On Being Sane…

“How many people, one wonders, are sane but not recognized as such in our psychiatric institutions? How many have been needlessly stripped of their privileges of citizenship, from the right to vote and drive to that of handling their own accounts? How many have feigned insanity in order to avoid the criminal consequences of their behavior, and, conversely, how many would rather stand trial than live interminably in a psychiatric are wrongly thought to be mentally ill? How many have been stigmatized by well-intentioned, but nevertheless erroneous, diagnoses? . . . Psychiatric diagnoses are rarely found to be in error. The label sticks, a mark of inadequacy forever.”

David Rosenhan

Professor Rosenhan’s paper “Being sane in insane places” (click to view pdf) appeared in the journal Science in 1973. His famous experiment involved healthy “pseudopatients” presenting to hospitals complaining of hearing voices: “Asked what the voices said, [the pseudopatients] replied that they were often unclear, but as far as he could tell they said “empty”, “hollow” and “thud”.”

I suggest using the paper as the focus for a team education session. It’s an easy and fascinating read – no tables, no boring data to sift through – made even more intriguing knowing that Rosenhan himself was one of the pseudopatients. The follow up experiment where Rosenhan reversed the process, warning hospitals “that at some time during the following 3 months, one or more pseudopatients would attempt to be admitted into the psychiatric hospital” makes it doubly intriguing.

I do not agree with Rosenhan’s conclusion that “We now know that we cannot distinguish insanity from sanity”. I accept the construct of schizophrenia – or rather the schizophrenias (see my previous posting on Bleuler) – as a practical one, for now. Hopefully we’ll have a better understanding in the not too distant future. At the same time for those of us working with persons with severe and persistent mental illness we should always remember how powerful labels are.

My suggestion is that every ACT team read “Being sane in insane places”  once a year. Psychiatrists should read it twice a year.

PS: Lorna Moser posted a thoughtful response below to the Forcing Treatment blog that should be read by all (and I”m therefore copying it here as some might otherwise not come across it).

“Great topic, and one near and dear to my heart. It’s a very grey space to work within, and that is often underappreciated by many. In trainings, I have spoken about some teams/agencies/staff seemingly either too risk tolerant in the “name of recovery and personal choice,” and then there are those who are very quick to take control and be coercive. Finding the “sweet spot,” is knowing that conditions for outpatient commitment (as an example) are rarely black and white (“Must receive treatment” — what does that mean? receive therapy, but no meds? refuse 2 of 5 recommended meds?) — there is still personal choice within the apparent constraints of IOC/assisted outpatient treatment (AOT). It’s the skillful and caring clinician who knows how to best use such a shared decision making approach within the parameters of those leverages, and knowing the extent of the risks, which may in turn call for pushing the lever down — but in a measured way, where possible (you don’t have to go full throttle right away). For many people, whatever leverages that are in place will at some point go away, and if you didn’t do your work to build a trusting and caring relationship in the meantime, they, too, will go away when the leverage is lifted.”

Thank you Lorna.

Shalom Coodin

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