Pseudo-patients in Psychiatric Hospitals

In January 1973, the American psychologist David L. Rosenhan of Stanford University published a report in the prestigious scientific journal Science, on an unusual experiment that had been carried out by him and his assistants. He wanted to know how the staff of psychiatric hospitals treated its patients and how effective the doctors were in establishing psychiatric diagnoses. The article entitled “On Being Sane in Insane Places” in which he gave a detailed description of the results of his experiment is believed to be one of the most resounding articles in the field of psychology because it initiated the long-lasting polemic about the validity of psychiatric diagnostics.

Pretending to hear voices

Rosenhan, four male and three female colleagues, of which three psychologists, a pediatrician, a psychiatrist, a painter and a housewife, decided to experience for themselves how it would be to be admitted into a psychiatric hospital. For the needs of the experiment they chose several hospitals in five different American states and tried to get admitted by simply appearing on their doorsteps.

In all of the cases the experiment started in a similar way. The pseudo-patient would first call the hospital and set up an appointment to be examined. When he came to the reception he would complain of sometimes hearing voices. When asked what kind of voices these were, he would answer that they were mostly indistinct, but that he could recognize some words among which “empty” and “hollow” would often appear. These very words were chosen deliberately because there was no report on hallucinations referring to emptiness and the meaningless of life in the literature of the time. The psychiatric profession had not yet written about the supposed existential psychosis which they had enacted. The inner voices belonged to the same sex as the patient, but the patient was not able to link it to any familiar person.

Except for the fake symptoms, profession, occupation and name which they provided at their arrival, everything else was true. All questions concerning their personal history and other medical difficulties were answered truthfully. Once admitted into the hospital the pseudo-patients would behave completely normally and no longer heard voices in their heads. They had genuine conversations with both the patients and the staff and followed the instructions they were given, except for swallowing the prescribed medication.

Once you get a diagnosis, it’s hard to get rid of it

After being admitted, seven were diagnosed with schizophrenia and, when they were discharged, received the diagnosis of schizophrenia in remission. Of course this did not mean that they were healthy, but simply that they were no longer very ill. One of them was diagnosed with manic depression. Even though the doctors treated them as if they were ill, other patients were quick to discover that there was nothing really wrong with them. The actual psychiatric patients would tell them: “You’re not crazy. You’re a journalist (or a professor, because they often took notes). You are only here to check the hospital’s work.”

In several cases of the pseudo-patients who were hospitalized, some anxiety occurred as none of the participants of the experiment expected that the hospital would be so eager to keep them. Because most of them had never visited a psychiatrist before, they mostly worried about being exposed as imposters and scorned. The pseudo-patients were also instructed to try and get discharged on their own. They would have to convince their doctor that there was nothing wrong with them which was actually true, except for the lie about hearing voices which they had told in the reception office. However, they soon found out that the only way they would be released to go home would be if they agreed with the doctors that they also believed they were mentally ill and then pretend they were feeling much better. The length of hospitalization for the fake patients who took part in the experiment ranged from 7 to 52 days, with the average period of 19 days spent in the hospital.

For the needs of the research they tried to write down as many observations as possible and, out of fear that the notes would be destroyed by the hospital staff, hid them in safe places each day. At first they took their notes in secret because they expected that they would not be allowed to do so, but as the staff showed no particular interest in their activity, they started to write in their journals right in the common social rooms. It turned out that taking notes was not problematic, as the hospital staff usually considered it to be part of the illness compelling the patient to write everything down. Once they were labeled as schizophrenic, even their most common activities were viewed as potentially pathological.

During the entire period of the experiment the fake patients were prescribed a total of 2100 pills by their doctors. Of these, only two were swallowed and all others ended up in pockets or were flushed down the toilet. Another interesting thing is that fake patients often discovered that the toilet seed already contained medication, left there by the actual patients.


Expecting pseudo-patients

During the research they discovered two major difficulties facing people admitted to psychiatric hospitals; the feeling of helplessness and the feeling of depersonalization. The staff talked about the patients as if they were not present in the same room or even invisible. On one occasion, for example, a nurse unbuttoned her uniform in front of the entire ward and started readjusting her bra despite the presence of many male patients. But it was not at all meant as an act of exhibitionism because she did not regard the patients as people in front of which she would feel uncomfortable.

When doctors from other hospitals across the United States heard about the results of this unusual experiment they were naturally certain that nothing of the kind could happen in their wards. Rosenhan later made the arrangements with one of the most prestigious hospitals to send them a couple of false patients during a period of three months. The doctors there were convinced that they would have no problems in identifying the ones that were not really ill, but were only simulating their illness. For a couple of the months that followed, each new patient was intentionally evaluated as a possible imposter. Out of 193 patients altogether 41 were identified as false and another 42 were placed under suspicion. Of course the doctors were in for another shock as Rosenhan did not send them a single false patient, but they still managed to find so many.

BBC repeats the experiment

Recently, BBC repeated the experiment within the popular science series Horizon. However, this time the volunteers did not get themselves admitted into hospitals; the experiment was carried out as a sort of reality show. They chose five typical psychiatric patients with the most common diagnoses: bipolar disorder, depression, eating disorder, obsessive-compulsive disorder and social anxiety disorder. All the patients had been in treatment for quite a while, so they could not be simply recognized as different from the five volunteers who had never experienced any difficulties with their mental health.

Three experienced psychiatrists, experts on mental disorders, followed the group of ten for one week. Their task was to separate the ill from the healthy by observing them and performing tests. For an experienced diagnostician this should not be too difficult, but it soon turned out that this process of identification would prove to be a very demanding challenge. They only succeeded in correctly identifying the two disorders that were most characteristic. The obsessive-compulsive disorder was exposed when they observed the patients cleaning a stable as one of the ten was much more meticulous in washing up thoroughly after the dirty work was done.

They were also successful in diagnosing the eating disorder because one of the participants showed a 30 percent deviation in assessing her actual physical appearance. The patients were told to correct a deformed image of themselves using a computer program so that it would match their real image. Most of the participants in the experiment were able to correct their image more or less successfully, only a former anorexic patient, who had already been rehabilitated and is now leading a completely normal family life as a mother of three, failed to see the realistic image of her body; she thought she was one third fatter than in reality.

When it came to other diagnoses, the experts unfortunately failed. A once severely depressive patient was actually declared to be the healthiest of the group. It should be mentioned, though, that all they had at their disposal while making the diagnoses was footage of the candidates performing the task they were given, and the chance to pose a couple of short questions. The diagnoses therefore had to be made on the basis of very limited information.