Bernard Weiner's Process Critique of 'On Being Sane in Insane Places'
Overview of Bernard Weiner’s Critique
Bibliographic Information: Bernard Weiner's article, "'On Being Sane in Insane Places': A Process (Attributional) Analysis and Critique," was published in the Journal of Abnormal Psychology, , Vol. , No. , pages .
Central Objective: Weiner employs principles of attribution theory and logical analysis to critique David Rosenhan’s report, which claimed that sanity cannot be distinguished from insanity in mental hospitals.
Core Counter-Argument: Weiner argues that the data reported by Rosenhan regarding hospitalization length and diagnostic labels actually reflect logical inferences that would be drawn in any attributional endeavor, rather than a failure unique to psychiatry.
The "Sins" of Rosenhan's Study: * Sins of Omission: Rosenhan failed to examine the relationship between diagnostic change and treatment efficacy. Additionally, he failed to examine the actual inferential processes used by diagnosticians. * Sins of Commission: Rosenhan incorrectly believed that a purely behavioral diagnosis would solve the issues raised and falsely claimed that errors in psychiatric diagnosis are qualitatively different from those in general medicine.
Context of the Symposium (Editor’s Note)
Academic Climate: Leonard D. Eron (Editor) notes that diagnosis, classification, and labeling (e.g., the DSM II) have come under attack from various groups, including nondirective therapists, behavior modifiers, and humanistic psychologists.
Rosenhan’s Impact: Rosenhan’s field experiment appeared to corroborate suspicions that psychiatric diagnosis is unreliable, invalid, and socially destructive.
Symposium Structure: This critique by Bernard Weiner is the first in a series of five papers. It is followed by responses from: * Robert Spitzer: A psychiatrist involved in DSM II and lead for DSM III (projected for ). * Sidney Crown: A psychiatrist and psychologist practicing in England. * Theodore Millon: A Consulting Editor and consultant to the APA committee. * David Rosenhan: Providing a response to the critiques. * I. E. Farber: Providing a final summary/evaluation in the December issue.
Summary of the Rosenhan (1973) Procedure
Admission Strategy: Pseudopatients sought voluntary admission by reporting a single symptom: hearing voices that said "empty," "hollow," and "thud."
Symptom Interpretation: The symptoms were intended to evoke existential concerns regarding the meaninglessness of life.
Post-Admission Behavior: Once admitted, pseudopatients ceased faking symptoms, behaved normally, and informed staff they no longer experienced hallucinations.
Findings: Rosenhan reported that the "normals" were "not detectably sane." The average hospitalization length was \,days. Upon discharge, the diagnosis was typically Schizophrenia "in remission."
Rosenhan’s Conclusion: He argued that labeling dominates psychiatric assessment; once tagged as schizophrenic, a patient’s behavior is forever colored by that label.
Attribution Theory Principles Applied to Diagnosis
Definition of Attribution Theory: A "naive psychology" of common sense concerned with perceptions of causality (the reasons why events occur). It focuses on internal (personal) vs. external (environmental) causality.
Information Cues (Kelley, 1967): * Consistency: The reliability of an action. Pseudopatients described hallucinations as occurring "often," suggesting they were relatively enduring. * Social Consensus: Compatibility with others' behavior. Since normals do not typically hear voices, and the specific content of these voices had "never been reported in the literature," the consensus was low.
Inference of Internal Locus: High consistency coupled with low consensus leads an observer to believe the cause of a behavior resides within the person (internal attribution). Thus, the cause of the hallucination is ascribed to an enduring property of the individual rather than the environment.
Diagnostic Logic: Weiner argues the leap to a schizophrenia diagnosis was not just based on hallucinations but also on the patient’s volition (seeking help) and observed "concomitant nervousness." If hallucinations covary with other maladaptive traits, it is logical for a diagnostician to infer those traits or anticipate their onset.
Comparison to General Medicine
Medical Analogy (The Seizure Case): Weiner argues that if a patient reports frequent seizures (comparable to hallucinations), a doctor might hospitalize them for observation. Even if tests (EEG, brain scans) are normal and no seizures occur in the hospital, the doctor may discharge the patient with a label like "idiopathic epileptic" and place them on medication.
Symptom Disappearance: In both the psychiatric and medical scenarios, the temporary absence of a symptom in a controlled environment does not logically prove the underlying condition is gone; it often suggests the condition is simply not currently active (in remission).
The Logic of Labels and Label Changes
Assimilation vs. Accommodation: Weiner acknowledges that labels cause staff to assimilate new information (e.g., interpretation of pacing as anxiety). However, the fact that students were eventually discharged proves that accommodation (change in the staff's cognitive structure) did occur.
Variability of Symptoms: Weiner notes that "the insane are not always insane." Because symptoms are unstable, it takes time for an observer to distinguish a true change from a temporary lull in symptoms.
Temporal Specifics: The mean stay was \,days. Weiner notes that if one extreme case of a private hospital stay (\,days) is excluded, the mean time is \,days. This is not a "lengthy period of exposure" in the context of chronic mental illness.
The Search for Causes and Causal Inferences
Heider (1958): Finding causes makes the world predictable and controllable. Diagnosticians naturally search for the "why" behind an illness.
Case Histories: Rosenhan critiqued a case summary where a patient's shifting relationship with parents was used as a cause for the illness. Weiner argues that even if the history is "normal," the diagnostician is trained to look for correlations (covariations) between early life and later illness.
Twin Study Analogy: If a pseudopatient truthfully reported a monozygotic twin with psychosis, a diagnostician would logically infer a genetic factor. Weiner contends this is a rational causal inference regardless of whether the specific patient is currently "faking."
Analysis of Discharge Labels ("In Remission")
Treatment Efficacy: Weiner posits that diagnostic labels change most readily when an effective treatment is applied (e.g., pneumonia treated with antibiotics).
Stability of Structure: For conditions like idiopathic epilepsy or schizophrenia, where specific structural cures are absent, labels remain "sticky" because the underlying structure is perceived as stable.
Readmission Stats: Data show that individuals with a prior diagnosis of schizophrenia have a significantly higher likelihood of readmission than the general population. While labeling might play a role, it is also logical to conclude the "in remission" group is genotypically different from the "normal" group.
Critique of the Behavioral Focus
Rosenhan’s Proposal: Rosenhan suggested limiting terminology to specific behaviors (e.g., "hallucinating") to avoid the stigma of a diagnosis.
Weiner’s Rebuttal: Simply changing the name to a behavioral description does not solve the underlying diagnostic problem. It fails to answer: 1. When is a patient officially "no longer hallucinating"? 2. Is a person who has hallucinated in the past identical to one who has never hallucinated? 3. How do we differentiate the two groups if the former is more likely to hallucinate again?
Failure to Test the Core Hypothesis
The Real Question: Rosenhan’s data shows fakers can get into hospitals; it does not prove that the sane cannot be distinguished from the insane.
Proposed Test: Weiner suggests placing diagnosed schizophrenics and matched normals in a ward together. He asserts that even unsophisticated diagnosticians would achieve highly significant "hit rates" in identifying who is which, especially with prolonged observation.
Summary Conclusion of Weiner’s Analysis
Rationality of Diagnosticians: Weiner concludes that psychiatric staff acted rationally based on five attributional points: 1. Internal attributions are made for unique/consistent behavior. 2. Unstable prior history makes new situations hard to discriminate quickly. 3. Causal searching is a fundamental human drive directed by psychiatric training. 4. Untreated causes lead to expectations of symptom reappearance (remission logic). 5. Covariation (symptoms outside vs. no symptoms inside) suggests the hospital setting is the external cause of temporary suppresses of symptoms.
Validation of Rosenhan's Credits: Weiner concedes Rosenhan is correct about: * Preference for single diagnoses over alternative hypotheses. * Inaccurate summaries due to memory distortion (Bartlett, ). * Immediate perceptions being biased by prior labels.
Final Verdict: Most of Rosenhan's criticisms are unfounded or apply equally to all medical/inferential fields.