Being Sane In Insane Places: The Rosenhan Experiment Changed Psychiatry. But Was It All It Seemed?

The paper – On Being Sane in Insane Places – told the story of eight “pseudopatients” admitted to psychiatric hospitals in the US, after falsely claiming to have psychiatric symptoms. 

“After calling the hospital for an appointment, the pseudopatient arrived at the admissions office complaining that he had been hearing voices. Asked what the voices said, he replied that they were often unclear, but as far as he could tell they said ’empty’, ‘hollow’, and ‘thud.’ The voices were unfamiliar and were of the same sex as the pseudopatient,” the paper, by Stanford professor and psychologist David Rosenhan, explains.

“Beyond alleging the symptoms and falsifying  vocation, and employment, no further alterations of person, history, or circumstances were made.”

The goal was to see how long these patients would remain inside the institutions after reporting the symptoms had ceased, as well as to experience life as a patient within them.

“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.”

According to the report by Rosenhan, all but one of the patients were diagnosed with schizophrenia, with one female pseudopatient who went to the only private hospital diagnosed with manic-depressive psychosis. 

On the wards, the pseudopatients described feelings of depersonalization as the staff, well-meaning though many they were, often treated them like they weren’t there at all. While there, the “patients” were prescribed nearly 2,100 pills, but were able to pocket or discard the pills down the toilet without catching the attention of staff. In the toilets, they would often report finding tablets left by real patients, who had been able to do the same.

“On the ward, attendants delivered verbal and occasionally serious physical abuse to patients in the presence of other observing patients, some of whom (the pseudopatients) were writing it all down,” Rosenhan, who himself was a pseudopatient, describes. “Abusive behavior, on the other hand, terminated quite abruptly when other staff members were known to be coming. Staff are credible witnesses. Patients are not.”

Therein lay the problem for Rosenhan. Once the patients had this label of a psychiatric illness, it was hard to shift. The patients were kept in the institutions for between seven and 52 days, with the average stay being 19, and with a diagnosis of being “in remission” from schizophrenia.

“We now know that we cannot distinguish insanity from sanity. It is depressing to consider how that information will be used,” Rosenhan wrote.

“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? How many have feigned insanity in order to avoid the criminal consequences of their behavior, and, conversely, how many would rather stand trial than live interminably in a psychiatric hospital – but are wrongly thought to be mentally ill? How many have been stigmatized by well-intentioned, but nevertheless erroneous, diagnoses? […] Psychiatric diagnoses are rarely found to be in error. The label sticks, a mark of inadequacy forever.”

As well as this, Rosenhan wondered how many people inside the institutions reacted perfectly rationally to their “bizarre” setting, with this rational behavior being viewed as further evidence of their insanity.

After the experiment was published, it caused an uproar across the country and a sense of distrust in psychiatry. In a follow-up experiment, an institution that claimed that this result could never happen under their watch was told they would be sent pseudopatients over a three-month period. They were asked to rate the likelihood that each patient who came into the hospital was a pseudopatient sent by Rosenhan. Forty-one imposters were identified by staff members, while 23 were suspected of being a pseudopatient by a psychiatrist, after which Rosenhan revealed he had sent no one to the hospital at all.

Psychiatrists were not all convinced by its findings, with some believing that the whole premise was flawed to begin with.

“If I were to drink a quart of blood and, concealing what I had done, come to the emergency room of any hospital vomiting blood, the behavior of the staff would be quite predictable,” neuroscientist Seymour S. Kety said of the experiment.

“If they labeled and treated me as having a bleeding peptic ulcer, I doubt that I could argue convincingly that medical science does not know how to diagnose that condition.”

Nevertheless, the study prompted changes in the profession, some of which were much needed. Prior studies, though they did not capture the attention of the public like Rosenhan’s, found similar problems with diagnoses, while there were other broader problems, such as classifying homosexuality as a mental illness, all of which was in urgent need of addressing.

“After prolonged discussion, the trustees of the [American Psychological Association] came to a decision,” a paper on the study explains. “The association would set up a task force charged with evaluating and reworking the Diagnostic and Statistical Manual (DSM) that had proved so grievously inadequate.”

The result was DSM–III, which introduced explicit diagnostic criteria for psychiatrists “aided by extensive work on constructing and validating the diagnostic criteria and developing psychiatric interviews for research and clinical uses”, as well as precise definitions of psychiatric disorders.

While the study caused progress towards better practices in psychiatry, in later years, questions have been raised about its validity. 

Rosenhan closely guarded the identity of the pseudopatients, and years later only one could be identified by investigative journalist Susannah Cahalan. This person’s results were not included by Rosenhan in the study as they were deemed not to have followed procedure, but when they were tracked down it was found that their accounts differed in key aspects from Rosenhan’s own accounts.

“Rosenhan […] claimed that, with the sole exception of the female treated in a private mental hospital, all of the study’s subjects were released with the diagnosis of ‘schizophrenia in remission’,” Andrew Scull writes in the History of Psychiatry. “No such notation exists in Underwood’s hospital chart, which is strikingly devoid of entries. The date of his discharge was recorded, but the space labelled ‘reason for discharge’ was left completely blank. Underwood recounts that when he wanted to be released, he simply told the staff that he wanted to go to attend a motor-cross tournament, and they readily acceded to his request.”

As well as not receiving the training or making copious notes on the ward he found himself in, the participant was also drugged during his time in hospital. Meanwhile, his hospital notes were found to counter claims made in the study. For Cahalan, the difference between the accounts, and lack of other accounts from other pseudopatients, begged the question whether they were an invention of Rosenhan himself.

“Rosenhan’s study played a major role in the complete re-orientation of American psychiatry. Very early in the 1980s, the psychoanalysis that had dominated it since World War II lost its hold over the profession, and soon withered away to almost nothing. In its place, biology and neuroscience came to rule the roost, and both profession and public came to adopt a radically different perspective on mental illness,” Scull concluded. “These were momentous changes. Remarkably, I suggest, the study that greatly helped to smooth the way to their acceptance was thoroughly dishonest, a scientific scam that stood largely unchallenged for nearly a half century. It is time for it to be revealed for what it is: a successful scientific fraud.”