Thud

I was too dilatory to blog this story ("Into the Cuckoo's Nest") while it was still up at the Guardian, but fortunately it's been archived by the Alternative News Network. Its major entertainment value is the detailed description of one of everyone's favorite psychology studies, David Rosenhan's "On Being Sane in Insane Places." Briefly, in 1972 Rosenhan and a bunch of his friends presented themselves at various psychiatric hospitals claiming to hear a voice saying "empty," "hollow," and "thud." All were hospitalized, at which point they stopped claiming to hear the voices and began to act completely normally. No one but their fellow patients ever noticed. Rosenhan's original paper can be found here, and is *well* worth reading for its chilling descriptions of how dehumanizing psychiatric treatment was in the 1970s, and how the most normal of behaviors were pathologized by staff members who thought they were observing crazy people.

The Guardian article is by a psychologist, Lauren Slater, who decided to replicate Rosenhan's experiment. Sort of. No one gets hospitalized just for hearing voices these days, and indeed, she wasn't. She went to various emergency rooms and told her story of the voice that said "thud," and each time she was diagnosed with psychotic depression or some variation thereof, and given prescriptions for antipsychotic and antidepressant drugs. She tries to spin this as evidence that psychiatry hasn't changed much in the thirty-odd years since Rosenhan, but I'm not buying it. The key element of Rosenhan's findings was not that the pseudopatients were admitted - they were, after all, faking auditory hallucinations - but that they were still judged to be ill even after they had reverted to totally normal behavior. Slater was never admitted, so the psych professionals never saw her behaving normally. They're guilty of being fooled by her lies, but they're not guilty of pathologizing normal behavior. The other key feature of Rosenhan's findings was the dreadful, dehumanizing treatment received by the pseudopatients and their fellows; Slater says she was treated with uniform kindness. (Enough so that she started to feel guilty.) So this partial attempt at replication makes a nice dramatic story, but I don't think it proves much of anything in particular.

Another point: Rosenhan and all of his fellow pseudopatients were psychologically healthy. Slater, I find in a review of one of her books, has a history of "[psychiatric] hospitalizations, suicide attempts, anorexia, and self-mutilation resulting from a variety of mental illnesses, obsessive-compulsive disorder the most recent among them." And yet we're supposed to be disturbed that the ER psychiatrists thought there was something mentally wrong with her - given her assertion in the article that "really, I'm fine now." Maybe she is fine now, but a history of severe mental illness certainly does tend to leave marks - physical and otherwise.

Some minor annoying things leap out at me upon re-reading the article now - things that Slater, as a psychologist, should've known better than to say. For example, she makes a point of saying that nowhere in psychiatric literature are there valid reports of voices saying "thud" - as if it's the content of hallucinations that matters, rather than the basic fact of hearing voices that aren't really there. (Even more annoyingly, she makes a snide comment about a patient who heard voices repeatedly saying "It's okay," saying that the symptom sounded "okay" to her. Again, as if the content of the hallucination makes it innocuous. Actual people who hallucinate tend to be disturbed by the fact that there's, you know, a voice in their head - regardless of what it's saying.) Or, for example, here:

"When will I get out?" we can imagine Rosenhan asked, his voice perhaps rising now, some panic here - what had he done, my God.

"When you are well," a doctor answered, or something to this effect. But he was well: 110 over 80, a pulse of 72, a temperature that hovered in the mid-zone of moderate, homeostatic, a machine well greased. It didn't matter. He was diagnosed with paranoid schizophrenia and kept for many days.

Lauren Slater's a psychologist, so she's got to know that blood pressure, pulse, and temperature have not a damn thing to do with whether a person has paranoid schizophrenia or not. It's like saying, "he was nondepressed and his judgment and memory were intact, but it didn't matter. He was diagnosed with pneumonia and kept for many days." Non sequitur as counter-evidence.

If I sound really pissed at Slater, that's probably because, in my experience, it's vastly more common these days to have trouble getting people in to the hospital than it is to get them out again. I've had to coach some of my clients - suicidal folks who wanted to be admitted for their own safety - on what to tell the ER doc to be sure they wouldn't just be sent home with a prescription. People hearing voices that say a lot scarier things than "thud" wind up living on the streets because there's no place for them in the system. Slater's story is sensationalistic and not really to the point, but because it's so compellingly written it deflects attention from real problems with emergency psychiatric care.