Friday, September 6, 2013

On Being Sane In Insane Places  ローゼンハン論文


On Being Sane In Insane Places
David L. Rosenhan
Science
Vol. 179 no. 4070 pp. 250-258
DOI: 10.1126/science.179.4070.250                       


Abstract (and Conclusion): It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals (精神科の病院で正常者と精神異常者を見分けるのは不可能であることは、明らかである. The hospital itself imposes a special environment in which the meanings of behavior can easily be misunderstood. The consequences to patients hospitalized in such an environment—the powerlessness, depersonalization, segregation, mortification, and self-labeling—seem undoubtedly countertherapeutic.

 

PSEUDOPATIENTS AND THEIR SETTINGS

(Eight sane people gained secret admission to 12 different hospitals.)  The eight pseudopatients were a varied group. One was a psychology graduate student in his 20’s. The remaining seven were older and “established.” Among them were three psychologists, a pediatrician, a psychiatrist, a painter, and a housewife. Three pseudopatients were women, five were men. All of them employed pseudonyms, lest their alleged diagnoses embarrass them later.

 

After calling the hospital for an appointment, the pseudopatient arrived at the admissions office complaining that he had been hearing voices…

 

Beyond alleging the symptoms and falsifying name, vocation, and employment, no further alterations of person, history, or circumstances were made. The significant events of the pseudopatient’s life history were presented as they had actually occurred. Relationships with parents and siblings, with spouse and children, with people at work and in school, consistent with the aforementioned exceptions, were described as they were or had been. Frustrations and upsets were described along with joys and satisfactions. These facts are important to remember. If anything, they strongly biased the subsequent results in favor of detecting insanity, since none of their histories or current behaviors were seriously pathological in any way.

Immediately upon admission to the psychiatric ward, the pseudopatient ceased simulating any symptoms of abnormality. In some cases, there was a brief period of mild nervousness and anxiety, since none of the pseudopatients really believed that they would be admitted so easily.

 

 

The pseudopatient, very much as a true psychiatric patient, entered a hospital with no foreknowledge of when he would be discharged. Each was told that he would have to get out by his own devices, essentially by convincing the staff that he was sane. The psychological stresses associated with hospitalization were considerable, and all but one of the pseudopatients desired to be discharged almost immediately after being admitted. They were, therefore, motivated not only to behave sanely, but to be paragons of cooperation. That their behavior was in no way disruptive is confirmed by nursing reports, which have been obtained on most of the patients. These reports uniformly indicate that the patients were “friendly,” “cooperative,” and “exhibited no abnormal indications.”

 

THE NORMAL ARE NOT DETECTABLY SANE

Despite their public “show” of sanity, the pseudopatients were never detected. Admitted, except in one case, with a diagnosis of schizophrenia,[4] each was discharged with a diagnosis of schizophrenia “in remission.” 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 pseudopatient’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.

The uniform failure to recognize sanity cannot be attributed to the quality of the hospitals, for, although there were considerable variations among them, several are considered excellent. Nor can it be alleged that there was simply not enough time to observe the pseudopatients. Length of hospitalization ranged from 7 to 52 days, with an average of 19 days. The pseudopatients were not, in fact, carefully observed, but this failure speaks more to traditions within psychiatric hospitals than to lack of opportunity.

Finally, it cannot be said that the failure to recognize the pseudopatients' sanity was due to the fact that they were not behaving sanely. While there was clearly some tension present in all of them, their daily visitors could detect no serious behavioral consequences—nor, indeed, could other patients. It was quite common for the patients to “detect” the pseudopatient’s sanity. During the first three hospitalizations, when accurate counts were kept, 35 of a total of 118 patients on the admissions ward voiced their suspicions, some vigorously. “You’re not crazy. You’re a journalist, or a professor (referring to the continual note-taking). You’re checking up on the hospital.” While most of the patients were reassured by the pseudopatient’s insistence that he had been sick before he came in but was fine now, some continued to believe that the pseudopatient was sane throughout his hospitalization. The fact that the patients often recognized normality when staff did not raises important questions.

Failure to detect sanity during the course of hospitalization may be due to the fact that physicians operate with a strong bias toward what statisticians call the Type 2 error. This is to say that physicians are more inclined to call a healthy person sick (a false positive, Type 2) than a sick person healthy (a false negative, Type 1). The reasons for this are not hard to find: it is clearly more dangerous to misdiagnose illness than health. Better to err on the side of caution, to suspect illness even among the healthy.

But what holds for medicine does not hold equally well for psychiatry. Medical illnesses, while unfortunate, are not commonly pejorative. Psychiatric diagnoses, on the contrary, carry with them personal, legal, and social stigmas. It was therefore important to see whether the tendency toward diagnosing the sane insane could be reversed. The following experiment was arranged at a research and teaching hospital whose staff had heard these findings but doubted that such an error could occur in their hospital. The staff was informed that at some time during the following three months, one or more pseudopatients would attempt to be admitted into the psychiatric hospital. Each staff member was asked to rate each patient who presented himself at admissions or on the ward according to the likelihood that the patient was a pseudopatient…

Forty-one patients were alleged, with high confidence, to be pseudopatients by at least one member of the staff. Twenty-three were considered suspect by at least one psychiatrist. Nineteen were suspected by one psychiatrist and one other staff member. Actually, no genuine pseudopatient (at least from my group) presented himself during this period.

The experiment is instructive. It indicates that the tendency to designate sane people as insane can be reversed when the stakes (in this case, prestige and diagnostic acumen) are high. But what can be said of the 19 people who were suspected of being “sane” by one psychiatrist and another staff member? Were these people truly "sane" or was it rather the case that in the course of avoiding the Type 2 error the staff tended to make more errors of the first sort – calling the crazy “sane”? There is no way of knowing. But one thing is certain: any diagnostic process that lends itself too readily to massive errors of this sort cannot be a very reliable one.

 

THE STICKINESS OF PSYCHODIAGNOSTIC LABELS

As far as I can determine, diagnoses were in no way affected by the relative health of the circumstances of a pseudopatient’s life. Rather, the reverse occurred: the perception of his circumstances was shaped entirely by the diagnosis. A clear example of such translation is found in the case of a pseudopatient who had had a close relationship with his mother but was rather remote from his father during his early childhood. During adolescence and beyond, however, his father became a close friend, while his relationship with his mother cooled. His present relationship with his wife was characteristically close and warm. Apart from occasional angry exchanges, friction was minimal. The children had rarely been spanked. Surely there is nothing especially pathological about such a history. Indeed, many readers may see a similar pattern in their own experiences, with no markedly deleterious consequences. Observe, however, how such a history was translated in the psychopathological context, this from the case summary prepared after the patient was discharged.

 

This white 39-year-old male . . . manifests a long history of considerable ambivalence in close relationships, which begins in early childhood. A warm relationship with his mother cools during his adolescence. A distant relationship with his father is described as becoming very intense. Affective stability is absent. His attempts to control emotionality with his wife and children are punctuated by angry outbursts and, in the case of the children, spankings. And while he says that he has several good friends, one senses considerable ambivalence embedded in those relationships also . . .

 

The facts of the case were unintentionally distorted by the staff to achieve consistency with a popular theory of the dynamics of a schizophrenic reaction… Clearly, the meaning ascribed to his verbalizations (that is, ambivalence, affective instability) was determined by the diagnosis: schizophrenia. An entirely different meaning would have been ascribed if it were known that the man was “normal.”

 

THE CONSEQUENCES OF LABELING AND DEPERSONALIZATION

…The facts of the matter are that we have known for a long time that diagnoses are often not useful or reliable, but we have nevertheless continued to use them. We now know that we cannot distinguish sanity from insanity. It is depressing to consider how that information will be used.

Not merely depressing, but frightening. How many people, one wonders, are sane but not recognized as such in our psychiatric institutions? How many have been needlessly stripped of their privileges of citizenship, from the right to vote and drive to that of handling their own accounts?

 

Rosehan, D. L. (1973). On being sane in insane places.

Full Text: http://psychrights.org/articles/rosenham.htm

2 comments:

n said...

ローゼンハン実験(Rosenhan experiment)は、心理学者デイビッド・ローゼンハンによって行われた精神疾患の診断の有効性についての実験であり、1973年雑誌サイエンスに『狂気の場所の正気の存在("On being sane in insane places")』の題名で掲載。この実験は、精神疾患の診断について重要な研究と見做されている
この実験は2部で構成される。
1:精神疾患の診断を受けていない疑似患者(3名の女性、5名の男性)は幻聴があるふりをして、アメリカ合衆国内5州に位置する12の精神病院の入院許可を得る。全疑似患者は精神疾患があると診断される。入院時、疑似患者は幻聴は無くなったと病院に伝える。全疑似患者は病院によって、精神疾患(8名中7名は、統合失調症の回復期であると診断を受ける)があることを認めること、抗精神病薬の服用を条件に退院許可を出す。 疑似患者の平均入院期間は19日間。
2:これに反応した医療機関は、ローゼンハンが送り込む疑似患者を特定すると伝える。 ローゼンハンはこの提案に同意し、医療機関は新しい患者193名のうち、41名を疑似患者の可能性があり、精神科医1名と職員1名により、19名を疑似患者と疑いをかけた。しかしながらローゼンハンは1人も疑似患者を起こり込んでいなかった。
この調査研究によって、「精神病院施設内において正気と狂気を区別することは不可能であること」…を結論とした


類似する実験
• アメリカ合衆国の調査報道者ネリー・ブライは、1887年に精神疾患のふりをして精神病院へ入所。 施設内の劣悪な環境を報じた。 調査結果は、『狂気の家の10日間(Ten Days in a Mad-House)』として出版
• 2008年、BBCホライゾン『"How Mad Are You?"』制作。5名の過去に精神疾患と診断を受けた人物と、5名の過去に精神疾患の診断を受けたことが無い人物合わせて10名の生活様子から、3名の精神疾患診断の権威が過去に精神疾患と診断を受けた5名を特定する科学ドキュメンタリー 専門家は、全10名中、2名を特定、1名を誤診、2名の診断経験を持たない人物を診断を受けたことがあると誤診
(Wikipedia)

n said...

ローゼンハン論文に登場する「タイプ2エラー」ですが、念のためウィキ日本語版を見ると、かなり解りにくい説明しか載ってないので、補足を。「タイプ2エラー」とは例えばHIV検査を行なう際、罹患していないのに「罹患している」と誤判定(タイプ2エラー)するよりも、罹患しているのに「罹患してない」と誤判定するほうが、その結果おこる問題が重大なので、医療検査においては基準数値を少しきびしくしておき、罹患していないのに「罹患している」という誤判定(タイプ2エラー)がある程度出るのは、やむを得ないこととしましょうという概念ですね。

しかしこれがローゼンハンの行なった実験において、精神異常でもないのに「精神異常者だ」と医師が誤診断を下した言い訳にはならない理由がいくつか述べられています。例えばご、第2回実験では、今度はサクラとして参加した全員がもともと精神異常(と既に診断された)者であったのに、そのうちの数名を「正常者」だと誤診してしまっているから、などですね。
(n)