That Time a Group of Psychiatrists Pretended to be Mentally Ill to Prove a Point
In 1972, eight people presented themselves to 12 psychiatric hospitals across the United States. They had seemingly nothing in common save for a very specific set of symptoms, with all eight reporting hearing voices saying a single word: “thud,” “empty,” or “hollow.” They were all immediately admitted, seven being diagnosed with schizophrenia and one with manic depression. Following admission, all eight patients suddenly stopped hearing the voices and reported feeling entirely normal. Nonetheless, they remained hospitalized for between 7 and 52 days, being treated with a variety of antipsychotic drugs before finally being released with a diagnosis of “schizophrenia in remission.” It was, at its face, little more than a curious coincidence. But in January 1973 an article appeared in the journal Science revealing that the eight patients were not who they appeared to be. In fact, they weren’t patients at all, but members of a secret study organized psychiatrist David Rosenhan of Stanford University. The results of that study, now known as the Rosenhan Experiment, would shake the psychiatric establishment to its very core.
The Rosenhan Experiment was inspired by the work of R.D. Liang, Thomas Szasz, Erving Goffman, and other leading figures of the anti-psychiatry movement. These men were concerned by the dehumanizing effects of psychiatric diagnosis and institutionalization, and the use of psychiatry as a tool of social and political repression. Indeed, in the Soviet Union, East Germany, and other communist states, forcible commitment to psychiatric hospitals was commonly used to silence political dissidents. Thomas Szasz in particular focused on the use of psychiatric labels in Western countries as a means of enforcing societal norms, citing such examples as “drapetomania”, the supposed “mental illness” that caused slaves to flee captivity; “hysteria,” the catchall diagnosis for misbehaving women; and the fact that homosexuality was officially categorized as a mental illness until 1974.
David Rosenhan believed that mistaken or overzealous diagnoses – indeed, the very act of labelling psychiatric disorders – could have serious detrimental effects at the personal and community level, due to the persistent stigma associated with mental illness. As he wrote in his famous 1973 article, On Being Sane in Insane Places:
“The term “mental illness” is of recent origin. It was coined by people who were humane [and] wanted very much to raise the station [of] the psychologically disturbed from that of witches and “crazies” to one that was akin to the physically ill…but while treatment has improved, it is doubtful that people really regard the mentally ill in the same way that they view the physically ill. A broken leg is something one recovers from, but mental illness allegedly endures forever. A broken leg does not threaten the observer, but a crazy schizophrenic? [Attitudes] toward the mentally ill are characterized by fear, hostility, aloofness, suspicion, and dread. The mentally ill are society’s lepers.”
“A psychiatric label has a life and an influence of its own. Once the impression has been formed that the patient is schizophrenic, the expectation is that he will continue to be schizophrenic…such labels, conferred by mental health professionals, are as influential on the patient as they are on his relatives and friends, and it should not surprise anyone that the diagnosis acts on all of them as a self-fulfilling prophecy. A diagnosis of cancer that has been found to be in error is cause for celebration. But psychiatric diagnoses are rarely found to be in error. The label sticks, a mark of inadequacy forever.”
Due to these potentially harmful effects, Rosenhan became concerned about the objective reliability of psychiatric diagnoses – that is, the ability of psychiatrists to tell the sane from the insane. The seed of the idea that would become the Rosenhan Experiment was planted in 1969 when Rosenhan was teaching psychology at Swarthmore College in Pennsylvania. When his students complained that the course was too abstract, Rosenhan suggested that they check themselves into the nearby Haverford State Hospital and interact with real people suffering from schizophrenia. Just to be safe, however, Rosenhan decided to check himself in first. He emerged nine days later utterly traumatized by the experience, and refused to subject his students to the same ordeal. However, he soon began thinking of an experiment to expose the deficiencies of the mental health system – an experiment he would finally carry out three years later.
Rosenhan’s team of eight test subjects, whom he called “pseudopatients,” consisted of five men and three women and included a graduate student, a paediatrician, a painter, a housewife, three psychologists, and Rosenhan himself. The 12 hospitals they were to infiltrate were similarly diverse, ranging from underfunded, understaffed state institutions to exclusive private hospitals. So their commitment would not result in social or professional embarrassment, the pseudopatients were given false names and professions, but were otherwise not to change or conceal any other details of their lives or personalities. They were instructed to present themselves to their assigned hospitals with a single symptom: hearing a voice saying “thud,” “empty,” or “hollow.” These words were selected due to their evocation of an “existential psychosis,” a hypothetical disorder in which a patient’s hallucinations reveal an inner feeling of hollowness and meaninglessness. As not a single case of existential psychosis had ever been reported, Rosenhan believed this might serve as a clue to hospital psychiatrists that the pseudopatients were feigning their illnesses.
Upon being admitted, the pseudopatients were to cease reporting any symptoms and act normally as they would outside the hospital. Their goal would then be to secure their release by convincing the staff of their sanity – but without revealing their involvement in the experiment.
As expected, Rosenhan and the other pseudopatients were immediately admitted to their respective hospitals and given diagnoses of schizophrenia and manic depression. But to their surprise, the immediate cessation of symptoms and resumption of “normal” behaviour did nothing to alter these diagnoses – or arouse the staff’s suspicion. On the contrary, the pseudopatients found their every behaviour on the ward framed by the staff as a manifestation of their supposed mental illness. For example, many pseudopatients took extensive notes on their fellow patients and the hospital staff, an activity which the doctors clinically described as “patient engaged in writing behaviour.” Not once, however, did a staff member enquire as to the actual nature of the patient’s writing. On another occasion:
“One psychiatrist pointed to a group of patients who were sitting outside the cafeteria entrance half an hour before lunchtime. To a group of young residents he indicated that such behaviour was characteristic of the oral-acquisitive nature of the syndrome. It seemed not to occur to him that there were very few things to anticipate in a psychiatric hospital besides eating.”
Normal displays of anger were likewise interpreted as symptoms of mental illness, while one pseudopatient’s fluctuating – though entirely normal – relationship with his parents was interpreted in his case file as being intrinsically tied to his psychosis. Yet while all patient reports indicate that the pseudo patients were “friendly,” “cooperative,” and “exhibited no abnormal indications,” at no point did any of the staff suspect that they were not, in fact, mentally ill. But one group very often did see through the charade: the other patients. Many pseudopatients described other patients accusing them of being journalists reporting on the hospital, and where records were available a full 35 of 118 patients on the ward reported similar suspicions. Rosenhan attributed the doctors’ inability to detect the pseudopatients’ deception to:
“… the fact that physicians operate with a strong bias toward what statisticians call the Type 2 error. This is to say that physicians are more inclined to call a healthy person sick (a false positive, Type 2) than a sick person healthy (a false negative, Type 1). The reasons for this are not hard to find: it is clearly more dangerous to misdiagnose illness than health. Better to err on the side of caution, to suspect illness even among the healthy.”
Thus, despite acting as “normally” as possible, the patients continued to receive regular psychiatric treatment, being collectively administered over 2100 pills which they pocketed and flushed down the toilet.
In addition to over-analysis and extreme boredom, Rosenhan and the others experienced first-hand the extreme dehumanization and abuse common to life inside a psychiatric hospital:
“The patient is deprived of many of his legal rights by dint of his psychiatric commitment. He is shorn of credibility by virtue of his psychiatric label. His freedom of movement is restricted. He cannot initiate contact with the staff, but may only respond to such overtures as they make. Personal privacy is minimal. Patient quarters and possessions can be entered and examined by any staff member, for whatever reason. His personal hygiene and waste evacuation are often monitored. The water closets have no doors.”
“At times, depersonalization reached such proportions that pseudopatients had the sense that they were invisible, or at least unworthy of account. On the ward, attendants delivered verbal and occasionally serious physical abuse to patients in the presence of others (the pseudopatients) who were writing it all down. Abusive behaviour, on the other hand, terminated quite abruptly when other staff members were known to be coming. Staff are credible witnesses. Patients are not.”
“During my own experience, one patient was beaten in the presence of other patients for having approached an attendant and told him, “I like you.” Occasionally, punishment meted out to patients for misdemeanors seemed so excessive that it could not be justified by the most rational interpretations of psychiatric cannon. Tempers were often short. A patient who had not heard a call for medication would be roundly excoriated, and the morning attendants would often wake patients with things like, “Come on, you m_ _ _ _ _ f _ _ _ _ _ s, out of bed!””
While Rosenhan acknowledged the role of inadequate funds and understaffing in precipitating such abuses, this was not the whole story. After all, similar behaviour occurred even in well-funded private hospitals. Instead, Rosenhan attributed the extreme depersonalization of psychiatric patients to the severe lack of interaction between patients and staff. According to the pseudopatients’ notes, much of the staff’s time was spent inside a glass-walled enclosure known as “the cage,” with attendants spending only 11% of their shifts interacting with patients. Nurses were even less available, briefly emerging only 11 times per shift, and physicians scarcer still, emerging 9 times per shift.
“That [these attitudes] affect the professionals…who treat and deal with the mentally ill is more disconcerting, both because such attitudes are self-evidently pernicious and because they are unwitting. Most mental health professionals would insist that they are sympathetic toward the mentally ill, that they are neither avoidant nor hostile. But it is more likely that an exquisite ambivalence characterizes their relations with psychiatric patients, such that their avowed impulses are only part of their entire attitude. Negative attitudes are there too and can easily be detected. Such attitudes should not surprise us. They are the natural offspring of the labels patients wear and the places in which they are found.”
When Rosenhan and the others were finally released, they had spent an average of 19 days in hospital. The diagnostic Catch-22 behind their release was later described by Rosenhan in an interview with the BBC:
“I told friends, I told my family: “I can get out when I can get out. That’s all. I’ll be there for a couple of days and I’ll get out.” Nobody knew I’d be there for two months … The only way out was to point out that the psychiatrists are correct. They had said I was insane, “I am insane; but I am getting better.” That was an affirmation of their view of me. If I was to be discharged, I must naturally be “in remission”; but I was not sane, nor, in the institution’s view, had I ever been sane.”
On learning of Rosenhan’s deception, the infiltrated hospitals challenged Rosenhan to send more pseudopatients, confident in the ability of their doctors to spot them. Rosenhan agreed, even sending a score sheet with a 10-point scale on which doctors could grade their suspicion of a particular patient. Over the next several months the hospitals scrutinized a total of 193 newly-admitted patients, confidently pronouncing 41 of them to be impostors. But then, to their utter embarrassment, Rosenhan dropped a bombshell: he hadn’t sent any.
When in Rosenhan’s article appeared in Science in January 1973, it sent shockwaves through the psychiatric community. His results appeared to undermine the last great revolution in psychiatric diagnosis: the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, or DSM. Created in 1952, the DSM was intended to replace the often arbitrary and esoteric diagnoses of the psychoanalytic tradition with diagnostic criteria based on real-world statistics and clear, observable symptoms. No longer would a patient be diagnosed on the basis of a single symptom or their family history; in order to be diagnosed with a given disorder, a patient had to simultaneously display a certain number of symptoms statistically associated with that disorder. While this system was meant to drastically improve the reliability and usefulness of psychiatric diagnoses, the Rosenhan Experiment revealed that in practice, psychiatric labels were just as arbitrary – and harmful – as ever. As Rosenhan explained in his article:
Whenever the ratio of what is known to what needs to be known approaches zero, we tend to invent “knowledge” and assume that we understand more than we actually do. We seem unable to acknowledge that we simply don’t know. The needs for diagnosis and remediation of behavioural and emotional problems are enormous. But rather than acknowledge that we are just embarking on understanding, we continue to label patients “schizophrenic,” “manic-depressive,” and “insane,” as if in those words we captured the essence of understanding. The facts of the matter are that we 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 sanity from insanity. It is depressing to consider how that information will be used.”
As a remedy, Rosenhan advocated a move away from the traditional institutional model of psychiatric care and towards:
“…[the] proliferation of community mental health facilities, of crisis intervention centers, of the human potential movement, and of behaviour therapies that, for all of their own problems, tend to avoid psychiatric labels, to focus on specific problems and behaviours, and to retain the individual in a relatively non-pejorative environment.”
The Rosenhan Experiment was highly influential, and helped to further speed the de-institutionalization movement started by the introduction of antipsychotic drugs in the 1950s. By the end of the 1980s most of the large State Hospitals had been emptied and shuttered, with the majority of patients being treated in community health centres or psychiatric wards in regular hospitals.
Yet despite its fame and influence, the Rosenhan Experiment soon drew vehement criticism for its allegedly manipulative and unscientific methodology. In the most damning of these critiques, published in Nature in 1975, Robert Spitzer outright dismisses the Rosenhan Experiment as pseudoscience, arguing that the study was designed in such a manner as to invariably confirm Rosenhan’s own preconceptions. In particular, Spitzer points out that despite Rosenhan’s claims,
“The pseudopatients did not behave normally in the hospital. Had their behaviour been normal, they would have walked to the nurses’ station and said ‘Look, I am a normal person who tried to see if I could get into the hospital by behaving in a crazy way or saying crazy things. It worked and I was admitted to the hospital, but now I would like to be discharged from the hospital.””
In other words, as the pseudopatients’ behaviour was deliberately intended to fool the hospital staff, it is hardly surprising that they succeeded. After all, as Spitzer points out, aside from cases of malingering – wherein a patient pretends to be ill in order to, for example, score narcotic drugs – there is little reason for doctors to doubt the authenticity of a patient’s reported symptoms. Thus, the fact that the hospital staff did not suspect the pseudopatients of feigning their illnesses says little about the reliability of psychiatric diagnosis:
“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. 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.”
Spitzer goes on to dismantle nearly all Rosenhan’s interpretations of the staff’s behaviour, pointing out, for example, that nurses’ notes like the infamous “engages in writing behaviour” are not diagnostic but instead used to update other staff on a patient’s daily activities. He also points out that the term “in remission” is almost never used to classify schizophrenic patients upon discharge, indicating that the hospital staff had in fact acknowledged that the pseudopatients were no longer suffering from any detectable mental illness. Indeed, Spitzer challenges Rosenhan’s foundational assertion that “schizophrenia” is a permanent, lifelong diagnosis, pointing out that the DSM acknowledges that the disorder can – and often does – go away, never to return. And while acknowledging that other symptoms typically present alongside hallucinations, he concludes:
“I would hope that if I had been one of the 12 psychiatrists presented with such a patient, I would have been struck by the lack of other signs of the disorder, but I am rather sure that having no reason to doubt the authenticity of the patients’ claim of auditory hallucinations, I also would have been fooled into noting schizophrenia as the most likely diagnosis.”
More recently, in her 2019 book The Great Pretender, author Susannah Cahalan claims that the little data Rosenhan presents in his 1973 article conflicts with that in his original notes, with key statistics such as the length of pseudopatients’ stays or the number of patients at each hospital being altered in the final publication. In addition, despite an extensive search, she was unable to track down any of the original pseudopatients, leading her to suspect that they had, in fact, been invented by Rosenhan.
And so it is that the Rosenhan Experiment joins the pantheon of extremely influential but fundamentally flawed psychological studies, along with the likes of the Milgram Obedience Experiment, the Stanford Prison Experiment, and the Robber’s Cave Experiment. Yet for all its flaws, it cannot be denied that Rosenhan’s stunt was instrumental in bringing about a more humane and personal era of mental healthcare. And the fear of institutionalization and dehumanization, perhaps best expressed by evolutionary biologist T.H. Huxley in 1893, are still with us to this day:
“One of the unpardonable sins, in the eyes of most people, is for man to go about unlabeled. The world regards such a person as the police do an unmuzzled dog, not under proper control.”
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Rosenhan, David, On Being Sane in Insane Places, https://web.archive.org/web/20041117175255/http://web.cocc.edu/lminorevans/on_being_sane_in_insane_places.htm
Myers, David, Psychology, Worth Publishers, NY, 2004
Abbott, Alison, On the Troubling Trail of Psychiatry’s Pseudopatients Stunt, Nature, October 29, 2019, https://www.nature.com/articles/d41586-019-03268-y
Spitzer, Robert, Pseudoscience in Science, Logic in Remission, and Psychiatric Diagnosis: A Critique of Rosenhan’s “On Being Sane in Insane Places”, Journal of Abnormal Psychology, 1975, Vol.84, No. 5, 442-452, https://pdfs.semanticscholar.org/57c8/aa6e7101b6cb7f1db2076401318cdb60b0c1.pdf?_ga=2.140566450.1217741913.1612541771-688871321.1612541771
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