Showing posts with label Rosenhan. Show all posts
Showing posts with label Rosenhan. Show all posts

Sunday, October 11, 2020

Book Review of The Great Pretender by Susannah Cahalan

 



 This is the second book review of this book on my blog.  I was asked by the editor of The Philosophy Special Interest Group of the Royal College of Psychiatrists - Dr. Abdi Sanati to write another review for this newsletter.  I looked at it as an opportunity to cover some things I may have missed in the first review.  I agreed to not put it on my blog until the newsletter came out.  The latest review follows:

The Great Pretender (1) is written as an exposé of a famous experiment conducted by Rosenhan (2) that purported to discredit psychiatric diagnoses.  The original article was published in in the journal Science in 1973.  Whether you we aware of the original article or not depended on when you were trained and the extent to which you followed that literature. I was just finishing my undergraduate degree at that point and did not complete psychiatric training until 1986.  We had a community psychiatry seminar for 6 months during my last year that was taught by some of the innovators in the field.  It was common to analyze and discuss controversial papers of the day.  A good example would have been the paper that suggested that people with schizophrenia had a much better outcome in the developing countries (3).  At no point did we hear about or discuss the Rosenhan paper.  In fact, for the next 24 years the paper never came across my desk. It was only when I started writing a psychiatry blog that I realized it played a major role in psychiatric criticism and antipsychiatry rhetoric.  At that point, I read the paper and the associated criticism and concluded independently that the methodology was extremely weak and that pseudopatients were not really a good test of medical or psychiatric diagnoses.  I thought it would just fade away on that basis.

I was as surprised as anyone when I heard that investigative reporter Susannah Cahalan had written a book about this experiment, the author, and the methods used.  The investigation begins with a visit to one of Rosenhan’s former colleagues. This colleague shows her a stack of anti-psychiatry books that he thinks “were the key to his thinking”. There is also a file labeled “pseudopatients” that contain the names of all eight pseudopatients and details surrounding their hospitalizations. All the names or aliases and the hospital names had also been changed.

Cahalan’s approach is to write about three parallel subjects.  The most thorough and objective analysis is about the pseudopatient experiment. She covers everything from the available remaining data and the problems with it to the likelihood that the experiment actually occurred the way it was described in the Science paper.  The second broad subject was a character study of Rosenhan.  How did people describe him?  What was he like? Did people especially his colleagues believe that he conducted the experiment.  And finally, the book is a vehicle for Cahalan to comment on psychiatry.  She comes to this work with the direct experience of having experienced autoimmune encephalitis and writing about that experience in the book Brain on Fire.

Reading the original paper is a good starting point for understanding the book.  If you do pull up that article, a few details are immediately evident. The author begins the introduction using the terms “sane” and “insane” as though this is technical language used by psychiatrists. That use of language is interesting because he is listed as a professor of both psychology and law at Stanford.  Since the days of my training, insanity is a strictly legal term and it is without meaning in psychiatry.  The use of these legal terms allows him to point out the unreliability of the “sane”-“insane” dichotomy based on expert witnesses disagreeing in adversarial court hearings.  That has nothing to do with the clinical diagnoses in psychiatry. To what extent were formal diagnoses used in 1973? Rosenhan refers to the Diagnostic and Statistical Manual in the body of his paper.  Interestingly, the authors of my community psychiatry paper (3) reported on the 2-year follow-up of patients from the International Pilot Study of Schizophrenia (1973) and concluded that schizophrenia could be reliably diagnosed so that international comparisons and follow up were possible.  A sanity metric during the same time frame is crude by comparison. There are many additional examples of a lack of objectivity toward the issue of psychiatric diagnosis in the introductory section of the paper (paragraphs 4-7) and the discussion. Excellent critiques of the scientific merit of the paper were available at the time most notably by Robert Spitzer. 

The author describes his pseudopatient experiment as consisting of 8 people – three women and four men of various occupations. Cahalan identifies Rosenhan as pseudopatient number 1.  Twelve hospitals in various locations were chosen.  One was a private hospital.  Pseudopatients were supposed to call the hospital, present for an intake appointment, and then complain that they were hearing voices. When asked to elaborate they were supposed to say the voices were unclear except for the words “empty”, “hollow”, and “thud”.  Rosenhan provides a rationalization for this symptom choice about how on the one hand these symptoms were supposed to have existential meaning and yet there was not a single report of existential psychosis in the literature. Once admitted, the patient was supposed to cease simulating any symptoms and give their actual social history and behave “normally”. They were to take notes and be as cooperative as possible to get discharged. The length of stay was 7-52 days with an average of 19 days. 

Rosenhan also claims in the body of this paper that a second experiment occurred at a “research and teaching hospital” where the staff were informed ahead of time that pseudopatients were going to seek admission during a 3-month period.  Staff were asked to rate whether a patient was a pseudopatient or not.  Of 193 admissions during that time 41 were ranked as likely being a pseudopatient. In this case, Rosenhan did not send any pseudopatients to the facility and claims this false experiment represents “massive errors”.  

One of the elements of the paper that is really never discussed is it structure. The primary data points were eight pseudopatients were admitted and discharged from psychiatric hospitals without being discovered. The secondary data points were a series of observations of the staff that is largely unstructured, highly anecdotal, and contrasted with other situations that seem to lack relevance. The bulk of Rosenhan’s discussion is judgmental and there is no discussion of the limitations of the experimental design or data. Instead the author leaps to clear-cut conclusions that are in some cases only peripherally connected to the data.

Cahalan expends a lot of effort to try to identify and find the pseudopatients and ask them what their experience was like. She locates the records of Rosenhan’s own admission as a pseudopatient. The first real sign of a departure from the research protocol described in Science, occurs in Rosenhan’s recorded admission interview. He recited the voices script and said the symptoms had been going on for four months. He was admitted on an involuntary commitment and discharged nine days later. The hospitalization ended in 1969 - four years before the article came out. The first major sign that the experiment described in Science was not quite the way it was described in the paper occurs when Cahalan looks at the record of the admission interview. In addition to the vague description of hallucinations, Rosenhan states that he believes he can “hear what people are thinking”, that he has tried to “insulate out the noises by putting copper over my ears”, and that he has “suicidal thoughts”. These are all more serious psychiatric symptoms than factitious “existential hallucinations”. Rosenhan also altered his occupational history during one assessment to say that his psychiatric illness led him to give up a job in economics 10 years earlier. At one point he stated that his wife is probably unaware of how useless he felt and that “everyone would be better off if he was not around”.  Considering the seriousness of his fake history, I was surprised that he was discharged in 9 days.

What about the other 8 pseudopatients?  Cahalan was able to locate two – only one of whom was part of the research protocol and shared Rosenhan’s experience. The second patient started out as a psychologist and co-authored a couple of papers with Rosenhan. The author was surprised at how little preparation went into the pseudopatient role. Patient 2 was taught to cheek medications and spit them out. He was reassured by Rosenhan that he had filed a writ of habeus corpus to get him out of the hospital at any time.  When Cahalan tracked down that attorney who said the writs had been discussed but never prepared and that he did not consider himself to be “on call” to get pseudopatients immediately released. Patient 2 was also in the hospital for 9 days and basically released upon his request.  There was no reason for discharge given on the official form but he recalled a psychiatrist approaching him prior to discharge and making remarks to suggest that there was still some concern that he may still be suicidal. Despite that concern there was apparently no discharge plan.

The third pseudopatient discovered by Cahalan was interesting in that he was eliminated from the original protocol and not counted by Rosenhan.  Cahalan discovered that the ninth uncounted pseudopatient was a research psychologist named Harry Lando.  Dr. Lando is well represented in the smoking cessation literature and had published an article in the Professional Psychologist (4) stressing the positive aspects of his pseudopatient experience.  His observations were in direct contrast to Rosenhan and he states as much in the observation: “My overall impressions of the hospital are overwhelmingly positive. The powerlessness and depersonalization of patients so strongly emphasized by Rosenhan simply did not exist in this setting.” He goes on to suggest that using better hospitals as models may be a way to improve the quality of care.  He also questions the ethics of placing pseudopatients in “already overcrowded and understaffed institutions”.  Lando does express a concern about the diagnostic process since all three pseudopatients received diagnoses of schizophrenia.

The key question about why the data of the ninth pseudopatient was omitted from the original paper is answered as a footnote number 6 on page 258 of the original paper:

“Data from a ninth pseudopatient are not included in this study because although his sanity went undetected, he falsified aspects of his personal history. Including marital status and parental relationships. His experimental behaviors therefore were not identical to the other pseudopatients.” 

That footnote is exactly what Rosenhan did when he was admitted as pseudopatient 1 as documented in the existing medical record.  Rosenhan’s lapses were discovered and discussed by Cahalan and are included in the following table.

 

 

Rosenhan’s Lapses

 

1.  Data was improperly recorded. The two pseudo-patients interviewed by Cahalan pointed out that their durations of stay in the hospital were not correctly recorded.

2.  His private notes indicated strong influence by Szasz and Laing. Prior to the pseudopatient experiment he assigned work to his students describing psychiatric hospitals as “authoritarian”, “degrading”, and “illness-maintaining”.

3.  He told a pseudopatient that a writ of habeas corpus was prepared and an attorney was on call to get them out of the hospital if necessary. That was not true.

4.  Professional and possibly “unethical” mistakes (p. 173) about length of stay in pseudopatient number two (7 days versus 8) and pseudopatient number 9 (26 days versus 9 days), patient population in the hospital 8,000 vs 1,510), the specific discharge diagnoses of pseudopatients 2 and 9, and details of staff behavior on the ward.

5.  Sending a pseudo-patient into a hospital that was in disarray because it was closing.

6.  Rosenhan at one point lied in correspondence to Spitzer about his stay in the hospital and said it was part of a “teaching exercise” that had nothing to do with research(p. 180). Cahalan describes this as “an outright lie”.

7.  During his admission Rosenhan “goes off script” and gives far more fabricated symptoms and history than the “empty, hollow, thud” existential hallucinations he described in the protocol. Additional symptoms suggest a significant psychiatric disorder. He describes suicidal ideation and significant conflict with his employer – the same falsification of personal history that led him to eliminate the data of the ninth pseudopatient.

8.  Rosenhan fabricated an excerpted portion of the medical record and both the original record and the excerpt are published for A - B comparison on page 190. Cahalan concludes that the facts “were distorted intentionally by Rosenhan himself.”

9.  Inadequate preparation of the research subjects. Patient 2 ended up taking a dose of chlorpromazine and patient 9 was given liquid chlorpromazine so it could not be cheeked as instructed.  Pseudopatient 9 estimated the preparation time for hospital admission by Rosenhan was about 15 minutes.

10.  When patient 9 was eliminated from the study none of the data about pills dispensed or staff contact time in the paper was changed.

11.  In an National Public Radio program that aired before the publication of his paper (December 14, 1972) he misstated his time in the hospital as a pseudopatient (several weeks versus 9 days) and the amount of medications dispensed to pseudopatients (5,000 pills versus 2,000 pills) while building to the conclusion that psychiatric hospitals are non-therapeutic and should be closed (p.234)

12.  Pseudopatient 9 commented that what Rosenhan had written about him in the experiment was “total fiction” (p.269)

13.  Rosenhan did not complete a book about the pseudopatient experience, despite an advance from the publisher, a subsequent lawsuit from the publisher and what is described as plenty of publicity around the time the paper came out in Science. He also never published on the topic again (p. 295). 

 

Rosenhan did continue to publish a description and discussion of his study in the text Abnormal Psychology (5). The discussion emphasized that the simple hallucinations described with nothing else being unusual would have been detected outside of a hospital. In the context dependent setting it was not.  In other words – he maintained one of the same themes as in the original paper.

One of the areas that really piqued my interest was why Science published this paper in the first place.  Cahalan got the opinion from an academic psychologist that the peer review in a non-psychology journal would be less rigorous.  When she approached the journal she was told that records were confidential and that they were not kept back that far.  Accessing Retraction Watch (6) demonstrated that there has been a total of 120 papers retracted from Science since 1963. The reasons for the retractions are given as data errors, errors in methods, result errors, errors in conclusions, errors due to contaminated experiments, falsification/fabrication of data, irreproducible results, misconduct by the author, ethical violations by the author, investigation by a company, institution, or third-party.  Only three of these papers had anything to do with psychiatry and those papers were primarily about the neurobiology of the brain. Cahalan’s investigation suggests that several of the reasons for retraction have been met.

Apart from the details of the Science paper, Cahalan also does a character study of Rosenhan. We learned that his brother had bipolar disorder and did well on lithium. It was suggested that was why he became interested in psychology. He was described as bright and charismatic. He was clearly influenced by the work of anti-psychiatrists and assigned work to his students that “describe psychiatric hospitals as authoritarian, degrading, and illness maintaining among other terms”. (p 73).  The title of the book highlights Rosenhan’s characteristics as a raconteur who would occasionally pretend to be someone who he was not. His son described an incident in New York City where he introduced himself as a professor of engineering at Stanford in order to get a tour of an interesting construction site with his son. In another scene he is joking about the wig he wore to get into the psychiatric hospital.  Cahalan finds the admission photo showing that he is bald without a wig. The people who knew him the best – acknowledge the he was difficult to know and just like Rosenhan’s arguments about psychiatric diagnoses being context dependent – his personality was as well.   

Apart from academic books about the history of psychiatry – most books review sensational history and arguments that by their very nature diminish the field.  This book is intermediate in that tone with those arguments interspersed through the investigative journalism about Rosenhan. They touch on the familiar themes of biological reductionism as opposed to a clinical psychiatry where patients are actually listened to with no reference to how clinical psychiatrists really practice every day. Some psychiatrists end up being caricatured and some are acknowledged as being highly motivated and humanistic. I am probably far too invested in clinical psychiatry and the good I have seen done to tolerate a journalist’s approach to the field.  I give Cahalan credit for touching on the current situation that has resulted in severely rationed care and the transinstitutionalization of patients in jails.  The overall concept that psychiatrists have little to do with the systems of care that are controlled by businesses and governments is not emphasized even though it was recognized as a problem by two of the pseudopatients.  She also points out that the pseudopatient experiment is irrelevant to psychiatric practice today but her resounding theme throughout the book was that it was extremely relevant irrespective of what actually happened.  The book also gives Rosenhan too much credit for psychiatric criticism. Like many books of this nature – there is little to no evidence that psychiatrists might be their own best critics or that outrage might be a legitimate reaction to outrageous criticism rather than defensiveness.

 In conclusion The Great Pretender identifies very specific problems with the original Rosenhan paper that have been listed in the narrative and table in this report. He gained initial celebrity status from the study and signed a book contract. Even though he was given an advance on the book and wrote a manuscript he never produced a book.  The author suggests that may have been due to the fact that Robert Spitzer was aware of Rosenhan’s nonadherence to the research protocol during his admission. As Rosenhan withdrew from the pseudopatient limelight he also stated that none of his research should lead to the conclusion that psychiatric hospitals were unnecessary and that represented a complete turnaround form earlier statements.

The controversy, the original paper and the book could be the subject of seminars in the history or philosophical aspects of psychiatry. It touches on a number of themes primarily the ethics of research and how it should be conducted. It also touches on psychiatric criticism and may be useful in discussing how future generations of psychiatrists can prepare to deal with it. 

 

George Dawson, MD, DFAPA

 

References:

 

1: Susannah Cahalan.  The Great Pretender. Grand Central Publishing. New York, 2019. 382 p.

2: Rosenhan DL. On being sane in insane places. Science 1973 Jan 19;179(4070):250-258.

3: Sartorius N, Jablensky A, Shapiro R. Cross-cultural differences in the short-term prognosis of schizophrenic psychoses. Schizophr Bull. 1978;4(1):102113. doi:10.1093/schbul/4.1.102

4: Lando, H. A. (1976). On being sane in insane places: A supplemental report. Professional Psychology, 7(1), 47–52. https://doi.org/10.1037/0735-7028.7.1.47

5: David E. Rosenhan, Martin E.P. Seligman. Abnormal Psychology- 2nd Ed. WW Norton and Company, New York City, 1984, 1989; p 181-183.

6: Retraction Watch: Retractions from Science.  Accessed on May 22, 2020: http://retractiondatabase.org/RetractionSearch.aspx#?jou%3dScience

7:  Gaudino M, Robinson NB, Audisio K, et al. Trends and Characteristics of Retracted Articles in the Biomedical Literature, 1971 to 2020. JAMA Intern Med. Published online May 10, 2021. doi:10.1001/jamainternmed.2021.1807

The authors cite retracted literature (5209 papers) back to the year 1923. Scientific misconduct like fabrication of data was cited as the most common reason.  


Supplementary:

The review was written for Philosophy Special Interest Group of the Royal College of Psychiatrists September 2020 newsletter and it can be found starting on page 8.


Additional Reference posted on July 17, 2021:

Justman, Stewart, "Below the Line: Misrepresented Sources in the Rosenhan Hoax" (2021). Global Humanities and Religions Faculty Publications. 13. https://scholarworks.umt.edu/libstudies_pubs/13

This author fact checks Rosenhan's references and footnotes and finds they do not support his points.

 

 

 

 

Tuesday, November 12, 2019

Rosenhan Uncovered






I have been on record for many years regarding the Rosenhan experiment. To briefly recap, that was a paper published in Science in 1973 (1). In the paper the author described how eight pseudopatients were admitted to psychiatric hospitals and the treatment they received. He describes their varied backgrounds. He says that they were admitted to 12 hospitals in five states on the East and West Coast. The hospitals also varied from research institutions to institutions with much fewer resources. Most importantly he describes the script that each pseudo-patient is supposed to adhere to in order to get admitted and how they are supposed to behave post admission. 

Specifically:

“After calling the hospital for an appointment, the pseudopatient arrived at the admissions office complaining that he had been hearing voices. Asked what the voices said, he replied that they were often unclear, but as far as he could tell they said "empty," "hollow," and "thud." The voices were unfamiliar and were of the same sex as the pseudopatient. The choice of these symptoms was occasioned by their apparent similarity to existential symptoms.” (p. 251)

Apart from the false symptoms, false name, false vocation, and false employment the social history provided by the pseudopatients was supposed to be identical to their real social history. After gaining admission so patient was supposed to “cease simulating any symptoms of abnormality.”

From the purported data, Rosenhan pointed out that none of the pseudo-patients were discovered, they were hospitalized for varying lengths of time, they were given medications that they may have been trained to not take and spit out, and they made a number of observations inside the hospital. Rosenhan concluded that “It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals”.  He also uses at least half of the article for highly speculative observations on powerlessness, depersonalization, and labeling none of which really pertain to the study.

I just finished reading Susannah Cahalan’s new book The Great Pretender. It is about Rosenhan’s study and Rosenhan himself.  She has quite a lot to say about him including how this paper changed the face of psychiatric care and was a major factor in closing down psychiatric institutions.

Let me start by describing what I experienced at that time. In 1973, I was just finishing an undergraduate degree and although I was a science major - heard nothing about this paper. I was reading Science and Nature at the time. I did medical school and residency training between the years 1978 and 1986 and again heard nothing about Rosenhan - even during psychiatry rotations and seminars. That was a controversial time in psychiatry because of the tension between biological psychiatry and psychotherapy. The controversy seemed to be largely from the psychotherapy side of the equation. Psychiatry residents were pulled to one side or the other. It was always clear to me that both modalities were critical. I got what I consider to be good psychotherapy training at two different Midwest residency programs.

A unique aspect of my training happened at the University Wisconsin training program. Community Psychiatry was a mandatory six-month rotation that consisted of an outpatient clinic, crisis intervention training, and an active seminar every week. One of the leaders of that seminar was Len Stein MD. Dr. Stein was a major force and originator of Assertive Community Treatment (ACT) and other forms of community treatment that were focused on maintaining people with severe mental illness in the community. To this day I can recall a slide from one of his presentations that showed a gymnasium sized room at the local state mental hospital. In that room were cots arranged edge to edge across the entire floor. Rows and rows of these cots covering the entire floor. The men who slept on those cots were standing in the foreground. They were all wearing the same pajamas. After showing that slide, Dr. Stein would point out that this was one of the motivators that led him to help people get out of hospitals into their own apartments.  His goal at the time of Rosenhan’s paper, was to develop a way to help people with severe mental illnesses live independently in the community.  He was not only successful at it – he trained psychiatry residents how to do it. After completing my training, I went to a community mental health center and helped run an ACT team for three years.  We were highly successful at maintaining people outside of the hospital and helping them function independently.

My introduction here is to illustrate that one of the main theses of The Great Pretender, namely that Rosenhan’s experiment was one of the main forces in deinstitutionalization and closing down psychiatric hospitals is something that I disagree with. It seems to be a good theory if you want to suggest that psychiatry only changes from the outside and the change happens by people who are not psychiatrists. You can probably make that argument if you don’t know psychiatrists like Len Stein and all of the other community psychiatrists out there who were highly motivated to maintain people outside of state hospitals because it was the right thing to do. It was the right thing to do because states ration resources to the mentally ill. They always have and they always will.  Politicians don't really care about anyone with severe mental illness. Community psychiatrists know that. They know the only way to provide good treatment to those patients is to make sure that public funds follow the individual patient.

In her book Susannah Cahalan, spends a lot of time describing how seminal the Rosenhan study was. She has numerous testimonials from important psychiatrists at the time. There is even a suggestion that Robert Spitzer, MD used the study politically to advance his own agenda in writing more precise diagnostic criteria for the DSM-III. I can state unequivocally that I had not heard of this experiment until I started encountering anti-psychiatrists. That didn’t happen much until I started this blog in 2012.

What did I like about the book? I was impressed with the investigative aspects of the book. She carefully details how Rosenhan’s original description in Science does not accurately reflect what actually happened. There is not enough information available to verify whether or not the entire pseudoexperiment was completed as written. In addition to that research, she has detailed impressions of Rosenhan from fellow faculty members, coworkers, friends, and family members who knew him well. Many of these people had reservations about him and his work. Many believed that there were problems with the original paper. Many had concerns about his character that are clearly described in this book. In brief, there is plenty of circumstantial evidence in addition to the direct evidence that something was wrong with this paper.  I take this circumstantial and character evidence with a grain of salt. In any clinical or academic settings, there are always plenty of personality conflicts and politics. There is one scene in the book where Rosenhan is throwing a party and tells a colleague that he had a wig made for the pseudopatient role (Rosenhan was bald). Cahallan confirms by photo and the attending psychiatrist’s notes that he was bald and not wearing a wig during the hospitalization. I also do not consider that to be a big deal. He was described as a raconteur who liked to hear himself talk. Making up stories at parties to keep people engaged is what raconteurs and extroverts do.  

She also builds a careful case of additional red flags along the way. Rosenhan apparently achieved celebrity status for brief period of time. When that occurs he got a book deal and was advanced substantial sum of money. He also wrote several chapters that were read by Cahalan. He never finished the book even when he was sued by the publisher.  He never did any further research on the subject of pseudopatients getting into psychiatric hospitals or psychiatric hospitals at all. He had an active correspondence with Spitzer and one point recruited psychiatrists to convince Spitzer not to publish criticisms of his paper. Spitzer was very content with his criticism, but Cahalan points out that he may have had direct information at the time to refute the paper entirely. Rosenhan clearly broke the protocol that he described as evidenced by the medical record. The treating psychiatrist apparently sent Spitzer a copy of those records showing that as the original pseudo-patient, Rosenhan broke protocol. In addition to describing vague auditory hallucinations he added historical data that would have resulted in him being hospitalized anywhere.  Excerpts from the exact medical record are included in the book on pages 184 and 190. The author concludes (and any reader can do the same) that the facts were intentionally distorted by Rosenhan primarily with more elaborate delusional material and suicidal thoughts including the statement “everyone would be better off if he were not around.” What is recorded in the actual medical record is a person feigning a much more serious mental illness than “existential symptoms.”

Cahalan was able to locate two more pseudopatients, but one of them was not included in the study. Cahalan was unable to locate any of the other six pseudo-patients described in the Science paper despite an intensive effort.  Rosenhan also removed the data from the ninth pseudo-patient. The data from the ninth pseudo-patient was inconsistent with the others in that this patient liked his experience in the psychiatric hospital and in fact found to be very positive. He liked it so much that he published that positive experience in Professional Psychology in February 1976 (2) including the following conclusion “He recommends stressing the positive aspects of existing institutions in future research.” (p 213).

Cahalan approached Science directly. She asked them directly why they published this article in the first place given the concerns she outlined in her book. They refused to discuss their editorial process. A psychologist speculated that the submission to Science would be less rigorously reviewed because they probably did not have the top peer reviewers in the field. Although Cahalan uses a fair amount of anti-psychiatry rhetoric in her book, and seems to talk authoritatively about that field, there is no speculation that bias against psychiatry may have been involved in publishing this article.  Given what we know about general bias against psychiatry, that would seem to be a real possibility to me.

I am already on record saying that there is enough information in this book to retract the original article. I admit I don’t know the criteria for retractions or whether there is any time limit. Having been a Science subscriber for decades I know that it certainly does not meet their typical standards. I will happily go back and read articles from medicine and psychiatry in their 1973 editions to illustrate that fact if there is a shot at retraction.

Retraction would certainly create a furor in the anti-psychiatry community. Their arguments rest almost entirely on false premises and pseudoscience. As I noted in my post from seven years ago, anyone can walk into a medical facility and lie about a condition for any number of motives. In my current field, I have talked with hundreds of people who tell me they asked for a second or third opioid prescription when they did not need it for pain. They were taking it to get high. Before that I did consults in a general hospital, we were often asked to see people with factitious disorders who are feigning some medical illness. We also saw significant numbers of people who had medical symptoms but were not consciously feigning illness. The author mentions some of this but is usually quick to make it seem like psychiatry is the wildcard relative to the rest of medicine. 

I have had several people ask me if they should buy this book. I have also been asked to write a book review for newsletter.  My response is consistently, buy the book if you want to see the clear evidence that the Rosenhan experiment was more than seriously flawed – the protocol was violated by the author himself and the evidence is there black on white. A second protocol violation occurred when the Rosenhan decided to eliminate the experience of the pseudopatient who enjoyed being in the hospital and found it to be useful. I will say again that I am not an expert in retractions but believe that papers are retracted today for violations of data integrity.

Don’t buy this book if you are expecting to read a valentine to psychiatry. The author's previous book was about her episode of inflammatory encephalitis that was misdiagnosed as a psychiatric disorder. She mentions it several times to point out her credibility as a person who has experienced severe psychiatric symptomatology. At one point in the book she undergoes a SCID (Structured Clinical Interview for DSM-IV) evaluation by a psychiatrist who had a lot of input into DSM-5. After a tedious exchange he tells her that his going charge for the exam is $550. When I read that, I asked myself why would this psychiatrist go along with a SCID when he knew it was irrelevant to Cahalan’s diagnosis? Several other prominent psychiatrists are quoted in the book in a way that fits Cahalan’s thesis that psychiatry is in fact a weak link in medicine and even though Rosenhan’s pseudoexperiment was grossly flawed there is a still some valuable lesson there.

I would suggest that is really not the case. I don’t know why anyone would want to try to resuscitate this work and I sure don’t know why Science wants to keep it in a reputable journal.  The original responses over 40 years ago pointed that out. I would highly recommend reading the  original responses by Spitzer.


George Dawson, MD, DFAPA



References:

1: Rosenhan DL. On being sane in insane places. Science. 1973 Jan 19;179(4070):250-8. PubMed PMID: 4683124.

2: Lando H. On being sane in insane places: a supplemental report. Professional Psychology, February 1976: 47-52.



Additional Reference posted on July 17, 2021:

Justman, Stewart, "Below the Line: Misrepresented Sources in the Rosenhan Hoax" (2021). Global Humanities and Religions Faculty Publications. 13. https://scholarworks.umt.edu/libstudies_pubs/13

This author fact checks Rosenhan's references and footnotes and finds they do not support his points.




Wednesday, July 18, 2012

On the Validity of Pseudopatients


Every now and again the detractors and critics of psychiatry like to march out the results of an old study as "proof" of the lack of validity of psychiatric diagnoses.  In that study,  8 pseudopatients feigned mental illness to gain admission to 12 different psychiatric hospitals.  The conclusion of the study author was widely seen as having significant impact on the profession, but that conclusion seems to have been largely retrospective.  I started my training about a decade later and there were no residuals at that time.  I learned about the study largely through the work of antipsychiatrists and psychiatric critics.

Several obvious questions are never asked or answered by the promoters of this test as an adequate paradigm.  The first and most obvious one is why this has not been done in other fields of medicine.  It would certainly be easy to do.  I could easily walk into any emergency department in the US and get admitted to a Medicine or Surgical service with a faked diagnosis.  I know this for a fact, because one of the roles of consulting psychiatrists to Medicine and Surgery services is to confront the people who have faked illness in order to be admitted.  Kety (9) uses a more blunt example in response to the original pseudopatient experiment (1):

"If I were to drink a quart of blood and, concealing what I had done, come to the emergency room of any hospital vomiting blood, the behavior of the staff would be quite predictable. If they labeled and treated me as having a bleeding peptic ulcer, I doubt that I could argue convincingly that medical science does not know how to diagnose that condition. "(9)

I also know that this happens because of the current epidemic of prescription opiate abuse and the problem of drug seeking and being successful at it.  An estimated 39% of diverted drugs (7) come from "doctor shopping."  By definition that involves presenting yourself to a physician in a way to get additional medications.  In the case of prescription opioids that usually means either faking a pain disorder or misrepresenting pain severity.  So it is well established that medical and surgical illness well outside of the purview of psychiatry can be faked.  And yet to my knowledge, there is hardly any research on this topic and nobody is suggesting that medical diagnoses don't exist because they can be faked.  Does that mean the researchers consider the time of these other doctors too valuable to waste?  More likely it did not fit a preset research agenda.

The second obvious question has to do with conflict of interest.  It is currently in vogue to suggest that psychiatrists are swayed in their prescribing practices by incentives ranging from a free pen to a free meal.  Compensation as a company employee or to give lectures is also thought of as a compromising incentive. The free pen/free meal incentive is pretty much historical at this time.  What about intentionally misrepresenting yourself?  What is the conflict of interest involved at that level and how neutral can you stay when you are trying to escape detection in order to prove a point?  A vague script like a mono-symptomatic presentation of schizophrenia should suggest that the intent is to escape detection.  How should a person with a vague script act when they are face to face with a real clinician?  The logical conclusion is that they would be as evasive as possible even if they were adhering to that protocol.

The bottom line is that the pseudopatient experiments were seriously flawed out of the box.  Continuing to promote them as meaningful reflects a serious lack of scholarship in reading the relevant literature and a need to suspend the reality that in fact mental illness does exist, that distinctions can be made among various types of mental illness, and that those distinctions are useful to psychiatrists trying to help people with those problems.

George Dawson, MD, DFAPA

1: Rosenhan DL. On being sane in insane places. Science. 1973 Jan 19;179(4070):250-8. PubMed PMID: 4683124.

2: Fleischman PR, Israel JV, Burr WA, Hoaken PC, Thaler OF, Zucker HD, Hanley J, Ostow M, Lieberman LR, Hunter FM, Pinsker H, Blair SM, Reich W, Wiedeman GH, Pattison EM, Rosenhan DL. Psychiatric diagnosis. Science. 1973 Apr 27;180(4084):356-69. PubMed PMID: 17771687.

3: Bulmer M. Are pseudo-patient studies justified? J Med Ethics. 1982 Jun;8(2):65-71. PubMed PMID: 7108909; PubMed Central PMCID: PMC1059372.

4: Spitzer RL, Lilienfeld SO, Miller MB. Rosenhan revisited: the scientific credibility of Lauren Slater's pseudopatient diagnosis study. J Nerv Ment Dis. 2005 Nov;193(11):734-9. PubMed PMID: 1626092

5: Spitzer RL. More on pseudoscience in science and the case for psychiatric diagnosis. A critique of D.L. Rosenhan's "On Being Sane in Insane Places" and "The Contextual Nature of Psychiatric Diagnosis". Arch Gen Psychiatry. 1976 Apr;33(4):459-70. PubMed PMID: 938183.

6: Zimmerman M. Pseudopatient or pseudoscience: a reviewer's perspective. J Nerv Ment Dis. 2005 Nov;193(11):740-2. PubMed PMID: 16260928.

7: Inciardi JA, Surratt HL, Cicero TJ, Kurtz SP, Martin SS, Parrino MW. The "black box" of prescription drug diversion. J Addict Dis. 2009 Oct;28(4):332-47.  PubMed PMID: 20155603; PubMed Central PMCID: PMC2824903.

8: Millon T. Reflections on Rosenhan's "On being sane in insane places". J AbnormPsychol. 1975 Oct;84(5):456-61. PubMed PMID: 1194506.

9: Kety SS. From rationalization to reason. Am J Psychiatry. 1974 Sep;131(9):957-63. PubMed PMID: 4413516.