psychology experiment mental hospital

Rosenhan (1973) Experiment – ‘On being sane in insane places’

Angel E. Navidad

Philosophy Expert

B.A. Philosophy, Harvard University

Angel Navidad is an undergraduate at Harvard University, concentrating in Philosophy. He will graduate in May of 2025, and thereon pursue graduate study in history, or enter the civil service.

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BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul McLeod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

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Key Takeaways

• Between 1969 and 1972, Prof. David Rosenhan, a psychiatrist at Stanford University, sent eight pseudo-patients to 12 psychiatric hospitals without revealing this to the staff. None of the pseudo-patients had any symptoms or history of mental disorders.
• In all 12 instances, pseudo-patients were diagnosed with a mental disorder and hospitalized. In no instance was the misdiagnosis discovered during hospitalization.
• In some of the 12 hospital stays, pseudo-patients observed significant deficits in patient-staff contact.
• In a follow-up study at one hospital, Prof. Rosenhan asked staff to rate patients seeking admission on a 10-point scale, from “highly likely to be a (healthy) pseudo-patient” (1 or 2) to “least likely to be a pseudo-patient.” Staff were aware of the previous study and told one or more pseudo-patients would be sent their way unannounced. Forty-one (21.24%) of 193 patients received a 1 or 2 score. No pseudo-patients were, in fact, sent.
• These findings provided convincing evidence against the accuracy and validity of psychiatric diagnoses.
• The current state of psychiatric diagnoses is still broadly at odds with recent neurological findings, leading to uncertainty regarding their accuracy. Several interventions are proposed or underway to correct this. None counts with widespread support yet.

In the years leading to 1973, professor of law and psychology at Stanford University, Mr. David L. Rosenhan, sought to investigate whether psychiatrists actually managed to tease normal and abnormal psychological states apart. As Prof. Rosenhan put it:

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? Rosenhan 1973, p. 251.

The recent publication of the APA’s DSM II in 1968 underscored the popular belief among practitioners that psychiatric conditions could be distinguished from each other and from normal psychiatric good health, much like physiological diseases can be distinguished from each other and from good health itself.

In the 1960s, an increasing number of critiques of this belief emerged, arguing that psychiatric diagnoses were not as objective, valid, or substantive as their physiological counterparts, but were rather more like opinions and, therefore, subject to implicit biases even when propounded by competent psychiatrists or psychologists.

Prof. Rosenhan set out to settle the matter empirically. He resolved to have people with no current or past symptoms of serious psychiatric disorders admitted to psychiatric hospitals.

If their lack of abnormal psychiatric traits were always detected, he reasoned, we would have good evidence that psychiatrists were able to tell normal from abnormal psychiatric states. Psychiatric normality, it was presumed, was distinct enough from abnormality to be readily recognized by competent practitioners.

Nine participants, including Prof. Rosenhan, were recruited. All were deemed to have no present or past symptoms of serious psychiatric disorders. Each gained admission to one of nine distinct hospitals.

In eight cases, admittance was gained without the hospital’s staff’s foreknowledge.

In Prof. Rosenhan’s case, the hospital administrator and chief psychologist knew of their hospital’s inclusion in the study. Data from Prof. Rosehan’s stay or stays were not excluded.

Data from one participant were excluded due to a protocol breach (falsification of personal history beyond that of name, occupation, and employment). Between one and four of the remaining eight participants thereafter gained further admission to four other hospitals.

Data from 12 hospital stays, at 12 different hospitals, by eight participants were included in the study. Five of the included participants were male adults; three were female adults. Five worked or were engaged in psychology or psychiatry.

One of the 12 hospitals was privately funded; the rest received public funding. An undisclosed number of hospitals were “old and shabby” or “quite understaffed.”

The 12 hospitals were located in five states in the East and West coasts of the US.

The admittance, stay, and discharge process was as follows —

• Participants set up an appointment at one of the hospitals under a false name, occupation, and employment.
• At the appointment, participants complained they had been hearing unfamiliar, often unclear voices which seemed to come from someone of their own sex and which seemed to say “empty,” “hollow,” and “thud;” participants provided truthful information on all matters other than name, occupation, and employment, with names, occupations and employment information of friends and family changed to fit with the participant’s assumed name, occupation, and employment.
• On admittance, participants stopped simulating any psychiatric symptoms, though there were a few cases of “brief[,] … mild nervousness and anxiety” which “abated rapidly.”
• In psychiatric wards, participants engaged with patients and staff as they would normally with colleagues in everyday life. When asked by staff how they were feeling, participants indicated that they were fine and that they no longer experienced symptoms. They received but did not ingest their prescribed medication, except in one or two instances. They recorded their observations regarding the ward, staff, and patients.
• Participants were discharged when the hospital’s staff responsible for their stay saw fit. A writ of habeas corpus was kept on file for each participant an undisclosed number of days after the study began.
• Between one and four participants repeated this process at four other hospitals.

Two further protocol breaches, which did not result in exclusion, were reported. One participant revealed their occupation in psychology to staff members. Another “attempted a romance with a nurse,” revealed their occupation in psychology to staff members, and provided psychotherapy to fellow patients.

Nursing reports for an undisclosed (“most”) number of the 12 stays were obtained from the hospitals. Coding protocols and training were not reported.

Depersonalization Observations

At four of the 12 hospitals, staff responses to patient-initiated contact were also investigated.

During their stay, four participants approached staff members with a request of the form, “Pardon me, Mr. [or Dr. or Mrs.] X, could you tell me when I will be eligible for grounds privileges?” or “… when I will be presented at the staff meeting?” or “… when I am likely to be discharged?”

No staff member was approached more than once a day. Staff responses were recorded.

Criteria for response classification, recording protocols, and pre-study training were not disclosed.

At six of the 12 hospitals, patients’ daily contact with staff (in minutes), from the initial admission interview to the final discharge meeting, inclusive of both, was measured.

Measurement protocol and pre-study training were not disclosed.

Non-existent Imposter Study

A second study was arranged at a research and teaching hospital in an undisclosed location. Its staff were aware of the first study’s results.

They were informed that one or more persons, previously instructed to simulate at least one symptom of a psychiatric disorder, i.e., a pseudo-patient, would attempt to gain admission within the following three months.

Staff were asked to rate each patient seeking admission on a ten-point scale, from most likely to be a pseudo-patient (1 or 2 on the scale) to least likely. No participants were, in fact, sent to the hospital. Scores were obtained for 193 patients.

No patients were independently evaluated by Prof. Rosenhan or affiliated researchers. No scoring protocol nor pre-study training was reported.

In eleven instances, participants were admitted on a diagnosis of schizophrenia and discharged with a diagnosis of schizophrenia in remission.

In one instance, a participant was admitted on a diagnosis of manic-depressive psychosis; their discharge diagnosis was not reported. Stays ranged from 7 to 52 days, with a mean of 19 days. Standard deviation was not disclosed.

Nursing reports “uniformly indicate[d] that the [participants] were “friendly,” “cooperative,” and “exhibited no abnormal indications.” Coding results and statistical significance were not reported.

Participants’ visitors “could detect no serious behavioral consequences [of hospitalization in participants].” No information on data collection from said visitors, nor statistical analyses on these data, were reported.

The errant diagnosis on admission, Prof. Rosenhan noted, could simply be attributed to physicians’ strong bias towards type II errors. As he put it:

The reasons [for this strong bias] are not hard to find: it is clearly [less] dangerous to misdiagnose illness than health. Better to err on the side of caution, to suspect illness even among the healthy. Rosenhan 1973, p. 252

Errant diagnoses after admission, once participants had dropped all pretense of psychiatric disturbance, were more surprising and troubling to Prof. Rosenhan.

It seemed that once diagnosed with an aberrant psychiatric trait, participants were unable to escape the diagnosis, despite their having dropped the farce immediately upon admission.

It was presumed that a competent practitioner, upon being well-acquainted with participants, would eventually identify the initial diagnosis as a type II error  and subsequently correct it. No such correction took place in any of the 12 hospital stays.

The admission diagnoses seemed, in Prof. Rosenhan’s words, “so powerful that many of the [participants’] normal behaviors were overlooked entirely or profoundly misinterpreted.”

Prof. Rosenhan offered the following explanation for this surprising result. Persons not diagnosed with a mental illness, nonetheless, at times, exhibit “aberrant” behavior, like pacing around or frequently writing. Without a psychopathic diagnosis, these behaviors are attributed to something other than psychopathy, like being bored or being a writer.

But in the presence of such a diagnosis, these behaviors are more often attributed to psychopathy, as they were in two instances in the study than not. This attribution, in turn, only reinforces the diagnosis, thereby fixing any type II errors in place.

The fact that such behaviors are often attributed to psychopathies in diagnosed patients, Prof. Rosenhan argued, points more to the “enormous overlap in behaviors of the sane and the insane” than to the competence of psychiatrists, psychologists, or nurses.

On initiating contact with staff members, participants were overwhelmingly not paid any attention by psychiatrists, nurses, or attendants at four of the hospitals. Inter-hospital differences were not deemed significant and were not reported. Statistical differences and significance were not reported.

Six participants, totaling 129 days of hospitalization, measured their daily contact with staff. Daily contact with psychiatrists, psychologists, residents, and physicians ranged from 3.9 to 25.1 minutes, with a mean of 6.8 minutes. Disaggregated data, contact time with other staff, statistical differences, statistical significance, and standard deviation were not reported.

Contact, Prof. Rosenhan notes, indicates “concern and individuation,” its lack, “avoidance and depersonalization.” Staff’s overwhelming avoidance of patients, Prof.

Table 1. Self-initiated contact by participants with psychiatrists, nurses, and attendants. Adapted from Table 1 of the 1973 Rosenhan study, p. 255. Copyright (c) 1973 AAAS.

Rosenhan notes resulted in an “overwhelming sense of powerlessness which invades the individual as he is continually exposed to the depersonalization of the psychiatric hospital.”

The import of this practice, and the powerlessness it elicited, Prof. Rosenhan argued, could be readily inferred.

[H]ow many patients might be “sane” outside the psychiatric hospital but seem insane in it_—not because craziness resides in them, as it were, but because they are responding to a bizarre setting … ? — Rosenhan 1973, p. 257

Of the 193 scores obtained, 41 patients were judged highly likely to have been a pseudo-patient by at least one staff member, 23 by at least one psychiatrist, and 19 by one psychiatrist and at least one other staff member. No pseudo-patients were sent by Prof. Rosenhan or affiliated researchers.

Of the 41 patients judged highly likely to have been pseudo-patients —

• Either they did not, in fact, have any abnormal psychiatric symptoms and were correctly judged pseudo-patients by the staff;
• Or they did, in fact, have abnormal psychiatric symptoms (as presumed by the fact that they wished to be admitted), in which case the staff misdiagnosed them as pseudo-patients and thereby made a type I error in seeking to avoid type II errors.

In either case, Prof. Rosenhan pointed out the results indicated “that the tendency to designate sane people as insane can be reversed when the stakes (in this case, prestige and diagnostic acumen) are high.”

But it is notable that, in the second case, the price for avoiding type II errors might just be a higher type I error rate.

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 meanings of behaviour can easily be misunderstood. Rosenhan 1973, p. 257

Both practitioners and patients, the study reveals, seem caught in Catch-22s. Out of an excess of caution, psychiatrists and psychologists strongly tend towards type II errors on admission. But once said error is made, there’s a slim chance it will be caught during in-patient treatment.

On the other hand, should practitioners try to avoid type II errors from sticking to patients, they run the risk of equally damaging type I errors. On the other hand, patients, once admitted, are likely to develop psychopathies, whether they truly had any on admission or not, given the bizarre setting they are thrust into on admittance.

But should they seek to avoid the setting — the psychiatric hospital — they run the risk of an untreated mental illness getting worse, in the case they truly suffered one, to begin with.

A way out for practitioners and patients is not immediately clear to Prof. Rosenhan. Two promising directions he noted were —

• The avoidance of psychiatric diagnoses of the form encouraged by the DSM II in favor of diagnosing patients with “specific problems and behaviors” so as to provide treatment outside of psychiatric hospitals and to keep any diagnostic label from “sticking” to a patient;
• Increasing “the sensitivity of mental health workers and researchers to the Catch-22 position of psychiatric patients,” for e.g., by having them read pertinent literature.

Other Conclusions

A good number of the study’s shortcomings should give us pause when drawing conclusions. Sampling, randomization, control, blinding, and statistical analysis methods were largely unreported and so likely not to have been up to present-day standards.

Participant training was not reported and so likely not undertaken before the study. No data on participants’ visitors and their evaluations were reported.

Study flaws aside, the observed effects were large enough to likely be clinically, and easily statistically, significant —

• All 12 hospitalizations resulted in type II errors both on admission and discharge;
• 2.94% of the 1,468 recorded participant-initiated interactions with psychiatric staff resulted in verbal engagement with the participant;
• 9.84% of the 193 patients scored at a research and teaching hospital were deemed very likely to have had no psychopathic traits on admission by both a psychiatrist and at least one other staff member.

The findings pointed to an unacceptable preponderance and persistence of type II errors by competent psychiatric staff and to the danger of psychiatric harm to patients posed by then-current psychiatric practices.

Critical Evaluation

Was the sample representative.

Field experiments have the major advantage of being conducted in a real environment and this gives the research high ecological validity. However, it is not possible to have as many controls in place as would be possible in a laboratory experiment.

Participant observation allows the collection of highly detailed data without the problem of demand characteristics. As the hospitals did not know of the existence of the pseudopatients, there is no possibility that the staff could have changed their behavior because they knew they were being observed.

However, this does raise serious ethical issues (see below) and there is also the possibility that the presence of the pseudopatient would change the environment in which they are observing.

Strictly speaking, the sample is the twelve hospitals that were studied. Rosenhan ensured that this included a range of old and new institutions as well as those with different sources of funding.

The results revealed little differences between the hospitals. This suggests that it is probably reasonable to generalize from this sample and suggest that the same results would be found in other hospitals.

Prof. Rosenhan’s 1973 paper does not detail —

• How his sample size was determined, nor how his sample was selected;
• The study’s inclusion/exclusion criteria;
• How past or present serious psychiatric symptoms were diagnosed, nor by whom;
• Whether past or present mild to moderate psychiatric symptoms were diagnosed, nor by whom;
• How hospitals were selected;
• How participants were matched with false names, occupations, and employment information;
• How participants were matched with hospitals.

What type of data was collected in this study?

There is a huge variety of data reported in this study, ranging from quantitative data detailing how many days each pseudopatient spent in the hospital and how many times pseudopatients were ignored by staff to qualitative descriptions of the experiences of the pseudopatients.

One of the strengths of this study could be seen as the wealth of data that is reported and there is no doubt that the conclusions reached by Rosenhan are well illustrated by the qualitative data that he has included.

Was the study ethical?

Strictly speaking, no. The staff were deceived as they did not know that they were being observed and you need to consider how they might have felt when they discovered the research had taken place.

Was the study justified? This is more difficult as there is certainly no other way that the study could have been conducted and you need to consider whether the results justified the deception. This is discussed later under the heading of usefulness.

What does the study tell us about individual/situational explanations of behavior?

The study suggests that once the patients were labeled, the label stuck. Everything they did or said was interpreted as typical of a schizophrenic (or manic-depressive) patient. This means that the situation that the pseudopatients were in had a powerful impact on the way that they were judged.

The hospital staff was not able to perceive the pseudopatients in isolation from their label and the fact that they were in a psychiatric hospital, and this raises serious doubts about the reliability and validity of the psychiatric diagnosis.

What does the study tell us about reinforcement and social control?

The implications of the study are that patients in psychiatric hospitals are ‘conditioned’ to behave in certain ways by the environments that they find themselves in.

Their behavior is shaped by the environment (nurses assume that signs of boredom are signs of anxiety, for example) and if the environment does not allow them to display ‘normal’ behavior, it will be difficult for them to be seen as normal.

Labeling is a powerful form of social control. Once a label has been applied to an individual, everything they do or say will be interpreted in the light of this label.

Rosenhan describes pseudopatients going to flush their medication down the toilet and finding pills already there. This would suggest that so long as the patients were not causing anyone any trouble, very few checks were made.

Was the study useful?

The study was certainly useful in highlighting the ways in which hospital staff interact with patients. There are many suggestions for improved hospital care/staff training that could be made after reading this study.

However, it is possible to question some of Rosenhan’s conclusions. If you went to the doctor falsely complaining of severe pains in the region of your appendix and the doctor admitted you to the hospital, you could hardly blame the doctor for making a faulty diagnosis.

Isn’t it better for psychiatrists to err on the side of caution and admit someone who is not really mentally ill than to send away someone who might be genuinely suffering?

This does not entirely excuse the length of time that some pseudopatients spent in the hospital acting perfectly normally, but it does go some way to supporting the actions of those making the initial diagnosis.

Outlook of Diagnostic Accuracy

Psychiatric diagnoses continue to be made as they were at the time of Prof. Rosenhan’s study — largely on the basis of inferences drawn from patient self-reports and practitioners’ observations of patient behavior and largely on the basis of criteria set by the APA’s DSM. This suggests two sources of diagnostic problems in psychiatry —

• the evidence used to reach a diagnosis, and
• the criteria by which said evidence is evaluated in reaching a diagnosis.

The evidence available to psychiatrists and psychologists in diagnosing mental disorders has long been much sparser than that available to other physicians.

There have been advances in the etiology of mental disorders — the relevant MeSH term now counts over 370,000 articles in PubMed, 4.00% of which are RCTs, meta-analyses, or systematic reviews.  This growing corpus has yet to yield diagnostic tests, though.

In 2012, a group of three psychiatrists, led by Prof. Shitij Kapur of King’s College London, argued that a number of reasons were responsible for this lag, including widespread methodological shortcomings and the DSM’s classification itself.

On that note, the DSM has left much to desire. As Mr. Thomas Insel, former director of the NIMH, put it —

Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. Insel 2013, second para.

Since its first publication in 1958, the DSM has reached a classification of mental disorders without data on their biological underpinnings.

Its nosology is increasingly at odds with aetiological research, which increasingly suggests that mental disorders are rather gradual deviations from typical brain functions.

This, in turn, suggests that mental disorders should be classified as points or areas on spectra rather than the neat categories propounded by the DSM. One effort at building such a nosology was begun by the NIMH in 2010.

The project dubbed the RDoC, is still confined to research, and is not ready for clinical application.

The myriad problems in psychiatric research and practice preclude any consensus on the accuracy of psychiatric diagnoses and are likely to do so until they are resolved.

The field has not converged on a corrective program, though there exist a number of such programs competing for widespread support.

What did the Rosenhan study suggest in 1973?

The Rosenhan study in 1973 suggested that psychiatric diagnoses are often subjective and unreliable. Rosenhan and his associates feigned hallucinations to get admitted to mental hospitals but acted normally afterward.

Despite this, they were held for significant periods and treated as if they were genuinely mentally ill. The study highlighted issues with the validity of psychiatric diagnosis and the stigma attached to mental illness.

What did the classic study by Rosenhan reveal about the power of labels that are applied to individuals?

The classic study by Rosenhan showed the influential effect of labels on individuals, specifically psychiatric labels. By pretending to have hallucinations, mentally healthy participants gained admission to psychiatric hospitals.

The study demonstrated that once labeled as mentally ill, their behaviors were consistently interpreted in that context, even when they stopped simulating symptoms.

Adam, D. (2013). On the spectrum. Nature, 496(7446), 416.

Insel, T. .R. (2013, 29th April). Transforming Diagnosis. [Weblog]. Retrieved 4 November 2020, from https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2013/transforming-diagnosis.shtml

Kapur, S., Phillips, A. G., & Insel, T. R. (2012). Why has it taken so long for biological psychiatry to develop clinical tests and what to do about it?. Molecular psychiatry, 17 (12), 1174-1179.

Rosenhan, D. L. (1973). On being sane in insane places. Science, 179( 4070), 250-258.

Sharp, C., Fowler, J. C., Salas, R., Nielsen, D., Allen, J., Oldham, J., Kosten, T., Mathew, S., Madan, A., Frueh, B. C., & Fonagy, P. (2016). Operationalizing NIMH Research Domain Criteria (RDoC) in naturalistic clinical settings. Bulletin of the Menninger Clinic, 80 (3), 187–212.

Further Information

• Rosenhan, D. L. (1973). On being sane in insane places. Science, 179(4070), 250-258.
• 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.”
• David Rosenhan’s Pseudo-Patient Study

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Key study: “On being sane in insane place” (Rosenhan, 1973)

Travis Dixon April 2, 2019 Abnormal Psychology , Qualitative Research Methods

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Rosenhan’s famous study attempted to demonstrate the unreliable nature of psychiatric diagnosis in the 1970s and how poorly patients were treated in psychiatric hospitals. While his methods were a little suspect, the study seemed to make the point Rosenhan was hoping for. 

Background Information

One of the most influential studies conducted investigating the difficulties in defining normality and abnormality, and the inherent repercussions for valid and reliable diagnoses of psychological disorders, was conducted by David Rosenhan. This research was published in 1973, a time when psychiatric hospitals were quite different to the way they are today.

Prior to this study, some researchers had conducted participant observations of psychiatric hospitals, but this was often for a short time and the hospital staff knew of their presence. Rosenhan wanted to take this research one step further and so he conducted a participant, naturalistic, covert observation. He was interested in investigating whether the 8 pseudopatients(people pretending to be patients)  would be diagnosed based on their objective symptoms and behaviours, or if the nature of the environment would influence the interpretation of their behaviours by the professionals who were diagnosing them. Perhaps his aim can be best summarised by the question he poses in the opening to his article:

Psychiatric hospitals were once called “insane asylums,” “mental hospitals,” or more informally “nut houses” or “loony bins.” The classic image of an “insane” person is them wearing a straightjacket.

“If sanity and insanity exist, how shall we know them?”

Methodology and Results

Rosenhan was one of the pseudopatients, along with 7 others. They were an eclectic mix of people who used false names and occupations. There was a graduate student of psychology, three psychologists, a pediatrician, a psychiatrist, a painter and a housewife.

They sought admission into 12 different hospitals on the East and West coasts of the United States. The only symptom they were told to give the hospitals was that they had been hearing voices from a stranger’s voice that was the same gender as them, and the voices were unclear but they thought they said “thud”, “empty” and “hollow”. One reason why these words were chosen was because there is a suggestion that they are signaling some sort of crisis in the individual’s life, such as their life “is empty and hollow”. Once they were granted admission into the hospital, all the other details about their lives and their personal histories that they told the hospital staff were true.

Of the 12 admissions to the hospitals, 11 were diagnosed with schizophrenia and one was diagnosed with manic-depressive psychosis. They remained in the hospitals for a range of 7 to 52 days, with an average of 19 days.

Schizophrenia is a mental disorder that has many varieties. It is mainly characterized by an inability to understand reality (e.g. not being able to determine what is real and what is not).

Once the pseudopatients were admitted to the hospital, they carried on behaving normally and told the staff their symptoms had stopped. They took notes and made other observations, at first hiding this in case the staff found out, but after they realized the staff weren’t paying attention to them, they took notes freely. This resulted in other patients in the hospital raising questions about the authenticity of the pseudopatients’ illnesses. In fact, during the first 3 admissions to hospitals, 35 of 118 patients expressed some concern regarding whether or not the pseudopatients were really ill. This raises an interesting question, like why can the diagnosed “mentally insane” recognize sanity, while the trained professionals cannot?

Follow-up study

After this original study was conducted, one hospital heard of the findings and challenged Rosenhan to send pseudopatients to their hospital with the belief that they would be able to spot the fakes from the genuine patients. Over a three month period, 193 patients were admitted for treatment and received a judgement based on the staffs’ beliefs if they were an actual patient or not. Of these 193, 41 were judged with high confidence by at last one member of the staff to be a pseudopatient, while 19 were suspected as being a pseudopatient by a psychiatrist and at least one other member of the staff. In fact, Rosenhan had not sent any pseudopatients during this time.

Conclusions

While they were on the hospital wards, the pseudopatients made notes about their experiences and in his article Rosenhan details the dehumanization that was experienced by the pseudopatients while they were in the care of the hospital staff. He believes that it is the power of the label (in this case schizophrenia) that influences the way the clinicians interpret their behaviour: “Once a person is diagnosed abnormal, all of his other behaviours are colored by that label”. For example, a perfectly normal description of one of the pseudopatient’s relationships with family members was interpreted by the clinician in a way that was consistent with his diagnosis of schizophrenia. Rosenhan’s study highlights ethical considerations regarding diagnosis, primarily those concerned with the power of labels and stigmatisation.

Critical thinking considerations

• How does this study demonstrate difficulties in defining normality and abnormality?
• How does this study demonstrate validity and reliability issues related to the diagnosis of psychological disorders?
• How does this study demonstrate ethical considerations in diagnosis, such as the effects of labels and the potential for stigmatisation?
• Are there limitations to this study? For example, why might we be limited in applying these findings to today’s psychiatric hospitals?

Interview with David Rosenhan…

Rosenhan, David L. “On Being Sane in Insane Places,” Science , Vol. 179 (Jan. 1973), 250-8. (Accessed from isites.harvard.edu). (Full “On Being Sane in Insane Places” article  here )

Ararat Lynatic Asylym – psychiatric hospitals were a lot less welcoming and pleasant in the past than they are today. (Image from wikipedia)

Psychiatric Hospitals

The following are some short clips to develop your schematic understanding of what psychiatric hospitals for mentally ill people used to be like. I also highly recommend reading and/or watching “One Flew Over the Cuckoo’s Nest” if you’re interested in this topic.

Clips from the film “Patch Adams” with the late and great Robin Williams…

Therapy Session:

Interview (this scene does a great job of highlighting the detachment and apathy from the Doctors.

Squirrels: A touching scene with two patients.

Patch Adams decides he wants to become a Doctor because he wants to help people….

One Flew Over the Cuckoo’s Nest

Travis Dixon is an IB Psychology teacher, author, workshop leader, examiner and IA moderator.

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On being sane in insane places: david rosenhan and his thud experiment.

The “ Rosenhan Experiment”  or Thud experiment was a study conducted to determine the validity of the psychiatric diagnosis. The participants feigned hallucinations to enter psychiatric hospitals but acted usually afterward. They diagnosed them with psychiatric disorders and gave them antipsychotic medication. David Rosenhan, a Stanford University professor, conducted this study, and published it in the journal Science in 1973 under the title “On Being Sane in Insane Places”.

Some consider it an essential criticism of psychiatric diagnosis and broach wrongful involuntary commitment. Rosenhan did the study in eight parts. The first part involved using healthy associates or “pseudopatients” (three women and five men, including Rosenhan himself) who briefly feigned auditory hallucinations to gain admission to twelve psychiatric hospitals in five states in the United States. They admitted all and were diagnosed with psychiatric disorders. After admission, the pseudopatients acted usually and told staff that they no longer experienced any other hallucinations. As a condition of their release, they forced all the patients to admit to having a mental illness and had to agree to take antipsychotic medication. The average time that the patients spent in the hospital were 19 days. They diagnosed all but one with schizophrenia “in remission” before their release. The second part of his study involved a hospital administration challenging Rosenhan to send pseudopatients to its facility, whose staff asserted that they could detect them.

Rosenhan agreed, and they found in the following weeks forty-one out of 193 new patients as potential pseudopatients, with 19 of these receiving suspicion from at least one psychiatrist and one other staff member. Rosenhan sent no pseudopatients to the hospital. While listening to a lecture by R. D. Laing, associated with the anti-psychiatry movement, Rosenhan conceived the experiment to test the reliability of psychiatric diagnoses. The study concluded that “we cannot distinguish the sane from the insane in psychiatric hospitals” and illustrated the dangers of dehumanization and labelling in psychiatric institutions. It suggested that using community mental health facilities that concentrated on specific problems and behaviours rather than psychiatric labels might be a solution. It recommended education to make psychiatric workers more aware of the social psychology of their facilities.

The procedure

Results of the Study

They diagnosed all but one pseudopatient with schizophrenia (the other with the bipolar depressive disorder). They admitted all of them to the hospital and discharged each with a diagnosis of schizophrenia in remission. (i.e. Symptoms were not present at the time of release) the length of hospitalization varied from 7 to 52 days, with an average of 19 days. They never detected pseudopatients, no records or behavior by hospital staff showed that there were any doubts over the authenticity of the patients’ visitors and other patients recognized that some pseudopatients were sane. During the first three hospitalizations, 35 out of 118 patients on the admissions wards voiced their suspicions, such as you are not crazy. You are a journalist or a professor. 

Conclusions

Failure to detect sanity may be because doctors are more likely to favour a type 2 error (they are more likely to diagnose a healthy person as sick) than a type 1 error (than a sick person as healthy) less dangerous this works for medicine but is not necessarily the case for psychiatry as once we label a person as being mentally ill, it is challenging to shift the label the fact that some patients noticed the pseudopatients were sane when the staff did not raise important questions perhaps the results seem to suggest that diagnosis is reliable as they gave all but one individual a diagnosis of schizophrenia when presenting similar symptoms discharge of schizophrenia in remission when they were not actually suffering from any known disorder (affects reliability)it is interesting to note that the staff interpreted many of the pseudo-patients behaviours as being in line with the symptoms of the condition they had diagnosed them with. Rosenman believed that once given a label, we overlook all normal behaviours. For example, they saw their notetaking as an aspect of their pathological behaviour. Staff wrote in one patient’s notes: the patient engages in writing behaviour.

Second Experiment

Another hospital had heard of the findings of the first part of the study, and the staff over there did not believe the results would have occurred in their hospital. Rosenhan informed the staff that in the next three months, one or more pseudopatients would try again to gain entry to the hospital each member of staff was asked to rate every patient (either at admission or on the ward) who wanted admission on a scale from 1 to 10 in terms of whether they thought the patient was a real or fake score of 1 reflected an elevated level of confidence that the patient was fake. Over the 3 months, 193 patients tried to gain admission.

• What was the aim of Rosenhan?
• He wanted to test the reliability of a mental health diagnosis, to see if medical professionals could tell the sane from insane. 
• Was Rosenhan’s experiment or the Thud experiment an experiment?

No, it was an observational study. 

Who were the participants of the thud experiment?

The participants were staff and patients at the twelve hospitals.

Where were the hospitals of Rosenhan’s experiment?

In five states on the East and West coasts of the US. 

Who knew about the pseudopatients in the Thud experiment?

The hospital administrator and chief psychologist

How many pseudopatients were they, and who were they?

8 (3 women and five men) confederates.

Was Rosenhan a pseudo-patient?

Yes, Rosenhan also volunteered as a pseudopatient.

How would patients leave the hospital?

They had to convince the staff they were sane.

What did patients act like when they were admitted them?

They behaved like normal individuals. 

What did the staff do once in the wards?

Took notes. 

Were notes taken in the open?

Only once they were sure staff were not suspicious

What words they chose as the voices?

Thud, empty, and hollow.

What did they change about the patient’s information?

Just the name and occupation, all personal backgrounds stayed the same

How did patients contact the hospital?

Called them up.

What did patients report?

Hearing voices

What did Rosenhan measure?

How many days it took for the psychiatrists to release the patients.

Did they give the patients drugs?

Yes, but they did not swallow the medications. 

What were the patients diagnosed with?

11 schizophrenia and 1 manic depressive disorder

What did the average days of stay in the hospital?

Who many days did it vary by?

Were patients detected?

No, no evidence or records that staff doubted the authenticity

How many of the patients on the ward voiced their concerns?

What did real-life patients say?

‘You’re not crazy, you’re a journalist. 

How many were admitted to hospitals?

What is a type 2 error?

Diagnose a healthy person as sick

What is a type 1 error?

Diagnosing a sick person as healthy

What error did the doctors make?

Why did they make this type of error?

Considered less dangerous?

What is the problem with a type 2 error in mental health?

Hard to move the stigma

Why was it thought that even when behaving normally they were not let out?

Once given a label, they overlook all normal behavior.

Is reliability good?

Could be said to be as all same diagnosis but did not have it

What was the aim of his second study?

To investigate if we could reverse the tendency to diagnose sane as insane.

Why did a second experiment take place?

They said that the results in the first one would not happen in theirs.

What did Rosenhan inform the hospital in experiment two?

That he would send one or more pseudopatients in over the course of three months

What were the staff asked to do in experiment-two?

Rate patients on a scale of 1-10 of how real they were (1 being fake)

How many patients tried to gain admission during experiment two?

How many patients did Rosenhan send in for the second experiment?

How many patients did they judge as fake in the second experiment?

How many did one psychiatrist suspect in the experiment two?

Twenty-three

What is the conclusion?

The results show issues with the reliability and validity of diagnosis and strongly suggest that it is not possible to detect the sane from the insane, as staff members could not identify that none of the patients were pseudopatients

What do the results show?

Issues with reliability and validity

When did the study take place?

•   Gaughwin, Peter (2011). “On Being Insane in Medico-Legal Places: The Importance of Taking a Complete History in Forensic Mental Health Assessment”. Psychiatry, Psychology, and Law. 12(1): 298–310. doi:10.1375/pplt.12.2.298. S2CID 53771539.
• Rosenhan, David (19 January 1973). “On being sane in insane places”. Science. 179 (4070): 250–258. Bibcode:1973Sci...179..250R. doi:10.1126/science.179.4070.250. PMID 4683124. S2CID 146772269. Archived from the original on 17 November 2004.
• Slater, Lauren (2004). Opening Skinner’s Box: Great Psychological Experiments of the Twentieth Century. W. W. Norton. ISBN 0-393-05095-5.
• Kornblum, William (2011). Mitchell, Erin; Jucha, Robert; Chell, John (eds.). Sociology in a Changing World (Google Books)(9th ed.). Cengage learning. p. 195. ISBN 978-1-111-30157-6.
• Spitzer, Robert (October 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): 442–52. doi:10.1037/h0077124. PMID 1194504. S2CID 8688334.
• Abbott, Alison (29 October 2019). “On the troubling trail of psychiatry’s pseudopatients stunt”. Nature. 574 (7780): 622–623. Bibcode:2019Natur.574..622A. doi:10.1038/d41586-019-03268-y. “But some people in the department called him a bullshitter,” Kenneth Gergen says. And through her deeply researched study, Cahalan seems inclined to agree with them.
• Temerlin, Maurice (October 1968). “Suggestion effects in psychiatric diagnosis”. The Journal of Nervous and Mental Disease. 147 (4): 349–353.  doi:10.1097/00005053-196810000-00003 . PMID 5683680. S2CID 36672611.
• Loring, Marti; Powell, Brian (March 1988). “Gender, race, and DSM-III: a study of the objectivity of psychiatric diagnostic behavior”. Journal of Health and Social Behavior. 29 (1): 1–22. doi:10.2307/2137177. JSTOR 2137177. PMID 3367027.
• Moran, Mark (7 April 2006). “Writer Ignites Firestorm With Misdiagnosis Claims”. Psychiatric News. American Psychiatric Association. 41 (7): 10–12. doi:10.1176/pn.41.7.0010. ISSN 1559-1255.

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The Rosenhan experiment

By Susannah Cahalan

Dr. David Rosenhan

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In January 1973, Science published a nine-page paper written by Stanford law and psychology professor David Rosenhan that created a media sensation and sent shock waves throughout the mental health professions.

“If sanity and insanity exist,” Rosenhan opened the paper, “how shall we know them?”

For the study, eight “pseudopatients” – Rosenhan himself and seven volunteers – presented themselves at institutions across the country with the same symptoms: they reported hearing voices that said, “thud, empty, hollow.” Beyond a few biographical adjustments for privacy reasons, the pseudopatients used their own life stories. All eight were admitted and diagnosed with serious mental disorders. The question became, once you’ve been labeled with a psychiatric condition, how do you prove yourself “sane”?

The pseudopatients spent between seven and 52 days in psychiatric institutions ; not one hospital staff member identified the participants as fake patients, even though many other real patients did express the belief that they were undercover agents. “You’re a journalist,” one reportedly said, according to the paper. The pseudopatients eventually left all hospitals against medical advice with their diagnoses “in remission.”

“[W]e have known for a long time that diagnoses are often not useful or reliable, but we have nevertheless continued to use them. We now know that we cannot distinguish insanity from sanity,” Rosenhan concluded.

The paper was nothing short of explosive. Published at a time of extreme skepticism aimed at psychiatry and its institutions, it provided support for the growing anti-psychiatry movement and was used to justify a trend toward deinstitutionalisation, in which large psychiatric hospitals were shuttered in favour of community-based care centres. Even four decades after its publication, the study is still taught in a majority of introductory psychology courses.

Yet it may not have been all it seemed. A six-year investigation into the real story behind the study has revealed many troubling inconsistencies, suggesting that there were multiple levels of deception in this iconic experiment.

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• 29 October 2019

On the troubling trail of psychiatry’s pseudopatients stunt

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The Great Pretender: The Undercover Mission that Changed our Understanding of Madness Susannah Cahalan Grand Central Publishing (2019)

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Nature 574 , 622-623 (2019)

doi: https://doi.org/10.1038/d41586-019-03268-y

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