This spring, three psychiatric nurses, employed by a consulting company, got themselves admitted as patients to a locked psychiatric ward in the Netherlands. The nurses, posing as patients, were acting as “mystery shoppers” in an effort to evaluate conditions at the hospital. Generally mystery shoppers are individuals employed to evaluate the quality of retail services or amass information about specific consumer goods. In this case, the service to be evaluated was psychiatric care. Such investigative work is reminiscent of past studies of psychiatric care that used pseudopatients to evaluate hospital conditions and challenge the validity of psychiatric diagnosis.

In this current study, staff at the hospital were informed that these mystery shoppers, or pseudopatients, would be visiting the facility, although the individuals posing as patients were not identified to the staff. According to the New York Times,

The undercover patients developed their fictive biographies in months of meetings with an acting coach and a psychotherapist. “Ronald,” for example, was a middle-aged man with a history of aggression problems, and after a supposed suicide attempt he was taken to De Riethorst by an actor playing his brother. To make their stories believable, the patients memorized details about where their children went to school or which supermarket they shopped at, and the psychotherapist advised them on how to present their given mental illness convincingly.

To ensure their safety, the fake patients checked in via text message every three hours, and they carried letters identifying them as plants.

Plans are underway to evaluate a further five to eight hospitals in this way in 2010.

Investigating psychiatric centre conditions from the inside is not a new development. In the late-nineteenth century the pioneering American female journalist Nellie Bly took on an undercover assignment at the Woman’s Lunatic Asylum on Blackwell’s Island (now known as Roosevelt Island), in New York. After getting herself committed and spending ten days in the asylum Bly was released. She went on to write of her experience for the New York World, before writing a book Ten Days in a Mad-House. After her experience Bly also advocated for improved asylum conditions.

Perhaps the best known instance of pseudopatient investigation is that conducted by psychologist David Rosenhan (pictured at left) in 1973. Published in Science as “On Being Sane in Insane Places” Rosenhan’s study challenged the validity of psychiatric diagnoses by having individuals simulate hallucinations to gain admittance to twelve psychiatric hospitals. Once admitted, the pseudopatients refrained from showing any futher psychiatric symptoms and informed psychiatric staff that they felt fine. Nonetheless, staff failed to detect a single fraud and continued to report psychiatric symptoms in these patients. A further study involved asking hospital staff to detect “fake” patients, a task staff were unable to do, identifying many genuine patients as frauds.

From his studies Rosenhan concluded that,

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 behavior can easily be misunderstood. The consequences to patients hospitalized in such an environment – the powerlessness, depersonalization, segregation, mortification, and self-labeling – seem undoubtedly counter-therapeutic. (Rosenhan, 1973)

Currently, the use of pseudopatients or “mystery shoppers” to evaluate standards of care is the subject of increasing discussion. Last year the American Medical Association considered issuing guidelines for the use of such “secret shopper patients” but stopped short of such measures. The ethics of using mystery shoppers for psychiatric care continues to be debated.

As recently reported in the New York Times.