Fooling the shrinks

by Chris Bertram on January 31, 2004

The Guardian has a readable and disturbing piece about what happens if you try to fake your way into a mental instutution:

In 1972, David Rosenhan, a newly minted psychologist with a joint degree in law, called eight friends and said something like, “Are you busy next month? Would you have time to fake your way into a mental hospital and see what happens?”

Lauren Slater reports on the extreme hostility this researcher faced when he published and since, on the fact that his fellow inmates could tell he was sane even when the doctors couldn’t, on how he wrote down his experiences and had this labelled as “writing behavior” (which I suppose it was). But what would happen if you tried to do the same thing today? Slater tried ….

{ 14 comments }

1

asg 01.31.04 at 2:35 pm

Fascinating article, great link. The article isn’t as disturbing as all that, though, as Slater’s verdict on modern psychiatry is much kinder than on the 1972 version targeted by the original experiment. Reading the article actually imparted some hope that there has been some progress and that the psychiatric profession has been striving for progress rather than just running in place, even though they face new temptations in the form of medication.

2

Ophelia Benson 01.31.04 at 5:43 pm

Dang, that is a fascinating article. The whole thing raises so many teasing questions. Labeling shapes what we find, sure – but what follows from that? Depends. Some labels are worthless, some are fake, some are useful but not always relevant – and so on. Such is life.

3

tcb 01.31.04 at 6:05 pm

There is a fine Dickensian finish to the second article; the daughter sickening, the old man recovering. Just the thing to make people run out and buy the book to read the sequel.

As a patient, I have to add my anecdotal two cents that whatever has happened in psychiatry in the past 30 years, the net effect is for the better. I don’t necessarily say that fewer people are being misdiagnosed, but that those who are correctly diagnosed feel subjectively better and integrate into society more quickly with today’s treatments than with those of the 1970s.

This may be an oversimplification, but I give most of the credit to the advances in psychopharmacology. Because, at least to a rationalist, mental states are rooted in biology. And despite the fact that doctors may rely upon meds as panacea as much as the patients do, at least the meds can be stopped or altered if they are inappropriate. And it’s quite likely that one of these days we really will know it all. Better living through chemistry, I always say.

4

Rather Not Say 01.31.04 at 7:48 pm

As asg above, I found the article did offer some hope that better pharm science may have mitigated some of the worst effects of errant and arrogant pseudo-scientific psychiatry.

But the pseudo-science and the monkey tribe behavior of pseudoscientiests is still a fearsome weapon in the hands of artful and designing persons.

In classical slashdot format, here is how it works.

1. Desire relative’s property.
2. Make up and report relative’s “odd and possibly self-harmful behavior” to state authorities.
3. State will institutionalize relative, at gunpoint.
4. Profit!! (unless a small army of civil libertarians and lawyers happens to help the victimized relative.)

If you don’t believe this is remarkably easy for vicious schemers to bring off, just google for “Roby Ridge” (that’s ROBY, not RUBY).

5

Tom T. 01.31.04 at 8:25 pm

Psychiatry is getting a bit of a bum rap from these experiments. I have to imagine that if I went to eight emergency rooms with a fictitious complaint of back pain, I would consistently walk out with a prescription for a muscle relaxant. Mmmmmm…muscle relaxant.

Slater does seem to have an axe to grind. Her statement that the drive to prescribe “does seem to be more a product of fashion, or fad” strikes me as unfair; one could just as easily say that it arises from a genuine desire to help sick people. It seems to reasonable to me to believe that the doctors are prescribing antipsychotics because, in cases where someone really is hearing voices, those antipsychotics have frequently proven to be helpful. Sure, there’s a risk of a false positive based on deceptive behavior by the patient, but it’s hard to see how that risk could be minimized without then producing a lot of false negatives (i.e., truly sick people turned away).

Slater seems to have little empathy for those who are genuinely sick. Certainly, the term “thud” sounds cartoonish and risible to us, but a statement that “aliens are controlling my brainwaves” would sound just as laughable if we weren’t used to hearing that sort of thing from schizophrenic people. Slater particularly angered me when she belittled the patient who was troubled by a voice continually repeating “It’s OK.” Her remark that “a voice saying, ‘It’s OK’ sounds pretty OK to me,” is feckless and really just mean.

There is also a lurking institutional conflict. To put the matter in commercial terms, Rosenhan and Slater, as psychologists, are competing for much the same patient business as psychiatrists. A finding that criticizes psychiatry for making errant diagnoses or over-prescribing drugs fully serves the competing interests of psychologists, who cannot make medical diagnoses or prescribe drugs.

6

Tom T. 01.31.04 at 8:33 pm

So others don’t have to: As suggested, I googled “Roby Ridge.” What resulted was a stack of tendentious websites describing an incident whereby a woman barricaded herself in her home and fired on police rather than obey a court order for a psych exam. She held off police for several weeks with the threat of further violence, before finally being removed safely from her home. The psych exam was then carried out, and it found no basis for committing her.

This doesn’t strike me as an especially abusive exercise of state power, and someone who shoots at police officers doesn’t seem like a desirable poster child.

7

tcb 01.31.04 at 8:58 pm

Tom hit several nails on the head with both his posts. I have to chime in with another two cents (and I know that no-one gives tuppence for my two cents, but what the hey).

During my divorce in 2001, my doctor and I agreed that I would voluntarily enter a psychiatric hospital. Diagnosis: acute dysphoric mania. He called the place and made arrangements.

So I got to the hospital and they refused to let me check in unless I paid a deposit of $5000, because I’m not insured! So I went home.

Welcome to America. Oh, if only I’d known the magic word, “Thud.”

(PS >> Yes, there is a county-run hospital for emergency cases. But really.)

8

Conrad Barwa 02.01.04 at 1:27 am

The story has some interesting parallels to Sam Fuller’s excellent film “Shock Corridor” where a struggling journalist who is determined to win the fame and recognition decides to go undercover in a lunatic asylum to expose a murderer of one of the inmates. He gets himself committed after repeated coaching by a former psy who teaches him to mimic incestuous feelings towards his false sister (in reality his girlfriend) in order to get admitted and ‘fool’ the doctors; a feat which is demonstrated to be a considerable obstacle. Once in the asylum he meets the various inmates, all of whom show some sort of wider sickness in society at the time: the victim of anti-Communist and then Communist brainwashing, a physicist who worked on the atomic bomb and the first black cadet into a military academy suffused with racism who cracks under the pressure and imagines himself to be a member of the KKK. The journalist gets more and more sucked in and eventually writes his story and wins his Pulitzer but is rendered insane by the experience and doesn’t recover.

Fuller was a very depressing film-maker, in many ways.

9

Keith M Ellis 02.01.04 at 1:35 am

Psychiatry suffers in comparison to the rest of medicine partly because people don’t realize how uncertain any medical diagnosis is and how little we really know. As tom t. guesses, there’s a whole host of symptoms a pseudopatient could present in a conventional ER which would be taken at face value. Of course they would. It’s not normal to hear a voice say “thud”. It’s also not normal to suffer continual abdominal pain. And for the most part, the physician can only take your word for it.

I think the real insight in Slater’s experience is that while we may be little more confident of a correct diagnosis today than in 1972, mental patients are more likely to be treated with dignity and compassion than they were thirty years ago. That’s a big change.

An aside: a few years ago I was suicidally depressed and was admitted to a mental ward on two occasions for about a week each. I got very good care, although I didn’t get much better via anything other than time. I actually have very fond memories of the place, because, I think, it was a safe place where people were very concerned about me. And the rest of the world “stopped”—I didn’t have to worry about anything other than figuring out how to want to be alive. 80% of the patients were women, and 95% were acutely depressed. We patients were also very concerned and supportive with each other, which was also very helpful. This was the largest part of the good the stay does for most people, I think—it indicates that (at least with depressed people) a lot could be done with non-medical support and “safety nets” for people in crisis.

10

gunner 02.01.04 at 3:17 am

Thank you for finding such a great article.

11

Mark 02.01.04 at 4:32 am

Great article. I’m an academic pediatric emergency physician and I share her concern for the apparent overuse of antipsychotic and antidepressive medications. Patients feigning any number of illnesses will leave the emergency department with medications because physicians are taught to listen to the patient, and over 80% of diagnoses come primarily from the history. In my opinion the threshold for prescribing antidepressives or antipsychotics should be higher than muscle relaxants or analgesics, but my frequent use of those meds makes me more comfortable with them. Psychiatrists get very comfortable with their meds.

Primum no nocere, first do no harm, is a dictum of the past. Physicians today are inclined to treat rather than observe in the abscence of certainty. Most would rather commit an error of commission than an error of omission. At least s/he tried. There are many reasons for this, one of which is the perceived threat of litigation.

12

andrew 02.02.04 at 9:52 am

I’m sure everybody knows this, but hearing voices is absolutely not normal, and a sure sign of paranoid schizophrenia – a very dangerous disease. People with it are prone to hurt themselves or others. It doesn’t normally just go away. Anyone not taking the symptom “hearing voices” seriously would be negligent. I’m surprised that she wasn’t admitted everytime, even against her will. But they did prescribe a antipsychotic, which is non-narcotic and not particularly dangerous. They then made sure she should follow up. I don’t think the psychologists overreacted at all – I’d say the opposite. It’s strange to me that the article suggests otherwise.

13

Chris Martin 02.02.04 at 5:03 pm

Qutie a coincidence that this topic came up. Just yesterday I was reading Gulag by Anne Applebaum, and was fascinated by the ways in which prisoners faked symptoms to get hospitalized. The gulag administration then developed counter-strategies to discover which prisoners were faking.

Although many prisoners faked schizophrenia, administrators found that the easiest way to “out” fakers was to put them in a ward with real schizophrenics. The fakers would beg to be let out within a few hours. Another strategy was to fake paralysis. Doctors would then put the patient on an operating table and anaesthetize him. When the patient woke up, he would get off the table and start walking before remembering that he was supposed to be faking paralysis at which would point he would fall to the floor.

I would highly recommend Gulag by the way for anyone interested in the history of the much overlooked concentration camps of Soviet Russia.

14

Monica 02.07.04 at 6:28 pm

Tom T and tcb, very interesting comments. I get the same feeling as Tom about Slater’s “bias”, so to speak.
She wrote one too many books on her own “success story” and I tend to think one would have sufficed. Also, she wrote an entire one in praise of Prozac, so I don’t get exactly what her point about medication and diagnosis is…

I’m ambivalent about her whole story, as well as the original experiment/prank in the sixties. On the one hand, it is a great read, thought-provoking, and, also, funny. On the other, I don’t think playing this sort of “jokes” is very respectful of people who are really suffering, or of the work of doctors and nurses. There are all kinds – good ones, bad ones, so-and-so ones, but what do you expect if you’re just faking it?

You can’t assess the quality of psychiatric care by pretending to have a disorder. You need to *really* have one, to be able to tell if you’re getting good or bad treatment. You may also need to try out different places, different doctors, different methods. I’d have thought someone who went through problems like Slater did would have know that already, without needing this sort of thing.

So these experiments alone really don’t prove much, because they alter the whole premise, that the person seeking therapy is *really* suffering from an illness, a disorder, a temporary crisis. They only prove you can fool a doctor, well, doh. This is not about measuring fever or blood pressure. That a doctor will take a person claiming to suffer from delusions at her word, is only proof they’re listening to the patient. Not a bad start, for a psychiatric therapy.

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