The Horror of Unjust Psychiatric Hospitalization

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AFFIRMING PSYCHIATRY

Unjust Hospitalization? The Acadia Controversy

In a New York Times “hard hitting expose”¹ in September, former patients and employees accused Acadia Healthcare of hospitalizing psychiatric patients inappropriately and of keeping them in the hospital for financial reasons. “Acadia has lured patients into its facilities and held them against their will, even when detaining them was not medically necessary,” as the Times boldly summarized it. The allegations included 12 of the 19 states with Acadia psychiatric hospitals, with reports from “dozens of patients, employees, and police officers” who accused Acadia of unethical and illegal practices.²

Needless to say, the story is a big one. Acadia Healthcare is valued at $7 billion and administers 54 inpatient psychiatric hospitals nationwide. They are a major player in mental health and have joint ventures with more than 20 nonprofit health systems in addition to their own privately run hospitals. (I happen to work for one of those nonprofit systems.) The 2 reporters who authored the story have subsequently related that the story has generated more reader response than any other in their decades of reporting. They asserted they had only included stories of individuals who could provide independent corroboration of their experiences, and also claimed that they have subsequently heard from more employees and dozens of patients and families who wanted to share similar experiences.³

The content of the story is extremely serious. Involuntary psychiatric hospitalization due to a life- and health-threatening medical emergency is one thing. Keeping a well person locked in a hospital and taking away their privacy and autonomy is another thing altogether. It is horrific and grossly unjust. Even 1 such incident should arouse us all to the determination that such a thing will never happen again in our communities. There are few greater injustices in mental health than fraudulent hospitalization.

Unjust Hospitalization? The Rosenhan Study

The story about Acadia Healthcare reminds me of another story alleging fraudulent psychiatric hospitalization. This one occurred many years ago, created a public sensation, and inflicted long-term damage to the reputation of psychiatry. The story appeared in the prestigious journal Science in 1973 as a study called, “On Being Sane in Insane Places.”⁴ Its author, David Rosenhan, PhD, reported that individuals complaining of only minimal symptoms and otherwise acting normally were admitted to psychiatric hospitals and had difficulty obtaining a rapid discharge.

The details and conclusions of the study were unambiguous and damming. Participants appeared at psychiatric hospitals and reported “hearing voices,” which said only “empty,” “hollow,” and “thud.” Once they entered the hospital, participants ceased complaining of any symptoms and acted normally. Yet, their hospital stays stretched up to 52 days (with an average of 19) and they were almost all discharged with the diagnosis of “schizophrenia, in remission.”

The results of the experiment appeared to discredit psychiatry and, even worse, to portray psychiatric hospitalization as a capricious violation of our most basic civil rights. “We now know that we cannot distinguish insanity from sanity,” Rosenhan concluded. Psychiatric diagnoses themselves are “not useful or reliable.” Therefore, he wondered, who really knew how many individuals who were perfectly sane were forced into psychiatric institutions? Going by his own study, a scandalous number of individuals were being held in psychiatric hospitals, not due to medical necessity but due to the needs and whims of the hospitals and psychiatrists involved.

Not surprisingly, the publication triggered a firestorm of public controversy. Science published 9 pages of letters to the editor from psychiatrists, and the Journal of the American Medical Association published 2 editorials in support of Rosenhan’s conclusions. His work had a “massive impact on psychiatry.”⁵ It was “like a sword plunged into the heart of psychiatry.”⁶ Within weeks, the American Psychiatric Association Board of Trustees held an emergency meeting, which led (along with other considerations) to the task force that created the revolutionary DSM-III. Meanwhile, movements toward deinstitutionalization and the defunding of public psychiatric hospitals (begun a decade before) only picked up momentum in response.

Rosenhan’s study came during a time of deep doubts about the validity of psychiatry, and at a high point in the history of the antipsychiatry movement. Coming as it did on top of all the other critiques of mental health treatment, this single report provoked such outrage and embarrassment that it changed the course of psychiatry in the US and worldwide.⁷ At the very least, this tiny study (with 8 persons and sparse, spotty data) was the straw that broke the camel’s back of mid-century American psychiatry.

Rosenhan vs Acadia: Not the Same Thing

In one way, the Rosenhan study and the Acadia story form a neat parallel. Separated by 50 years of rapid change in mental health care, these reports portray the same sort of negligence and callousness about patients and involuntary hospitalization. But in another way, the 2 stories make for a set of stark contrasts. While superficially the same, the 2 narratives could not be more different in either origin or outcome.

Regarding the origin of these 2 stories, the New York Times story appears to be a good faith effort at thorough reporting on a troubling topic. The Rosenhan study, on the other hand, appears to be a fraud. The Rosenhan study, based on thorough investigation by 1 very dogged journalist,⁸ is based on very few data and strong indications that much of those data were fabricated. For instance, in order to gain psychiatric hospitalization for himself, Rosenhan went further than claiming to hallucinate only a few nonspecific words. He also claimed to hear other people’s thoughts, to be suicidal, and to have failed 2 trials of psychiatric medications as an outpatient. As for other participants in the “study,” careful efforts to locate them have identified just 2 graduate students. One was so positive about his hospitalization that Rosenhan excluded him from the study, and the other was readily released (after 9 days) when he told staff he wanted to go participate in a motocross tournament. Though Rosenhan promised to explain all such details in a full-length book (for which he received a hefty publisher’s advance), the book never came.

What about the outcome of the 2 studies? The Rosenhan study, one of the most influential in the history of psychiatry, was fraudulent and yet had a titanic effect. The New York Times story, on the other hand, appears to have been carefully reported and has as yet generated a very limited response. While some other news outlets have passed on The New York Times reporting, further stories have not emerged. Online, the most interest has come from law firms seeking potential lawsuits⁹ and business sites reporting on the investment implications.¹⁰ Several law enforcement agencies are pursuing investigations,¹¹ but there has been no public outcry. Compared with the Rosenhan study, the public reaction has been muted—tepid at best.

Perhaps the general public has been right about its nonreaction. Perhaps this is an isolated problem that will be addressed in the legal system. Perhaps the public is now sure that psychiatric medical practice is legitimate, and so this story does not stir up a wider debate about the legitimacy of psychiatric treatment. Perhaps the public now recognizes that psychiatry rests on firm foundations, regardless of the behavior of some mental health corporation. Perhaps we (as a culture) have bigger problems to worry about right now, with war abroad and an election at home.

But Where Are All the Psychiatrists?

As a psychiatrist, all these attitudes seem fine to me personally. But what does not seem fine to me is the apparent lack of reaction by psychiatrists and other mental health professionals. Regardless of how worried the general public is about inappropriate psychiatric hospitalization, we as a community should be very worried. If the public yawns and moves on to more exciting stories, we psychiatrists ought to stand up and demand better.

I do not want to overreact to the Acadia controversy, which is why I think of the Rosenhan study. The Rosenhan study reminds us that it is easy to jump to wrong conclusions, especially about complicated and high-pressure decisions that doctors make about psychiatric hospitalization.¹² On the other hand, I do not want to underreact. I do not want to turn the other way if patients are being falsely locked up in the name of psychiatry. So, I ask: Where is the accountability here? Where is psychiatry’s public demand for an answer to these allegations? Isn’t it part of the duty of psychiatrists to look out for the interests of all those experiencing mental illness? Will we not advocate for them? What about our leaders in organized psychiatry, government, and academia? Even if we do not rush to judgment, should not we at least demand answers?

Should the allegations of the New York Times story prove to be true, then it is the duty of all psychiatrists to demand better. It is our duty, as individuals and a group, to demand accountability and change. It is our sacred duty to speak up for the needs and interests of our patients, and we should be every bit as energetic about defending their rights to refuse treatment as we are in advancing their right to access treatment. Anything less amounts to a kind of passive corruption of our profession, turning the other way to avoid facing inconvenient and painful wrongs within our field. Anything other than an energetic response to such reports implicitly tells the public that we as psychiatrists are not particularly interested in the way patients are treated. Needless to say, any such implication does great long-term harm to psychiatry and the cause of mental health in our country. And so, I wonder: How will psychiatrists, as champions of those with mental illnesses, respond? More fundamentally, will psychiatrists respond at all?

Dr Morehead is a psychiatrist and director of training for the general psychiatry residency at Tufts Medical Center in Boston. He frequently speaks as an advocate for mental health and is author of Science Over Stigma: Education and Advocacy for Mental Health, published by the American Psychiatric Association. He can be reached at dmorehead@tuftsmedicalcenter.org.

References

1. Rogers S. Held involuntarily in a psychiatric hospital. New York Times. September 15, 2024. Accessed October 28, 2024. https://www.nytimes.com/2024/09/15/opinion/involuntary-acadia-psychiatric-hospital.html

2. Silver-Greenberg J, Thomas K. How a leading chain of psychiatric hospitals traps patients. New York Times. September 1, 2024. Accessed October 28, 2024. https://www.nytimes.com/2024/09/01/business/acadia-psychiatric-patients-trapped.html

3. Lindner E. Exposing a hospital chain’s disturbing practices. New York Times. September 9, 2024. Accessed October 28, 2024. https://www.nytimes.com/2024/09/09/insider/acadia-healthcare.html

4. Rosenhan DL. On being sane in insane places. Science. 1973;179(4070):250-258.

5. Scull A. Rosenhan revisited: successful scientific fraud. Hist Psychiatry. 2023;34(2):180-195.

6. Spitzer RL, Lilienfeld SO, Miller MB. Rosenhan revisited: the scientific credibility of Lauren Slater’s pseudopatient diagnosis study. J Nerv Ment Dis. 2005;193(11):734-739.

7. Decker HS. A crisis in American psychiatry and the development of DSM-III. Oxford Research Encyclopedia of Psychology. March 25, 2021. Accessed October 28, 2024. https://oxfordre.com/psychology/display/10.1093/acrefore/9780190236557.001.0001/acrefore-9780190236557-e-631

8. Cahalan S. The Great Pretender. Grand Central Publishers; 2019.

9. Acadia Healthcare Company sued for securities law violations; investors should contact Block & Leviton to learn how they might recover their losses. News release. October 18, 2024. Accessed October 28, 2024. https://www.accesswire.com/932891/acadia-healthcare-company-sued-for-securities-law-violations-investors-should-contact-block-leviton-to-learn-how-they-might-recover-their-losses

10. Larson C. Acadia Healthcare faces scrutiny over patient holds. Behavioral Health Business. September 3, 2024. Accessed October 28, 2024. https://bhbusiness.com/2024/09/03/acadia-healthcare-faces-scrutiny-over-patient-holds/

11. Silver-Greenberg S, Thomas K. Veterans Dept. investigating Acadia Healthcare for insurance fraud. New York Times. October 18, 2024. Accessed October 28, 2024. https://www.nytimes.com/2024/10/18/business/acadia-healthcare-veterans-affairs-investigation.html

12. Morehead D. What the public does not know about involuntary hospitalization. Psychiatric Times. 2023;40(5).