Insanity: In the Eye of the Beholder
The myth that mental illness
is incurable and that the mentally ill are beyond rehabilitation remains
pervasive, writes Malou Mangahas of the Philippine Center for Investigative
Journalism in her recent three-part series on the problems at the National
Mental Hospital. The series was published in the Standard and at least
two other newspapers.
There's one trouble with
her statement about the pervasiveness of the myth that mental illness is
incurable. Her statement suggests that we know the differrence between
mental health and mental illness.
In fact, the definition
of mental illness remains problematical for the simple reason that what
is considered normal in one culture may be regarded as abnormal in another.
``More generally, there
are a great deal of conflicting data on the reliability, utility and meaning
of such terms as `sanity,' `insanity,' `mental illness' and `schizophrenia,'
observed psychiatrist David L. Rosenthal in an article published 20 years
ago in Science, the jounal of the Amerrican Association for the Advancement
of Science.
``From Blueler through Kirtschmer,
through the formulators of the recently revised Diagnostic and Statistical
Manua of the American Psychiatric Association, the belief has been strong
that patients present symptoms, that those symptoms can be categorized,
and, implicitly, that the sane are distinguishable from the insane,'' Rosenhan
said.
``More recently, however,
this belief has been questioned. Based in part on theoretical and anthropological
considerations, but also on philosophical, legal and therapeutic ones,
the view has grown that psychological categorization of mental illness
is useless at best and downright harmful, misleading and pejorative at
worst. Psychiatric diagnoses, in this view, are in the minds of the observers
and are not valid summaries of characteristics displayed by the observed.''
Rosenhan reasoned: Let us
suppose that normal persons, that is, persons who do not have and have
never suffered symptoms of serious psychiatric disorder are admitted into
a psychiatric hospital; if they are discovered to be sane, there would
be prima facie evidence that a sane individual can be distinguished from
the insane context in which he is found.
``Normality (and presumably
abnormality) is distinct enough that it can be recognized wherever it occurs
for it is carried within the person,'' Rosenthal continued.
``If, on the other hand,
the sanity of the pseudopatients were never discovered, serious difficulties
would arise for those who support traditional psychiatric diagnosis.''
Rosenhan actually tested
this reasoning. He got himself and seven others -- a psychology graduate
student, three psychologists, a pediatrician, a painter and a housewife
-- admitted into 12 different hospitals across the United States.
They gained admission by
presenting themselves to the admissions office complaining that they were
``hearing voices.'' As soon as they
were admitted, they ceased simulating any symptoms of abnormality and behaved
as they normally did.
``Despite their public `show'
of sanity, the pseudopatients were never detected,'' Rosenhan reported.
The length of hospitalization ranged from seven to 52 days, with 19 days
as the average length of stay. ``Admitted, except in one case, with
a diagnosis of schizophrenia, each was discharged with a diagnosis of schizophrenia
`in remission,'" Rosenhan said.
``The label `in remission'
should in no way be dismissed as a formality, for at no time during any
hospitalization had any question been raised about any psudopatient's simulation.
Nor are there any indications in the hospital records that the pseudopatient's
status was suspect.
``Rather, the evidence is
strong that, once labeled schizophrenic, the pseudopatient was stuck with
that label. If the pseudopatient was to be discharged, he must naturally
be `in remission,' but he was not sane, nor, in the institution's view,
had he ever been sane.''
Rosenhan's findings got
to be known to psychiatrists at a prestigious research and teaching hospital
-- and these specialists claimed that such an error could not happen at
their hospital.
He told these psychiatrists
that over the next three months, he would send one or more sane persons
who would try to get themselves admitted into the hospital.
He asked staff members of
the hospital to rate each patient who presented himself at admission or
at the ward on the likelihood that the patient was a normal person pretending
to be insane.
Of the 193 patients who
were evaluated, 41 were alleged -- with high confidence -- to be a pseudopatient
by at least one member of the staff; 21 were considered suspect by at least
one psychiatrist; 19 were suspected by one psychiatrist and one other staff
member.
In fact, Rosenhan had not
sent a single pseudopatient to this hospital.
Rosenhan concluded, ``It
is clear that we cannot distinguish the sane from the insane in psychiatric
hospitals,'' although he did concede that the pseudopatients -- like all
the other inmates -- had not been carefully observed by the psychiatrists
and the hospital staff.
It was quite common for
hospital inmates to detect the pseudopatients' sanity. He recalled, ``During
the first three hospitalizations, when accurate counts were kept, 35 of
a total of 188 patients on the admissions ward voiced their suspicons,
some vigorously.''
These inmates made statements
like, ``You're not crazy,'' -- and, in reference to the pseudopatients'
extensive note-taking, ``You're a professor,'' ``You're a journalist,''
or ``You're here to check on the hospital.''
Rosenhan commented, ``The
fact that the patients often recognized normality when staff did not raises
important questions.''
Rosenhan's article -- titled
``On being sane in insane places'' -- makes one wonder about Ms. Manghas'
statement about the pervasiveness of the myth that mental illness is incurable
and that the mentally ill are beyond rehabilitation.
Perhaps the myth persists
because the psychiatrists and staff members at the National Mental Hospital
presume that anyone confined at the hospital must be crazy -- no matter
how normally they might act -- and interpret the patient's behavior in
such a way as to be consistent with the original diagnosis of insanity.