by Susannah Cahalan; New York: Grand Central Publishing, 2019
383 pages • $28.00 (hardcover)
Dr Kaplan is Clinical Associate Professor, Graduate School of Medicine, University of Wollongong, Australia.
In 1973 the psychiatric profession was deeply shaken by a paper published in Science that purported to show that psychiatric diagnosis was effectively useless.1 The author, Stanford psychologist David Rosenhan, described a unique experiment: Eight volunteer “pseudopatients” presented at psychiatric hospitals under fake names, complaining they heard voices. The intention was to examine psychiatric diagnosis: was it scientifically valid or merely a random, subjective, and erratic process?
The pseudopatients were in the hospital for a mean of 19 days. All but one were diagnosed with schizophrenia in remission. The statistics from the study showed contact with doctors averaged just 6.8 minutes a day; 71% of doctors averted their heads when addressed. While patients suspected study participants were fake—possibly because they spent their time writing notes—the staff did not.
Rosenhan’s message was devastating: “We cannot distinguish the sane from the insane in psychiatric hospitals,” adding, “If sanity and insanity exist, how shall we know them?” These findings, taken at face value, were very difficult to refute.
Pseudopatients and their discontents: an historical perspective
Arguably the most influential psychological paper published in the last half of the 20th century, it caused a sensation. By the 1980s, it was mentioned in most psychology textbooks. Rosenhan became a star in his field and the study still one of the most cited social science papers, as well as prescribed reading in psychology and social work courses.
Related content: A Conversation in Critical Psychiatry with Susannah Cahalan
The timing was good; the anti-psychiatry movement started in the 1960s by Szasz, Laing, Goffman, and others had kicked into high gear.2 The movie One Flew Over the Cuckoo’s Nest played its part in persuading the counterculture to see psychiatry as inherently oppressive. Michael Foucault, the French intellectual superstar, said that asylums represented the punitive arm of society (based on his rather dubious historical research).
The response of psychiatrists to the paper was predictable. They rushed to defend their profession, although with varying degrees of conviction. It led to a vortex of discussion about the practice of psychiatry and its future. It fed into the deinstitionalization movement, an agenda driven by governments, radicals, the counterculture, and others. Although not realized at the time, the results were catastrophic. Community services could never come close to meeting the needs of the discharged patients and the vacuum was filled by the streets and prisons.
The fallout from the research played a part in the organizing principles that led to the Diagnostic & Statistical Manual (DSM-III) in 1980. For the first time, diagnoses were categorized with listed symptoms, free of etiological presumptions, notably psychoanalysis.
This brought with it an unexpected and unprecedented benefit. In a triumph of medical marketing, the American Psychiatric Association (APA) created a brand that may be as well-known as Apple or Coca Cola, culminating in its latest incarnation in 2013 with DSM-5. The APA made many millions and can expect the rivers of gold to keep flowing. But the solution was not megabucks alone. Has DSM solved the problems, not least epistemological, that beset psychiatric diagnoses? Hardly, if the furore of DSM-5 is any indication.
The paper did not lack supporters and news coverage. In Australia, an attempt was made to replicate it. Radical Sydney psychologist Dr Robin Winkler did two studies, published simultaneously in the Medical Journal of Australia in September 1974.3,4 The first paper reported the findings of pseudopatients who had visited general practitioners claiming to suffer depression; in the second article the infiltrators had themselves admitted to psychiatric hospitals.
Winkler concluded that “a permanent body should be established with the co-operation of medical, research and consumer organisations, to report regularly on health care services as evaluated with pseudopatient observations.” Psychiatrist Neil McConaghy, who had a distinguished research record, was skeptical.5 While there could be some value in such studies, Winkler had failed to account for observer bias, if not other issues.
This brings us to Susannah Cahalan
She first wrote of her psychiatric experience in Brain on Fire, the account of how psychotic symptoms developed. She was seen by a number of psychiatrists and set to be admitted to a psychiatric hospital. A neurologist, however, discovered she had a rare autoimmune condition: anti-NMDA receptor encephalitis. She received treatment and recovered.
1. Rosenhan DL. On being sane in insane places. Science. 1973;179:250-258.
2. Laffey P. Histories of Psychiatry after Deinstitutionalisation: Australia and New Zealand. Health History. 2003;5:17-36.
3. Owen A, Winkler RC. General practitioners and psychosocial problems: An evaluation using pseudopatients. Med J Aust. 1974;2:393–398.
4. Winkler RC. Research into Mental Health Practice Using Pseudopatients. Med J Aust. 1974;2:399–403.
5. McConaghy N. Pseudopatients and Evaluation of Medical Practice. Med J Aust. 1974;2:383-385.
6. Kayser MS, Dalmau J. Anti-NMDA Receptor Encephalitis in Psychiatry. Curr Psychiatry Rev. 2011;7:189–193.
7. Guide to the David L. Rosenhan Papers. Online Archives of California. https://oac.cdlib.org/findaid/ark:/13030/c8tq6082/entire_text. Accessed March 4, 2020.
8. Spitzer RL. On pseudoscience in science, logic in remission, and psychiatric diagnosis: A critique of Rosenhan's “On being sane in insane places.” J Abnorm Psychol. 1975;84:442–452.
9. Scull A. How a fraudulent experiment set psychiatry back decades. The Spectator. January 25, 2020. https://www.spectator.co.uk/2020/01/how-david-rosenhans-fraudulent-thud-experiment-set-back-psychiatry-for-decades. Accessed March 4, 2020.