On Being Sane In Insane Places – A Review

Psychology
Author

Lam Fu Yuan, Kevin

Published

January 15, 2012

In 1973, psychologist David L. Rosenhan published, in the journal Science, what is arguably one of the most widely read articles in the field of psychology, “On being sane in insane places”. Also, known as The Rosenhan Experiment, his field experiment in 12 different psychiatric hospitals across the United States of America questions the validity of psychiatric diagnosis in mental institutions. The article’s criticisms of “counter-therapeutic” environments in psychiatric wards serve as a poignant reminder to mental health practitioners all over the world on the importance of the humane treatment of psychiatric patients, a conception that resonates with the ideas of Philippe Pinel, an 18th Century French physician. The arguments that have been presented in the article, however, lack credibility. Furthermore, in an attempt to discredit the edifice of psychiatry, the article provides a distorted view of mental health practices in a way similar to how members of the staff of the psychiatric hospitals have been reported to have distorted the pseudopatients’ behaviours “to achieve consistency with a popular theory of the dynamics of a schizophrenic reaction”.

The author’s arguments, although valid, may not be sound. An argument is said to be valid if and only if there is no instance where the premises are true and the conclusion false. On the other hand, an argument is sound if and only if it is valid, and its premises are true. I shall illustrate with an example. Consider the following statements,

Premise 1 If Tom cries, Tom is said to suffer from major depression.
Premise 2: Tom cries.
Conclusion: Therefore, Tom is said to suffer from major depression.

From the definition of validity, the above deduction is valid. However, it is very likely that we do not find it believable. This could be attributed to the fact that the argument is not a sound one. The truth of the first premise, in fact, is very questionable; a situation where Tom cries but is not suffering from major depression is possible.

Rosenhan asserts that if “the sanity of the pseudopatients were never discovered, serious difficulties would arise for those who support traditional modes of psychiatric diagnosis”. As the “pseudopatients were never detected”, this “uniform failure [by all 12 psychiatric hospitals] to recognise sanity” leads the author to conclude that “it is clear that we cannot distinguish the sane from the insane in psychiatric hospitals”. By a rule of inference known as modus ponens, we conclude that his argument is valid. In other words, given the truth of the premises, psychiatric diagnosis is inaccurate.

An analysis of such an argument should also encompass an evaluation if it is sound. It would seem unreasonable to dismiss psychiatry as inaccurate by virtue of a valid argument alone. One way to do this is to question the truth of the premise “if ‘the sanity of the pseudopatients were never discovered, serious difficulties would arise for those who support traditional modes of psychiatric diagnosis’”. In other words, is it true that if eight out of the eight pseudopatients were never discovered by the hospital staff in the 12 psychiatric institutions, psychiatric diagnosis is inaccurate?

The table that follows lists out various situations leading to an accurate or inaccurate psychiatric diagnosis.

These scenarios provide a simplified view of psychiatric diagnosis. The following assumptions have to be taken into account when reading the table.

  1. Mental normality and abnormality exists.

A similar assertion has also been made, by Rosenhan, that “To raise questions regarding normality and abnormality is in no way to question the fact that some behaviours are deviant or odd.”

  1. Mental normality and abnormality is defined by a single person known as The Psychiatristwho is not allowed to leave the hospital grounds.

To accurately diagnose a patient as “normal” or “abnormal” outside of his psychiatric hospital, The Psychiatrist has to leave his hospital, which is impossible. Hence he must choose to either trust or distrust the patient.

To accurately diagnose a patient as “normal” or “abnormal” within his psychiatric hospital, The Psychiatrist makes daily observations of the patient.

  1. The Psychiatrist is said to have made an inaccurate diagnosis if and only if his diagnosis of the patient inside his psychiatric hospital contradicts with the diagnosis he would have given the patient if he were allowed to leave the hospital grounds.

  2. Personality disorders that manifest themselves in the form of pathological lying do not exist.

From the table, a doctor who consistently trusts his patient is likely to make an inaccurate diagnosis of the Type II sort half the time, and a doctor who consistently does not trust his patient is likely to make an inaccurate diagnosis of the Type I sort half the time. Either way, it would be fallacious to make the assertion that “We now know that we cannot distinguish sanity from insanity”. What the author is doing can be seen as an act cherry-picking, where exceptions to his rule are ignored.

The author has also committed another fallacy by ending his debate with the thought-terminating cliché “We now know that we cannot distinguish sanity from insanity” and moving on to the “depressing” and “frightening” consequences of depersonalisation, resulting in an erroneous logical leap. Here, the argumentum ad metum or an appeal to fear is also being used to scare his readers into the negative consequences of psychiatric misdiagnosis without exhaustively examining the truth of his initial premise.

Furthermore, Rosenhan appears to be overly critical in his attacks against psychiatry as a pseudo-science in comparison to medicine. In his discussion of the consequences of labelling and depersonalisation, Rosenhan noted that “a ‘Type 2 error’ in psychiatric diagnosis does not have the same consequences as it does in medical diagnosis ’”. Expanding on his assertion, the author states that “A diagnosis of cancer that has been found to be in error is cause for celebration. But psychiatric diagnoses are rarely found to be in error. The label sticks, a mark of inadequacy forever.”. Here, a non-sequitur fallacy has been made. To verify if Type II errors have same consequences in psychiatric diagnoses and medical diagnoses, the following comparisons should be made.

A detection of a false positive of cancer is a “cause for celebration”. A detection of a false positive of schizophrenia is / is not a “cause for celebration”.

Oncological diagnoses are rarely / not rarely found to be in error. Psychiatric diagnoses are rarely found to be in error.

An oncological diagnosis sticks on to the patient. A psychiatric diagnosis sticks on to the patient.

It is important to question if it is the type of diagnosis, whether psychiatric or medical, or the source of diagnosis, whether from a figure of authority such as a professional in the field or not, that is sticky. Also, it is possible that a detection of a false positive of mental illnesses, such as schizophrenia, is a “cause for celebration” or that oncological diagnoses are rarely found to be in error.

Criticism can be seen to be useful to the extent that it promotes positive changes in the environment in which we operate. Instead of focusing on arguments for or against the field of psychiatry, one could look for ways in which the problems that have been identified in the experiment could be overcome in the future. For example, the table illustrating possible outcomes in psychiatric diagnosis show that a large emphasis has been placed on doctor-patient trust, at least in the 1970s. If mental health practitioners have improved methods of determining the truth of the patient’s account upon admission, gains can be made in minimising the committing of erroneous psychiatric diagnoses. One way in which this could be done is to rely on accounts made by the patient’s friends and families as a means to ensure the consistency of the patient’s words. Alternatively, psychiatric staff could personally observe the patient in non-hospital grounds as a means to analyse the patient’s behaviour in what Rosenhan termed as the “real world”. However, ethical concerns may arise in this case because the integrity of the patient’s right to privacy is being compromised.

Although psychiatric diagnoses are not altogether invalid, inherent weaknesses in the assessment of the truth of psychiatric symptoms reported by patients do pose challenges for mental health practitioners. Rosenhan’s article, albeit fallacious, serves to provide specific scenarios in which mental health diagnoses can be wrong. Through the careful examination of these cases and the continuous improvement of psychiatric diagnostic criterion, we would find ourselves closer to the alleviation of psychiatric problems that plague our society.

References

David L. Rosenhan (1973) On Being Sane In Insane Places. [On-Line]. Available: http://www.psychblog.co.uk/as-study-full-text-references-spec-2008-282.html. (January 11, 2012)

Related videos

STGBree (2010) Pseudopatient Experiment (Rosenhan). [On-Line]. Available: http://www.youtube.com/watch?v=qrcuUwTYwwo&feature=related. (January 11, 2012).

TheBrookfieldPsychos (2011) David Rosenhan: Being Sane in Insane Places. [On-Line]. Available: http://www.youtube.com/watch?v=j6bmZ8cVB4o. (January 11, 2012)

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