An Insane Story

Psychiatric hospitals are not as good at diagnosing the mentally ill as you’d think, and they never really have been.
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Psychiatric hospitals are not as good at diagnosing the mentally ill as you’d think, and they never really have been.
Barack Obama's official Twitter page. (Photo: Gil C/Shutterstock)

Barack Obama's official Twitter page. (Photo: Gil C/Shutterstock)

Kam Brock was overcome with emotion as she made her way to a New York Police Department impound site to pick up her car, but the cops—for reasons that are still unclear—thought the 32-year-old Long Island woman was emotionally disturbed. Brock was cuffed and committed to a hospital for a 72-hour psychiatric evaluation, where she tried to convince her doctors there had been some sort of misunderstanding. “I told (the doctor) Obama follows me on Twitter to show her the type of person I am," Brock said, according to the New York Daily News. They locked her up for eight days.

The crazy thing is, Obama really was following her on Twitter ... kind of. As the Washington Post points out, @BarackObama is actually run by a non-profit created from Obama's campaign funds that tweets using his name in the hopes that potential donors will make the same mistake as Brock. But it's probably fair to say that if her doctors didn't even think to check if @BarackObama was following her, they wouldn't have understood that distinction either. And while its unclear what other factors may have contributed to her extended stay in a psychiatric hospital, it is clear that the Obama reference had a significant impact on the staff’s opinion that Brock was detached from reality. The Daily News reports that her treatment plan required her to “state that Obama is not following her on Twitter.”

The takeaway may be that psychiatric hospitals just aren’t very good at distinguishing the sane from the insane. Many in the field of psychiatry have held conflicting views on diagnosing psychiatric illnesses for decades, as Stanford University psychologist David Rosenhan wrote in a 1973 article in Science:

The belief has been strong that patients present symptoms, that those symptoms can be categorized, and, implicitly that the sane are distinguishable from the insane. More recently, however, this belief has been questioned. Based in part on theoretical and anthropological considerations, but also on philosophical, legal, and therapeutic ones, the view has grown that psychological categorization of mental illness is useless at best and downright harmful, misleading, and pejorative at worst. Psychiatric diagnoses, in this view, are in the minds of the observers and are not valid summaries of characteristics displayed by the observed.

The best way to test which of these were true, according to Rosenhan, would be to commit normal people to psychiatric hospitals, and wait to see if, when, and how they were discovered as sane. And, this being Stanford University in the 1970s and all, he did just that. Rosenthal and seven other sane individuals (three women and four more men) admitted themselves to 12 psychiatric hospitals across the country. The life histories they shared with their doctors were their own, with a few minor exceptions: They checked in under pseudonyms and lied about their employment to ensure their institutionalization would not affect their lives. And, most importantly, they told their doctors they heard voices whispering things like “empty,” “hollow,” and “thud.”

“How many people, one wonders, are sane but not recognized as such in our psychiatric institutions?”

“The pseudopatient, very much as a true psychiatric patient, entered a hospital with no foreknowledge of when he would be discharged. Each was told that he would have to get out by his own devices, essentially by convincing the staff that he was sane,” Rosenhan wrote.

As such, once admitted, the pseudopatients’ abnormal symptoms disappeared—aside from a bit of nervousness, as most of them believed “that they would be immediately exposed as frauds and greatly embarrassed.” They weren’t. They spent an average of 19 days in the hospital. The shortest stay was one week; the longest: 52 days. But not everyone was fooled. “It was quite common for the patients to 'detect' the pseudopatients’ sanity,” Rosenhan wrote. When the patients were finally discharged, it wasn’t because they had been discovered to be sane; as a testament to the power of labels, they left with diagnoses of schizophrenia “in remission.”

“Once a person is designated abnormal, all of his other behaviors and characteristics are colored by that label,” Rosenhan wrote. “Indeed, that label is so powerful that many of the pseudopatients’ normal behaviors were overlooked entirely or profoundly misinterpreted.”

The study participants observed the hospital staff consistently misinterpreting patients’ behaviors; acts that outside the institution wouldn’t be out of the ordinary—occasional fights with spouses, extensive note-taking, aimless strolling—were seen as pathological. Rosenhan highlights one particular case:

One psychiatrist pointed to a group of patient 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.

None of this is to say that psychiatric care is unnecessary or always detrimental. As Lauren Kirchner reported for Pacific Standard last year, jails and prisons are often overcrowded with mentally ill individuals, many of whom could benefit from the treatment they’d receive in a psychiatric hospital. But not every truly mentally ill patient finds relief in traditional psychiatric care, either. The field is still deeply flawed.

“How many people, one wonders, are sane but not recognized as such in our psychiatric institutions?” Rosenhan asked in the conclusion of his aptly titled 1973 study, “On Being Sane in Insane Places.” Brock's involuntary hospital visit is an unfortunate reminder that it’s a question that’s still relevant today.