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After doing a few severely long books posts in recent months, I thought maybe a shorter one was in order. Enjoy!
A few years ago, a book came out claiming that a famous early 1970s study of mental hospitals was highly suspicious, and perhaps entirely fabricated. An article in The Spectator describes the affair:
David Rosenhan, a Stanford social psychologist, reported that eight pseudo-patients had presented themselves at a variety of mental hospitals, 12 in all, complaining that they were hearing voices saying ‘hollow, empty and thud’, but otherwise behaving completely normally.
All of them, he reported, were promptly admitted, and all but one diagnosed as suffering from schizophrenia (the other receiving the somewhat more hopeful diagnosis of manic depressive psychosis). It took weeks for them to be released, though they were instructed to show no symptoms once admitted.
Only when a journalist went to track down former pseudopatients for a retrospective on the study, she came up empty and began to doubt most of them existed. As for the author himself, who served as one of these pseudopatients, the medical records of his stay contradict his story. For instance, they say he claimed other weird symptoms — hearing radio waves and other people’s thoughts — after his admission. Maybe the doctors weren’t so promiscuous in their diagnosis after all.
This study, “On Being Sane in Insane Places,” was influential. It contributed to the perception that mental hospital were terrible places that labeled healthy people insane on little evidence. It was part of a wave of scholarly work that was critical of mainstream psychiatry and mental hospitals, and that — along with movie character Nurse Ratched — helped turn public opinion against them.
The study was also one of many to use the method of sending pseudopatients — fakers — into mental hospitals. Another of these studies touches on one of my professional interests: 1977’s Suicide: Inside and Out, by David K. Reynolds and Norman L. Farberow.
The book is based on Reynold’s stay in a mental hospital, where he posed as a depressed person who had recently survived a suicide attempt. According to the authors he spent several days drawing on the depressive aspects of his own personality to work himself up into a credible appearance of depression — let’s call it a bit of method acting. Then he showed up at the VA hospital with bandaged wrists and claimed to be suicidal. He spent a week there, moving from the closed ward for high-risk patients to the open ward for general patients and eventually being discharged.
The main argument of the book is that life in a mental hospital contributes to many of the symptoms of mental illness. In this way hospitalization might be counterproductive. The two negative aspects that get the most attention are boredom and regulation.
Boredom
Patients, real or fake, have long periods of inactivity – just plain nothing to do for hours on end but sit around. There’s a few hours of TV in the common room, and maybe a deck of cards if you can get one from the staff, and not a whole lot else. Our infiltrator claimed that the boredom began to distort his sense of time, and he couldn’t tell if minutes or hours had passed. Another result of the prolonged boredom was that breaks in monotony, such as mealtimes, assumed a new importance. Other events and annoyances seem much more significant than they would in normal life.
I don’t find this aspect of the fake patient study difficult to believe, because one can experience it at the regular hospital as well. Sitting in a bed with an IV drip is boring as heck, I imagine sitting in a ward in a mental hospital is as well.
Regulation
Patients are also highly regulated, for obvious reasons. The authors see the resulting loss of autonomy as downward mobility, placing the patient in a demeaning position of child-like dependence upon doctors and staff.
It is also extremely frustrating for them, as patients must specifically request many common place items and services from staff, and busy staff often have to be asked numerous times for such items. They cite other pseudopatient studies on this point, and note that people might forgo simple pleasures like having a cigarette due to the awkwardness of having to always ask for a light. Some patients would get upset about having to wait for needed objects, as when a request for headache medication has to be relayed up the chain of command before a patient receives the medication.
Suicide Prevention as Social Control
One of the more interesting aspects of the book is the report on how staff respond to suicidal patients. Many patients show warning signs of an impending suicide, including overt threats, but not all are treated in the same way. Some suicidal threats are judged to be attempts at manipulation, while others are seen as truthful. Likewise, some patients who deny they are suicidal when questioned are seen as truthful, while others are thought to be lying in order to avoid precautions that would interfere with their suicide plans.
It seems like preventative social control decreases with intimacy and increases with distance. In at least one case, a patient was handled with fewer precautions because he was a long-timer and more trusted by the staff. Patients in the admissions ward — who are usually unknown to both the staff and to one another — seem to be subject to much greater precaution and scrutiny.
But at the same time, even though staff seem more concerned with preventing their self-harm, the treatment of less familiar patients is more callous. For example, one staff member remarked to an attempted suicide that “he didn’t try hard enough” to hang himself, while another suggested that the patient should have cut his throat instead.
This would seem to fit the pattern proposed by sociologist Donald Black where social control grows in quantity and severity as social distance increases.
Isolation and Intimacy
This should be obvious enough, but maybe it needs pointing out that being cut out of your daily round and plopped into a place full of strangers can leave one incredibly isolated. Sociologist Emile Durkheim long ago proposed that lacking social ties and involvements raised the risk of suicide, and there’s a lot of evidence this is so. So the isolating effect of hospitalization might be an especially important thing to consider when treating people for depression and suicide.
Along these lines, the authors note the importance of forming relationships with fellow patients during one’s stay. Newcomers are very lonely until they form some contacts with fellow patients, and some go on to form intimate and supportive relationships. Whether a new patient is accepted by other patients may be quite important for their well-being.
Our fake patient, Reynolds, speaks of the rapidity with which he formed attachments to other patients in the ward:
“I sat and reflected that on moving to the open ward the patients that I had grown to know in the locked unit seemed like old friends, not merely acquaintances of a bizarre week.”
This reminds me of summer camp friendship. You uproot kids from their usual round of school and neighborhood friends and dump them into a novel environment, where they quickly form bonds with others. A week later they’re having tearful goodbyes and making promises to write each other constantly — promises that fade away as they resume their old round of social ties.
All this appears to be consistent with Donald Black’s conception of intimacy as a zero-sum game: Isolating people from competing ties, even temporarily, speeds the growth of intimacy with new ties.
On Treating Those Who Aren’t Sick
One of my friends in grad school, Justin Snyder, summed up his big problem with pseudopatient studies. To paraphrase: “People who are well complain the hospital didn’t make them feel better. No kidding. The hospital isn’t for people who are well.”
Even without problems with fake data, that was always a major flaw with the pseudopatient approach. David the grad student is bored out of his mind and annoyed at the regulation — Jimmy who hears voices or Carol who really is trying to kill herself might have a different experience indeed.
Maybe that’s one reason the authors of these pseudopatient studies so often emphasize the demeaning aspects of patient status. This book cites several examples in addition to Reynolds’ own observations.
Granted, I believe there’s some truth in this — that medical professionals can be arrogant as heck, and that people might talk down to those under their authority, especially if they’re seen as mentally defective. But even aside from the issue of false accounts, I have to wonder how much of this emphasis on the lowly stature of the patient is due to the undercover researchers being educated professionals who resent not being treated as such. Here I am, a PhD, and this silly nurse treats me like I’m one of these crazies!