Thread by @drlouisehansen

“If sanity and insanity exist, how shall we know them? We may be convinced we can tell normal from abnormal; evidence is not compelling. A great deal of conflicting data exists on reliability, utility, meaning of "sanity," "insanity," "mental illness," and "schizophrenia.” 1/31

As early as 1934, Benedict suggested normality and abnormality are not universal. Thus, notions of normality and abnormality may not be quite as accurate as people believe they are. To raise these questions is in no way to question that some behaviors are deviant or odd. 2/31

Nor does raising such questions deny the existence of the personal anguish that is often associated with "mental illness." But normality and abnormality, sanity and insanity, and the diagnoses that flow from them may be less substantive than many believe them to be. 3/31

Do the salient characteristics that lead to diagnoses reside in the patients themselves or in the environments and contexts in which observers find them? The belief has been strong that patients present symptoms, that the sane are distinguishable from the insane. 4/31

However, more recently, based on theoretical, anthropological, philosophical, legal, and therapeutic considerations, the view has grown that psychological categorization of mental illness is useless at best and downright harmful, misleading, and pejorative at worst. 5/31

Gains can be made in deciding which of these is more nearly accurate by getting normal people (that is, people who have never suffered symptoms of serious psychiatric disorders) admitted to psychiatric hospitals; see whether they were discovered to be sane and, if so, how. 6/31

If the sanity of pseudopatients were detected, there would be prima facie evidence a sane individual can be distinguished from insane contexts which he is found. Normality is distinct enough that it can be recognized wherever it occurs, for it is carried within the person. 7/31

If, on the other hand, the sanity of pseudopatients were never discovered, serious difficulties arise for traditional modes of psychiatric diagnosis; this would indicate psychiatric diagnosis says little about the patient but much about the environment they are observed in. 8/31

Experiment 1: 8 sane people (psychologists, paediatrician, psychiatrist, painter, housewife) gained secret admission to 12 different hospitals. Beyond alleging symptoms, falsifying name and occupation, no alterations of the person, history, or circumstances were made. 9/31

The events of the pseudopatient's life history/relationships were presented as they occurred. Frustrations and upsets described along with joys and satisfactions. These facts are important: they biased the results in favor of detecting insanity since none were pathological. 10/31

Apart from short-lived nervousness, pseudopatient behaved on the ward as he "normally" behaved. Pseudopatients spoke to patients and staff as he might ordinarily. Because there is uncommonly little to do on a psychiatric ward, he attempted to engage others in conversation. 11/31

When asked by staff how he was feeling, he indicated he was fine, he no longer experienced symptoms. The pseudopatient, very much as a true psychiatric patient, was told that they would have to get out by their own devices, essentially by convincing the staff he was sane. 12/31

The psychological stresses associated with hospitalization were considerable, and all but one of the pseudopatients desired to be discharged almost immediately. They were, therefore, motivated not only to behave sanely, but to be paragons of cooperation. 13/31

‘The normal are not detectably sane’: Despite their public "show" of sanity, the pseudopatients were never detected. Admitted, except in one case, with a diagnosis of schizophrenia, each was discharged with a diagnosis of schizophrenia "in remission." 14/31

The evidence is strong that, once labeled schizophrenic, the pseudopatient was stuck with that label. If the pseudopatient was to be discharged, he must naturally be "in remission"; but he was not sane, nor, in the institution's view, had he ever been sane. 15/31

The uniform failure to recognize sanity cannot be attributed to quality of the hospitals, although there were considerable variations among them, several are considered excellent. Nor can it be alleged that there was simply not enough time to observe the pseudopatients. 16/31

Finally, it cannot be said the failure to recognize the pseudopatients' sanity was that they were not behaving sanely. While there was clearly some tension present, their daily visitors could detect no serious behavioral consequences -- nor, indeed, could other patients. 17/31

It was quite common for patients to "detect" pseudopatient's sanity. Patients voiced their suspicions, some vigorously. “You're not crazy. You're checking up on the hospital." The fact that patients often recognized normality when staff did not raises important questions. 18/31

Failure to detect sanity may be because physicians operate with a strong bias toward what statisticians call the Type 2 error; that physicians are more inclined to call a healthy person sick (a false positive, Type 2) than a sick person healthy (a false negative, Type 1). 19/31

The reasons for this are not hard to find: it is clearly more dangerous to misdiagnose illness than health. Better to err on the side of caution, to suspect illness even among the healthy. But what holds for medicine does not hold equally well for psychiatry. 20/31

Psychiatric diagnoses carry with them personal, legal, and social stigmas. It was therefore important to see whether the tendency toward diagnosing the sane insane could be reversed. 21/31

Experiment 2: was arranged at a research and teaching hospital whose staff had heard these findings but doubted that such an error could occur in their hospital. The staff were informed, one or more pseudopatients would attempt to be admitted into the psychiatric hospital. 22/31

Each staff member was asked to rate each patient according to the likelihood that the patient was a pseudopatient. Attendants, nurses, psychiatrists, physicians, and psychologists - were asked to make judgments. 23/31

Forty-one out of 193 patients were alleged, with high confidence, to be pseudopatients: 23 by at least one psychiatrist; 9 by one psychiatrist and one other staff member. Actually, no genuine pseudopatient presented himself during this period. 24/31

Therefore, the tendency to designate sane people as insane could be reversed. Were these people truly "sane”? There is no way of knowing. One thing is certain: any diagnostic process that lends itself too readily to massive errors of this sort cannot be a very reliable one. 25/31

Beyond the tendency to call the healthy sick - Once a person is designated abnormal, all other behaviors and characteristics are colored by that label. The label is so powerful that many pseudopatients' normal behaviors were overlooked entirely or profoundly misinterpreted. 26/31

The data speak to the massive role of labeling in psychiatric assessment. A psychiatric label has a life and an influence of its own. Once the impression has been formed that the patient is schizophrenic, the expectation is that he will continue to be. 27/31

Such labels are as influential on the patient as they are on relatives and friends; the diagnosis acts on all of them as a self-fulfilling prophecy. Eventually, the patient himself accepts the diagnosis, with all of its meanings and expectations, and behaves accordingly. 28/31

There is enormous overlap in the symptoms and behaviors of the sane and the insane. The sane are not "sane" all the time. They lose their tempers "for no good reason."; occasionally depressed or anxious, again for no good reason. Similarly, the insane are not always insane. 29/31

If it makes no sense to label one permanently depressed for occasional depression, it must take better evidence to label all insane for bizarre behaviours or cognitions. It seems more useful to limit discussions to behaviors, what provokes it, and their correlates. 30/31

Adapted from: On Being Sane in Insane Places by David L. Rosenhan. Originally published in Science, New Series, Vol. 179, No. 4070. (1973). 31/31