The aim of this
study was to test the hypothesis that psychiatrists cannot reliably tell
the difference between people who are sane and those who are insane.
The study actually
consisted of two parts.
The main study is
an example of a field experiment. The study also involved participant
observation, since, once admitted, the pseudo-patients kept written
records of how the ward as a whole operated, as well as how they
personally were treated.
were hospital staff in 12 different hospitals.
The first part of
the study involved eight sane people (pseudo-patients) attempting to
gain admission to 12 different hospitals, in five different states in
the USA. There were three women and five men.
pseudo-patients telephoned the hospital for an appointment, and arrived
at the admissions office complaining that they had been hearing voices.
They said the voice, which was unfamiliar and the same sex as
themselves, was often unclear but it said 'empty', 'hollow', 'thud'.
patients gave a false name and job, but all other details they gave were
true including general ups and downs of life, relationships, events of
life history and so on.
After they had
been admitted to the psychiatric ward, the pseudo patients stopped
simulating any symptoms of abnormality. The pseudo patients took part in
ward activities, speaking to patients and staff as they might
ordinarily. When asked how they were feeling by staff they said they
were fine and no longer experienced symptoms. Each pseudo patient had
been told they would have to get out by their own devices by convincing
staff they were sane.
patients spent time writing notes about their observations. Initially
this was done secretly although as it became clear that no one was
bothered the note taking was done more openly.
None of the pseudo
patients was detected and all but one were admitted with a diagnosis of
schizophrenia and were eventually discharged with a diagnosis of 'schizophrenia
pseudo-patients remained in hospital for 7 to 52 days (average 19 days),
Although they were
not detected by the staff, many of the other patients suspected their
sanity (35 out of the 118 patients voiced their suspicions).
patients’ normal behaviours were often seen as aspects of their supposed
illness. For example, nursing records for three of the pseudo patients
showed that their writing was seen as an aspect of their pathological
behaviour. 'Patient engages in writing behaviour'.
Another example of
where behaviour was misinterpreted by staff as stemming from within the
patient, rather than the environment, was when a psychiatrist pointed to
a group of patients waiting outside the cafeteria half an hour before
lunchtime. To a group of registrars (trainee psychiatrists) he
suggested that such behaviour was characteristic of an oral-acquisitive
syndrome. However, a more likely explanation would be that the patients
had little to do, and one of the few things to anticipate in a
psychiatric hospital is a meal.
In four of the
hospitals the pseudo patients carried out an observation of behaviour of
staff towards patients that illustrate the experience of being
hospitalised on a psychiatric ward. The results were compared with a
university study. In the university study, nearly all the requests were
acknowledged and responded to unlike the psychiatric hospital where the
pseudo patients were treated as if they were invisible. See
Table 1: Responses
of staff towards pseudo patients requests
making contact with patient
with head averted
In the secondary
study, staff of a teaching and research hospital, which was aware of the
first study, was falsely informed that during the next three months one
or more pseudo patients would attempt to be admitted into their
hospital. Staff members were asked to rate on a 10-point scale each new
patient as to the likelihood of them being a pseudo patient.
The table shows
that many patients of the hospitals regular intake were judged to be
pseudo patients. For example, around ten per cent of their regular
intake were judged by one psychiatrist and another staff member to be
Judgement of all admissions patients as to the likelihood that they are
patients confidently judged as pseudo patients by at least one
patients suspected by one psychiatrist
patients suspected by one psychiatrist AND one other staff
that the study demonstrates that psychiatrists cannot reliably tell the
difference between people who are sane and those who are insane.
experiment illustrated a failure to detect sanity, and the secondary
study demonstrated a failure to detect insanity.
that psychiatric labels tend to stick in a way that medical labels do
not and that everything a patient does is interpreted in accordance with
the diagnostic label once it has been applied.
He suggested that
instead of labelling a person as insane we should focus on the
individual’s specific problems and behaviours.
that experience of hospitalisation for the pseudo patients was one of
depersonalisation and powerlessness.
depersonalisation were evident in the ways in which the patients were
deprived of many human rights such as freedom of movement and privacy.
Medical records were open to all staff members regardless of status or
therapeutic relationship with the patient and personal hygiene was
monitored and many of the toilets did not have doors. Some of the ward
orderlies would be brutal to patients in full view of other patients but
would stop as soon as another staff member approached. This indicated
that staff were credible witnesses but patients were not.