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Old Curiosity Shop - On being sane in insane places

Thanks to those who have sent in suggestions. Bandolier has chosen a paper published 25 years ago which should be reread. It examines US attitudes to mental health, which have most likely changed, and though it is not directly relevant to today's UK practice, the philosophy keeps feet firmly on the ground.

On being sane in insane places

Yes, we all feel like this at some time or another. But the study in this paper from Stanford [1] was a bit different. Eight sane people (a varied group, from a psychology graduate in his '20s, three psychologists, a paediatrician, a psychiatrist, a painter and a housewife) gained admission to 12 psychiatric hospitals in five US states on the East and West coasts. They all alleged "pseudosymptoms" and those in mental health professions pretended to have other jobs. Their presence was not known to hospital staff.

Not one was spotted

Basically the pseudopatients arranged a hospital appointment, complained of hearing voices, but made no other significant change to their life history. All were admitted, except in one case, with a diagnosis of schizophrenia.

Immediately on admission the pseudopatients ceased simulating any symptoms, and apart from some understandable nervousness, behaved normally. They did make copious notes on the ward about what happened.

Despite their public show of sanity, the pseudopatients were never detected by medical or nursing staff, and were discharged (after between 7 and 52 days, average stay 19 days) with a diagnosis of schizophrenia "in remission". Fellow patients were better at spotting the pseudopatients - 35 of 118 fellow patients voiced suspicions about the pseudopatients.

It couldn't happen here!

Two hospitals which had heard of the findings doubted that such an error could happen there. So staff were informed that over the coming three months one or more pseudopatients would attempt to be admitted. Each staff member was asked to rate each patient presenting at admission according to the likelihood of that patient being a pseudopatient.

Judgements were obtained on 193 patients:

  • 41 patients (21%) were alleged, with high confidence, to be pseudopatients by at least one member of staff.
  • 23 patients (12%) were considered suspect by at least one psychiatrist.
  • 19 patients (10%) were considered suspect by one psychiatrist and one other staff member.

No pseudopatient actually presented during this time.

Sobering thoughts

The results are sobering enough. Reading the extensive commentary about the details of treatment and process is chilling. It certainly make one think about diagnostic accuracy (as Bandolier has pointed out in issue 37 for malignant melanoma). The message about how to treat people is one that even a caring service like the NHS should remember from time to time.


  1. DL Rosenhan. On being sane in insane places. Science 1973 179:250-8.

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