Appeal To The Man On The Clapham Omnibus by Alex Dunedin
On Sane People In Insane Places was a famous study done by David Rosenhan, a psychologist in America. Central to the study was the question he posed, ‘If sanity and insanity exist, how shall we know them?‘. This seems a pivotal inquiry if billions upon billions of pounds are now involved in psychiatric drugs that are proffered as treatments for what gets described as mental illness.
The medical models of mental health/mental illness are now coming under deep scrutiny and have been for some decades. It seems like a logical starting point to ask for defining characteristics in medicine, if people are to be given powerful and dangerous drugs for long periods of time. To qualify what is meant by powerful and dangerous, what is meant is the risks of addiction, damaging side effects such as tardive dyskinesia, and even sudden or premature death.
With so much as stake, it is no wonder that it is a hot topic, involving people’s emotions and worries. Health and happiness are so primary to human sensibilities, that they are regarded very much as sacred; as essential qualities of a life worth living.
Many battles rage around psychiatry, and many misunderstandings are borne without publicly and inclusively examining the information available to try and unravel some of the Gordian knots that touch all our lives. This is a primary issue as it is an issue which deals with how human society is dealing with human behaviour and our liberties.
In this context I invoke an appeal for ‘the man on the Clapham omnibus’. This is a famous expression used by the courts in English Law. It refers to a hypothetical reasonable person where it is necessary to decide whether a party has acted as a reasonable person would in a given situation. The person on the Clapham omnibus is a reasonably educated and intelligent but nondescript person, against whom the defendant’s conduct can be measured. The term was originally introduced into English law during the Victorian era, and is still an important concept in use in the UK and also in other places.
What must be resisted in all areas of society is the idea that understanding and knowledge is exclusively graspable to a small elite group of people. The notion that medicine (or any other area of knowledge) is only understandable, and therefore capable of being contributed to, by a rarefied subset of people empowered by a dominant position is a dangerously autocratic one. Using an analogy, I contend that it is not the CEO of the post office that delivers the post, it is the people sorting and carrying the mail throughout a whole process who are equally integral to bringing about the practical reality and how it is understood.
Therefore, the knowledge and understandings which are important are located throughout the different parts of the process and situated in different people, including the people who receive (or dont receive) the post.
Behaviour and how society reacts to the behaviour of individuals involves everyone, and the knowledge required to develop an understanding of any issues is located throughout the people and settings – it is diffuse. It is that local knowledge and first hand experience which is needed to develop any systemic understanding that is to have practical application. A pivotal flaw with a simplistic perspective of mental health is that the individual receiving the attentions of the clinician/institution are not taken as valuable/agencial and their social/environmental situation is often not acknowledged in forming understandings of their behaviour.
In medicine there are two initial inquiries made between the clinician and the patient – that of signs and symptoms. A medical sign is an objective measure of facts which are apparent to the outside world; a medical symptom is a subjective report of a feature of ailment. That is, it is a report from the subject which only the person experiencing it can directly observe. The subjective is commonly disregarded in psychiatry as fantasy, manipulative, co-incidence or circular reasoning; this is can manifest as diagnostic overshadowing.
In a democratic and open society, we must all endeavour to be that reasonable ‘Man On The Clapham Omnibus‘ as the way that institutions deal with behaviour needs to be understood as well as checked by the responsible citizen. There is a need to develop our analytical abilities and open dialogues so that when we are presented with complex situations, we can collectively and transparently reach towards an appropriate response.
Gaining experiential knowledge is imperative in this development of the reason and understanding we need as an irreplaceable partner to the institutional expertise.
Until I Have Walked In His Moccasins…
This is an examination of the work that David Rosenhan, Martin Seligman and others did to gain that experiential knowledge in how the individual encounters the psychiatric system. Rosenhan’s study was done in two parts; the first involved the use of 8 healthy associates (pseudopatients) including David Rosenhan himself. They went into 12 mental hospitals in five different states pretending to have a single symptom:
They heard voices that said ’empty’, ‘meaningless’ and ‘thud’. From the start, these pseudopatients acted the way ‘normal’ people did, but however, they were labelled as ‘crazy’ and treated as such.
Each person was admitted and diagnosed with psychiatric disorders. After their admission, the pseudopatients acted normally and told staff that they felt fine and no longer experienced any hallucinations. Martin Seligman and David Rosenhan assumed false names and wound up in the locked men’s ward of a state mental hospital in October of 1973.
All the ‘pseudopatients’ were forced to admit to having a mental illness and agree to taking anti-psychotic drugs as a condition of their release. The average time that the patients spent in the hospital was 19 days. All but one were diagnosed with schizophrenia “in remission” before their release.
The second part of the study involved a hospital administration challenging Rosenhan to send pseudopatients to their facility, whom its staff would then detect. Rosenhan agreed and in the following weeks out of 193 new patients the staff identified 41 as potential pseudopatients, with 19 of these receiving suspicion from at least 1 psychiatrist and 1 other staff member. In fact, Rosenhan had sent no one to the hospital.
Here is a quote from his paper: “At its heart, the question of whether the sane can be distinguished from the insane (and whether degrees of insanity can be distinguished from each other) is a simple matter: Do the salient characteristics that lead to diagnoses reside in the patients themselves or in the environments and contexts in which observers find them?.
At the time, the study concluded “It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals. The hospital itself imposes a special environment in which the meaning of behaviour can easily be misunderstood. The consequences to patients hospitalized in such an environment – the powerlessness, depersonalization, segregation, mortification, and self- labelling – seem undoubtedly counter-therapeutic.”
How do we make sense of these things ? Central to the philosophy of science is taking all perspectives rather than narrowing our field of vision to one – in this case the dominant medical model. It is important to be able to acknowledge, compare and contrast information giving it equal weight based upon its intrinsic qualities and not upon superficial aspects associated with the information. For example, it is not that a paper comes from the University of Cambridge or the University of Saskatchewan; it is irrelevant where the information is composed – what is important are qualities the information holds.
For these reasons it is irrelevant whether some information comes from within a university or outside – any judgement on this basis, or on the basis of where a university/institution is deemed to be in a league of prestige, is irrelevant to the true intellectual pursuit. These are heuristic cultural markers which can as readily create an ignorance as break one down.
In this presentation,we can find an analysis and critique of the Rosenhan experiment and first I will look at the discussion of the limitations:
- Subjective methods of data collection
- Didn’t ask for hospital approval/working with the hospital
- Limited release of details, one-sided arguments
- No objective video recording, only subjective data report
- “Setting them up to fail” – Rosenhan’s perception of hospital hierarchy and professional training
By way of a desire to stimulate conversation, I will offer devils advocate counterpoints around these important observations,. Firstly, the methods of data collection were subjective. This is a problem throughout the modern age of positivism.
“Positivism is the philosophy of science that information derived from logical and mathematical treatments and reports of sensory experience is the exclusive source of all authoritative knowledge, and that there is valid knowledge (truth) only in this derived knowledge”
This creates a number of solipsistic problems for fields of inquiry, particularly if we start discounting the value of the subjective – reports of the encounter with the reality from the subject themselves. This seems like a trust problem, and a dogmatic adherence to a mythical sense of the objective should be regarded as a source of unreliability in itself due to how carelessly it can rule out potentially valuable information. Various perspectives have been voiced objecting to the imposition of natural science methods on areas of inquiry when they are not suited; i.e. in the social sciences. One such argument can be found in the development of Existential Phenomenology.
The limitations of Rosenhan’s experiment which are raised above are also ones which could be raised about the psychiatric institutional situation itself, where patients are commonly not asked for approval, rationales and information is asymmetrically weighted to the institutions side, documentation and transparent open access conversations are not available for a right-to-reply process, and where a psychiatric setting might be regarded to set some people up to fail – should we be seeking to identify ‘normal behaviour’.
No matter which way the mental health puzzle is turned, it raises big questions, so maybe the best approach is not to be afraid to raise the questions but to collect them, bring them together, and construct them as a complex whole that needs to be taken as such – a whole rather than binaries….here are some alternative perspectives:
Some critiques by fellow scholars:
Reflection’s on Rosenhan’s “on being sane in insane places”:
- Rosenhan’s 1973 article,1 “On Being Sane in Insane Places,” was pseudoscience presented as science. Just as his pseudopatients were diagnosed at discharge as having “schizophrenia in remission,” so a careful examination of this study’s methods, results, and conclusions leads to a diagnosis of “logic in remission.” Rosenhan’s study proves that pseudopatients are not detected by psychiatrists as having simulated signs of mental illness and that the implementation of certain invalid research designs can make psychiatrists appear foolish. These rather unremarkable findings are irrelevant to the real problems of the reliability and validity of psychiatric diagnosis and only serve to obscure them. A correct interpretation of his own data contradicts his conclusions. There are purposes to psychiatric diagnosis that Rosenhan’s article ignores. His more recent suggestion that certain requirements be met prior to the adoption of a new psychiatric classification system is unrealistic.
- Lack of a control group: reconstructed an experiment to account for a control group questioning the removal of psychological labeling in favor of behavioral labeling.
Millon, T. (1975). Reflection’s on Rosenhan’s “on being sane in insane places”. Journal of Abnormal Psychology, 84(50): 456-461
- Criticizes Rosenhan’s emphasis on “sane” and “insane” definitions
- Thought Rosenhan’s own data could be used to come to opposite conclusions
- Pseudopatients did not act normal: normal person would have asked to be released because they lied to get in
Spitzer, R. L. (1975). On pseudoscience in science, logic in remission, and psychiatric diagnosis: A critique of Rosenhan’s ‘On being sane in insane places’. Journal Of Abnormal Psychology, 84(5), 442-452
Sane and insane: Constructions and misconstructions:
- Reviews the literature and concludes that concern about the existence of abnormality or the reality of the distinction between sanity and insanity is in large part philosophical puzzlement. The question whether insanity and its causes reside in people or in their environments relates to psychologists’ preferences among psychological theories differing in terminology and in assumptions about the usefulness of phenomenological and behavioral concepts. Psychodiagnostic concepts concern behavior in a given context. The reliability of psychodiagnostic classification is limited by knowledge of the laws of behavior and the training of clinicians. The unreliability of uselessness of any diagnostic method cannot be established by showing that pathological symptoms can be faked, and the effectiveness of psychiatric treatment ought not be judged solely by the impressions of those who know they are normal. (37 ref) (PsycINFO Database Record (c) 2014 APA, all rights reserved)
- Deconstructs Rosenhan’s shifting definitions and standards
- Despite limitations in methodology and weakness of data, Rosenhan makes broad inductive leaps
Farber, I. E. (1975). Sane and insane: Constructions and misconstructions. Journal Of Abnormal Psychology, 84(6), 589-620
- The stigma of mental illness is a profound social problem with a long history, and it is widely believed that diagnostic labels cause or contribute to such stigmatization. In an evaluation of labeling theory and the research that it prompted, special attention is devoted to a close examination of 3 widely cited studies (Langer & Abelson, 1974; Rosenhan, 1973a; Temerlin, 1968). Despite a pervasive confounding of diagnostic labels with the behaviors they denote, which increases the apparent influence of “mere labels,” the empirical literature does not support the putative negative effect. To more productively combat the stigma of mental illness, it is suggested that psychologists pursue community-based educational and contact-oriented programs, recognize the unavoidability and value of diagnoses, improve diagnostic reliability and validity, and compassionately convey diagnoses in the context of humane and effective treatments.
- Rosenhan shows little empirical evidence for labeling effect and other empirical data actually shows positives of labeling
- Rosenhan consistenly cited in texts and literature, but critiques rarely cited
- Behaviors cause stigma, not labels
Ruscio, J. (2004). Diagnoses and the Behaviors They Denote: A Critical Evaluation of the Labeling Theory of Mental Illness. The Scientific Review Of Mental Health Practice: Objective Investigations Of Controversial And Unorthodox Claims In Clinical Psychology, Psychiatry, And Social Work, 3(1), 5-22