. So that's a that's a false
positive identification of mental illness. Then in the second half
we've got tons of false negatives. People showing up with
(24:30):
actual complaints saying I have a mental illness, I need help,
and the hospital saying you faker. It's like a game
of Werewolf where you don't have an individual with the
werewolf roll. Uh do, you just end up making accusations
left and right. Okay, So what conclusions can we draw
from this experiment? Now? Remember, as we said, this was
(24:52):
back in nineteen seventy three, published in seventy three, took
place between sixty nine and seventy two, So, uh, it's
not a direct common terry on the current day. Yeah,
so this was back then, and we can at least
hope that things are to some extent largely informed by
this study better today, but at least back then. The
(25:13):
takeaways where that the diagnostic process for distinguishing sanity and
insanity is not reliable. It has shown massive errors, just
complete failure to identify correctly people's mental state going both ways,
the type one error and the type two error. Uh.
The other takeaway that I sort of get from this
(25:35):
is that sane and insane do not seem to be
helpful designations to begin with, but rather the sort of
arbitrary and likely harmful ones. They might be a completely
artificial distinction. Now, that doesn't mean that mental illness isn't
real and that you can't experience, you know, true suffering
(25:56):
and symptoms from afflictions that affect the mind and the psyche.
These are definitely real things, and that's acknowledged by rosen
Han in the study. But it's more that these catch
all categories that fundamentally designate a person as sane or
insane just don't make sense and they don't really work.
So I think the study provides a powerful example of
(26:17):
white might be best to find different ways of talking
about mental illness. Thus some you know, saying like Ted
has a mental illness rather than Ted is a mentally
ill person. Yeah, and this is very much an issue
still today, just in our attempts to try and talk
about mental illness and deal with it. And of course
(26:38):
this has been in the news a lot recently, uh,
in response to the gun violence in America. Totally, I
know what you mean. Whenever there's another mass shooting in America,
one of the narratives that pops up in the media
is whether or not we need to do something in quotes,
do something about mental illness to stop things like this
(26:59):
from happening. Now. I think there probably are a lot
of ways we could improve how we treat and care
for people with mental illnesses. But I think sometimes I
worry that a subset of the people advocating this narrative
of do something about mental illness are less focused on
specific ways we could improve treatment and more focused on,
in a kind of vague and general way, just increasing
(27:22):
stigma even more, which is unfounded. I mean, most people
who have a mental illness of one kind or another
are not dangerous and do not commit acts of violence.
But it's just this idea that you know that having
a mental illness makes you sort of a tainted person,
you're just automatically suspect. And that's certainly a major theme
(27:44):
in rosen Hans's experiment. Yes, absolutely that. The third main
takeaway that I wanted to introduce was, and I wanted
to quote rosen Hans's own words because I can't put
it any better. Quote. Having once been labeled schizophrenic, there
is nothing the pseudo patient can do to overcome the tag.
The tag profoundly colors others perceptions of him and his
(28:05):
behavior unquote. So instead of observing a person's behaviors to
determine mental illness, the observers use the diagnosis of mental
illness to interpret the behaviors. So the context seems to
rule how observations of behavior are interpreted. Sitting in a
coffee shop writing in a journal is considered by most
(28:28):
people normal behavior. Sitting in a mental institution with a
diagnosis of schizophrenia writing in a journal is considered pathological
writing behavior. The behavior is the same, but they're using
the diagnosis to to interpret the meaning of what the
person's actions are, and the same thing is reported by
Rosen Han in some of the therapy sessions and the
(28:50):
notes that were taken on those. So a person can
talk about the relationships in their life and say, um,
you know, my wife and I rarely argue. Every now
and then we get angry with one another, but most
of the time we have a very loving relationship. Okay,
so that sounds perfectly normal. But if you're trying to
look at this with a kind of with an eye
(29:12):
for instability and and you know, problems in one's personal life,
you can just latch onto the part where you said, well,
every now and then we get angry and argue, and say,
you know has issues with angry arguments at home, and
that becomes a part of this psychological diagnosis. I mean,
everybody gets angry with people that they love every now
(29:33):
and then. It happened, it's totally normal. Now to just
to put this in a certain uh in the framework
of the time and sort of in the timeline of
American um psychiatric care, I found this pretty helpful. So,
according to American psychiatrist Alan Francis, who was a chair
on the task force that created the American Psychiatric Association's
(29:54):
Diagnostic and Statistics Manual four or the d s M
four UM in war Uh. He said that the predominant
post war, post World War two model and psychiatry was
psychoanalytic with an extremely confident focus on treatment. So it's
out there, we can treat it, and we can treat
it well. That was kind of according to Francis, that
(30:15):
was we know what we're doing here. Step back, Yeah,
let the professionals handle it. The institutions can handle it.
But then of course came rosen Han's experiment, and along
with some other revelations, it really took the wind out
of everyone's sales, right, exposing the unreliability of psychiatric diagnosis.
And I can imagine if you worked in the field
of psychiatry or psychology at the time, this would come
(30:36):
as a huge blow to you. Yeah. Indeed. Uh. In
his book Saving Normal and Insiders Revolt against Out of
Controlled Psychiatric Diagnosis ds M five, Big Pharma and the
Medicalization of Ordinary Life, Francis writes that before d s
M three, which very much previous edition, yeah, but but
still comes after rosen Hans experiments UM, he said that
(31:00):
psychiatry was quote pure art forms, something brilliant, sometimes brilliant
usually idiosyncratic and always chaotic. Yeah, I mean, I have
heard this charge before. H And I don't want to
make judgments against psychiatry or psychology. I mean, I don't
have any relevant expertise that can let me stand in
(31:20):
judgment of them. But I've definitely heard people make the
accusation than in some ways, especially historically, psychology is more
of an art than a science. I could see where
one could make a case for that. Yeah. And then
of course another feature of it is that seemingly, at
this time at least, there is a lot that it
seems to grow out of an expert's intuitions, you know,
(31:43):
like that you can't it's difficult to do very accurate,
unbiased quantitative measurements of a person's psychological state. So you
I mean, I guess you can derive sort of standard
batteries like of of question errors and and psychological tests.
But still in the field, I think you're going to
(32:04):
have a lot of intuition coming into play. You're having
an expert who knows something about the field, has read
the medical literature, knows what the standard diagnoses and the
descriptions of them are, and then sort of looks at
what he or she sees and gets a feeling or
intuition about what's going on here. Then then again, I
(32:25):
think you could probably also say sometimes medical doctors, you know,
somatic illness doctors, would do the same thing, say, you know,
I'm just kind of looking at your symptoms and getting
a feel for the fact that you've probably just have
some virus infect viral infection of the upper respiratory system. Well,
you know, that actually leads me to one of the
big criticisms that was leveled against rosen Hans experiment at
(32:46):
the time, um and uh. And one of the individuals
doing this was the Columbia psychiatrist and DASM three chair
Robert Spitzer, And that is that psychiatric diagnosis relies on
the patient honestly reporting what they feel, and rosen Hans
experiment would seem to bend, if not break that right
(33:07):
because each pseudo patient story is a lie. And and
let's not forget that a healthy person can still enter
a hospital emergency room complain of non existent pain and
received treatment. That might be a useful criticism, But then again,
I think a lot of the point of rosen Han's
experiment was about the hospital not catching on over time,
(33:29):
So I can maybe understand the original admission to the hospital,
especially if the hospital is strapped for time, they can't
spend a lot of time with the patient. Um, but
they didn't have complex, fake psychological personas that were designed
cleverly to trick the psychologist. They just said empty, hollow thud,
(33:50):
heard a voice said it. That's it. They get in
and then they completely all symptoms went away, normal behavior,
and then they couldn't get out for a long time. Yeah.
And and to your point, they're judging the individual who
is no longer claiming to have any kind of auditory hallucinations.
They are diagnosing them as something other than saying yes
(34:13):
absolutely and again playing on that that really problematic distinction,
the overall categorical distinction between sane and insane. But I
think this is a really strong indication that it is
not good for us to use these categories of sane
person and insane person. Just a fact I want to
mention is that according to the U s National Institute
(34:36):
of Mental Health in there were an estimated forty three
point eight million adults aged eighteen or older in the
United States with any mental illness. So that's just any
mental illness of all the kinds recognized in the past year,
and this represented eighteen point five of all US adults.
(34:56):
So there's a huge chunk of people in any given country.
But we have the stats here for the United States
that at any given time will experience a mental illness.
But this doesn't mean they've always had it. It doesn't
mean they always will have it. It doesn't mean they're
a bad or suspect person for having it. I mean,
we don't think that about people who have illnesses of
(35:19):
the body. We don't label somebody who has a somatic
body illness as a sick person who from thereafter is
known as a person who has been sick. Yeah. I
mean it's like we end up treating the human mind
as this fixed state that is not susceptible to change
and influence. Yeah, it's almost as if we're importing a
(35:40):
kind of magical thinking. They're too, Like the having a
mental illness is in a very unfair way treated like
being in a state of sin or being in uh,
having some kind of magical taint to you that makes
people afraid of you. This is a thing that was
described in the part of the report where rosen Han
talks about the conditions inside the hospital, which is a
very also a very salient part of the report and
(36:02):
another great reason you should read it. But one of
the things he talks about is the lack of contact
between the staff and the patients, like that there's just
really very little interaction, and that sometimes it's as if
people who don't claim to suffer from a mental illness
were afraid that they could catch it by being near
(36:24):
or interacting with the people who did have a mental illness.
There was like a like an aversion that drove them away.
And this was partially explaining the lack of interaction between
the staff and the patients. Yeah, and I can definitely
imagine an unwillingness to have to look at and think
about this thing that we UH often have an inability
(36:46):
to to talk about and to to even quantify in
a in a meaningful sense. There was one last paragraph
I wanted to read from rosen Hans studied because I
just found it absolutely fascinating. I wonder what you thought
about this, Robert, but let me read it first. The
quote is conceivably when the origins of and stimuli that
(37:08):
give rise to a behavior are remote or unknown or
when the behavior strikes us as immutable, trait labels regarding
the behavior arise the trait labels like insane that we
were talking about. When, on the other hand, the origins
and stimuli are known and available, discourse is limited to
the behavior itself. Thus, I may hallucinate because I am sleeping,
(37:33):
or I may hallucinate because I have ingested a peculiar drug.
These are termed sleep induced hallucinations or dreams or drug
induced hallucinations, respectively. But when the stimuli to my hallucinations
are unknown, that is called craziness or schizophrenia. As if
that inference were somehow as illuminating as the others. I
(37:55):
thought that was absolutely fascinating because it almost uh tracks
this this problem we have in dealing with mental illness
as a function of our lack of understanding. Like, like,
we think we're very advanced or much more advanced than
we used to be in fields like psychiatry and psychology
because we're I guess we're a lot better than we
(38:17):
used to be. I mean, we no longer think people
have demons in them. Uh, we understand that that there
are conditions that can affect the mind, that can cause
people suffering and distress or cause people abnormal behavior, and
that there are hopefully physical or or at least like
you know, talk based ways of treating those and helping
get people get relief and and fix the problem that's
(38:40):
affecting them. But we're still very imprecise with psychology, aren't we.
I mean, it's not like in many ways of treating
body illnesses where we've come up with extremely just laser
targeted ways of fixing the problems that arise. If you
get a broken bone, you know, you can get a
surgery or a splint put on. You know, there there
(39:00):
are ways of fixing it that we're pretty sure are
gonna work and aren't gonna have too many weird side effects.
And you can do the same thing with say antibiotics
or other you know, drug treatments that we have for
body illnesses. And there is just a fundamental lack of
precision and lack of technological advancement we have in treating
(39:21):
illnesses that affect the mind. Yeah, and it it definitely
reminds me of content that looked at in the past,
just talking about like what is in the same way
we're talking about what is saying and what is insane,
um and and as flawed as those categories are, But
then you know what is what is an actual experience
of reality versus a skewed experience of reality, especially when
(39:42):
you start thinking of any human perception of reality is
essentially flawed. It's imperfect, it's based, it's it's not it's
not one for one, you know, So, so how do
you start There is no objective Yeah, there is no
objective reality. All reality is a subjective reality, and the
individual on the other side of the glass, their experience
(40:05):
of of subjective reality is just different. So then how
do you treat it? How do you quantify it? Uh?
You end up falling back on these false terms. Yeah, absolutely,
And I think that point Rosenhan makes uh still largely
applies today. Even though we may have come somewhere since
since the nineteen seventies, we still are at this place
(40:26):
where the fact that we don't understand the origins of
of of somebody's problem makes us treat it with less
compassion than we should. And so, if there's one takeaway
from today's episode, try to ditch the concepts of sane
and insane. And I know they're deeply ground into us,
but I say, do your best to chuck them out.
(40:48):
I mean, when you encounter somebody who has a mental
illness and has symptoms, think about what can be done
to help the person's symptoms or there or alleviate the
problems in their direct experience, rather than saying, this is
an insane person. Yeah, or even if you just go
back your daily life, it's so easy to fall into
the mindset of just walking down the street and going
(41:09):
that person saying that one's that one's insane, that one's crazy,
that one's crazy, that one maybe a little crazy, that
one's sane. Uh. But but again that's just falling upon
this this this this false dichotomy of a mental experience. Yeah.
So anyway, I think that's a very fascinating paper, but
really highly recommended. You can find it online. There are
copies you can find you can read the whole text
(41:30):
for will make sure to link to it as well
on the landing page for this episode. So fantastic in
the in the history of psychology and science, and really
in the history of human empathy. I think. Yeah. All right,
So in the meantime, check us out at stuff to
Blow your mind dot com. That's where you'll find all
the episodes, various videos, blog post links out to social
(41:52):
media accounts like Twitter and Facebook. Will Blow the Mind
on both of those and I tumbling. We're stuff to
blow your mind. And if you want to write us
and let us know your feet back about today's episode
or what you thought about the topic of the categories
of sanity and insanity and how we diagnose them, you
can email us at will the Mind at how stuff
works dot com for more on this and thousands of
(42:22):
other topics. Is it how stuff works dot com. Remember
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