On Being Sane In Insane Places

cranquis:

hownottoloseyourmind:

So a while ago @cranquis linked to the above in a post I reblogged (here). I opened the link but it took me a while to actually get to it (I have a lot of tabs open…) so here we are, months later. Anyway.

It’s the account of David L Rosenhan’s pseudopatients project which is now infamous in the psych world as the time “sane” people were admitted to institutions and hospitals despite their sanity. But that common knowledge notoriety is really just the tip of the iceberg. Please read the whole account. I picked out some excerpts and have added some commentary but before I start, I want to say that I hope you’ll all read the whole thing.

So eight people agreed to participate in the project. They went to hospitals, and they said they heard voices but changed no other details about themselves or their lives (besides to maintain anonymity). All of them were admitted. As soon as they were admitted, they stopped complaining of hearing voices, behaved as usual, and answered questions honestly. The patients on the units were more able to recognize something was up than the staff:

…it cannot be said that the failure to recognize the pseudopatients’ sanity was due to the fact that they were not behaving sanely. …their daily visitors could detect no serious behavioral consequences—nor, indeed, could other patients. It was quite common for the patients to “detect” the pseudopatient’s sanity… “You’re not crazy. You’re a journalist, or a professor (referring to the continual note-taking). You’re checking up on the hospital.” …The fact that the patients often recognized normality when staff did not raises important questions.

Failure to detect sanity during the course of hospitalization may be due to the fact that physicians operate with a strong bias toward what statisticians call the Type 2 error. This is to say that physicians are more inclined to call a healthy person sick (a false positive, Type 2) than a sick person healthy (a false negative, Type 1). The reasons for this are not hard to find: it is clearly more dangerous to misdiagnose illness than health. Better to err on the side of caution, to suspect illness even among the healthy.

But what holds for medicine does not hold equally well for psychiatry. Medical illnesses, while unfortunate, are not commonly pejorative. Psychiatric diagnoses, on the contrary, carry with them personal, legal, and social stigmas.

But I think the point that gets made as this piece goes on is that destigmatization isn’t enough. Our approach to mental health and illness that tried to structure it like medical illness purports that symptoms lie clearly trapped within a body whose boundaries are well-demarcated from the rest of the world, like a fracture housed cleanly in an arm. But this just isn’t the case with mental health.

…it has long been known that elements are given meaning by the context in which they occur. Gestalt psychology made the point vigorously, and Asch[5] demonstrated that there are “central” personality traits (such as “warm” versus “cold”) which are so powerful that they markedly color the meaning of other information in forming an impression of a given personality.  “Insane,” “schizophrenic,” “manic-depressive,” and “crazy” are probably among the most powerful of such central traits. Once a person is designated abnormal, all of his other behaviors and characteristics are colored by that label. Indeed, that label is so powerful that many of the pseudopatients’ normal behaviors were overlooked entirely or profoundly misinterpreted.

This underlies the “Great Divide” between staff and patient on a psych unit. Everything a patient does is “crazy” – even if it’s being made uncomfortable by observation by 5 students at once; even if it’s requesting pain medication that wasn’t given on time; even if it’s making art.

One tacit characteristic of psychiatric diagnosis is that it locates the sources of aberration within the individual and only rarely within the complex of stimuli that surrounds him. Consequently, behaviors that are stimulated by the environment are commonly misattributed to the patient’s disorder. For example, one kindly nurse found a pseudopatient pacing the long hospital corridors. “Nervous, Mr. X?” she asked. “No, bored,” he said.

… The notes kept by pseudopatients are full of patient behaviors that were misinterpreted by well-intentioned staff. Often enough, a patient would go “berserk” because he had, wittingly or unwittingly, been mistreated by, say, an attendant. A nurse coming upon the scene would rarely inquire even cursorily into the environmental stimuli of the patient’s behavior. Rather, she assumed that his upset derived from his pathology, not from his present interactions with other staff members. Occasionally, the staff might assume that the patient’s family (especially when they had recently visited) or other patients had stimulated the outburst. But never were the staff found to assume that one of themselves or the structure of the hospital had anything to do with a patient’s behavior. One psychiatrist pointed to a group of patients who were sitting outside the cafeteria entrance half an hour before lunchtime. To a group of young residents he indicated that such behavior was characteristic of the oral-acquisitive nature of the syndrome. It seemed not to occur to him that there were very few things to anticipate in a psychiatric hospital besides eating.

This is the point of yesterday’s DSM5 dystopia satire. The context matters, and the message we’re sending by putting the onus on the individual matters. This happens on a micro and macro level within society. Also, if you think all PRN IMs of haldol/ativan are warranted because of the patient’s disease, then read the above paragraph and think again.

The inferences to be made from these matters are quite simple. Much as Zigler and Phillips have demonstrated that there is enormous overlap in the symptoms presented by patients who have been variously diagnosed,[6] so there is enormous overlap in the behaviors of the sane and the insane. The sane are not “sane” all of the time. We lose our tempers “for no good reason.” We are occasionally depressed or anxious, again for no good reason. And we may find it difficult to get along with one or another person – again for no reason that we can specify. Similarly, the insane are not always insane. Indeed, it was the impression of the pseudopatients while living with them that they were sane for long periods of time – that the bizarre behaviors upon which their diagnoses were allegedly predicated constituted only a small fraction of their total behavior. If it makes no sense to label ourselves permanently depressed on the basis of an occasional depression, then it takes better evidence than is presently available to label all patients insane or schizophrenic on the basis of bizarre behaviors or cognitions…

It is not known why powerful impressions of personality traits, such as “crazy” or “insane,” arise. Conceivably, when the origins of and stimuli that give rise to a behavior are remote or unknown, or when the behavior strikes us as immutable, trait labels regarding the behavior arise. When, on the other hand, the origins and stimuli are known and available, discourse is limited to the behavior itself. Thus, I may hallucinate because I am sleeping, or I may hallucinate because I have ingested a peculiar drug. These are termed sleep-induced hallucinations, or dreams, and drug-induced hallucinations, respectively. But when the stimuli to my hallucinations are unknown, that is called craziness, or schizophrenia –as if that inference were somehow as illuminating as the others.

This article goes on to talk about the kinds of subtle dehumanizing actions that are perpetrated by staff on psych wards – e.g. lack of eye contact, avoidance of questions, etc – and I can confirm all of these microaggressions and more with my own experience working on hospital psych floors. It talks about the ways in which the Great Divide is built up and manufactured by literal glass walls. And it reminds us that this divide is, in fact, socially manufactured.

If you’re not convinced of the blurriness of the line between mental illness and not after reading this, maybe read it again. Or think harder about it. I dunno.
But don’t fool yourself into thinking these are things of the past. These scenarios occur daily on psych wards across the country – I would be surprised if these pseudopatients had much trouble being admitted today.

So – if sanity and insanity exist, how shall we know them?

Wow – careful analysis with an unsettling conclusion = my favorite kind of analysis.

(via wynesthesia)