The Rosenhan experiment was a famous experiment done in order to determine the validity of psychiatric diagnosis, conducted by psychologist David Rosenhan and published by the journal Science in 1973 under the title "On being sane in insane places". The study is considered an important and influential criticism of psychiatric diagnosis.
Rosenhan's study was done in two parts. The first part involved the use of healthy associates or "pseudopatients" (three women and five men) who briefly simulated auditory hallucinations in an attempt to gain admission to 12 different psychiatric hospitals in five different States in various locations in the United States. All were admitted and diagnosed with psychiatric disorders. After admission, the pseudopatients acted normally and told staff that they felt fine and had not experienced any more hallucinations. All were forced to admit to having a mental illness and agree to take antipsychotic drugs as a condition of their release. The average time that the patients spent in the hospital was 19 days. All but one were diagnosed with schizophrenia "in remission" before their release. The second part of his study involved an offended hospital challenging Rosenhan to send pseudopatients to its facility, whom its staff would then detect. Rosenhan agreed and in the following weeks out of 193 new patients the staff identified 41 as potential pseudopatients, with 19 of these receiving suspicion from at least 1 psychiatrist and 1 other staff member. In fact Rosenhan had sent no one to the hospital.
The study concluded "it is clear that we cannot distinguish the sane from the insane in psychiatric hospitals" and also illustrated the dangers of dehumanization and labeling in psychiatric institutions. It suggested that the use of community mental health facilities which concentrated on specific problems and behaviors rather than psychiatric labels might be a solution and recommended education to make psychiatric workers more aware of the social psychology of their facilities. However, the study has been critiqued and accused of being pseudoscience presented as science.
The pseudopatient experiment
Rosenhan himself and seven mentally healthy associates, called "pseudopatients", attempted to gain admission to psychiatric hospitals by calling for an appointment and feigning auditory hallucinations. The hospital staffs were not informed of the experiment. The pseudopatients included a psychology graduate student in his twenties, three psychologists, a pediatrician, a psychiatrist, a painter and a housewife. None had a history of mental illness. Pseudopatients used pseudonyms, and those who worked in the mental health field were given false jobs in a different sector to avoid invoking any special treatment or scrutiny. Apart from giving false names and employment details, further biographical details were truthfully reported.
During their initial psychiatric assessment, they claimed to be hearing voices of the same sex as the patient which were often unclear, but which seemed to pronounce the words "empty", "hollow", "thud" and nothing else. These words were chosen as they vaguely suggest some sort of existential crisis and for the lack of any published literature referencing them as psychotic symptoms. No other psychiatric symptoms were claimed. If admitted, the pseudopatients were instructed to "act normally", reporting that they felt fine and no longer heard voices. Hospital records obtained after the experiment indicate that all pseudopatients were characterized as friendly and cooperative by staff.
All were admitted, to 12 different psychiatric hospitals across the United States, including rundown and underfunded public hospitals in rural areas, urban university-run hospitals with excellent reputations, and one expensive private hospital. Though presented with identical symptoms, 7 were diagnosed with schizophrenia at public hospitals, and one with manic-depressive psychosis, a more optimistic diagnosis with better clinical outcomes, at the private hospital. Their stays ranged from 7 to 52 days, and the average was 19 days. All were discharged with a diagnosis of schizophrenia "in remission", which Rosenhan takes as evidence that mental illness is perceived as an irreversible condition creating a lifelong stigma rather than a curable illness.
Despite constantly and openly taking extensive notes on the behavior of the staff and other patients, none of the pseudopatients were identified as impostors by the hospital staff, although many of the other psychiatric patients seemed to be able to correctly identify them as impostors. In the first three hospitalizations, 35 of the total of 118 patients expressed a suspicion that the pseudopatients were sane, with some suggesting that the patients were researchers or journalists investigating the hospital.
Hospital notes indicated that staff interpreted much of the pseudopatients' behavior in terms of mental illness. For example, one nurse labeled the note-taking of one pseudopatient as "writing behavior" and considered it pathological. The patients' normal biographies were recast in hospital records along the lines of what was expected of schizophrenics by the then-dominant theories of its etiology.
The pseudopatients were required to get out of the hospital on their own by getting the hospital to release them, though a lawyer was retained to be on call for emergencies when it became clear that the pseudopatients would not ever be voluntarily released on short notice. Once admitted and diagnosed, the pseudopatients were not able to obtain their release until they agreed with the psychiatrists that they were mentally ill and began taking antipsychotic medications, which they flushed down the toilet. No staff member noticed that the pseudopatients were flushing their medication down the toilets and did not report patients doing this.
Rosenhan and the other pseudopatients reported an overwhelming sense of dehumanization, severe invasion of privacy, and boredom while hospitalized. Their possessions were searched randomly, and they were sometimes observed while using the toilet. They reported that though the staff seemed to be well-meaning, they generally objectified and dehumanized the patients, often discussing patients at length in their presence as though they were not there, and avoiding direct interaction with patients except as strictly necessary to perform official duties. Some attendants were prone to verbal and physical abuse of patients when other staff were not present. A group of bored patients waiting outside the cafeteria for lunch early were said by a doctor to his students to be experiencing "oral-acquisitive" psychiatric symptoms. Contact with doctors averaged 6.8 minutes per day.
"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 they're [the psychiatrists] correct. They had said I was insane, 'I am insane; but I am getting better.' That was an affirmation of their view of me." — David Rosenhan in the BBC program "The Trap".
The non-existent impostor experiment
For this experiment, Rosenhan used a well-known research and teaching hospital, whose staff had heard of the results of the initial study but claimed that similar errors could not be made at their institution. Rosenhan arranged with them that during a three-month period, one or more pseudopatients would attempt to gain admission and the staff would rate every incoming patient as to the likelihood they were an impostor. Out of 193 patients, 41 were considered to be impostors and a further 42 were considered suspect. In reality, Rosenhan had sent no pseudopatients and all patients suspected as impostors by the hospital staff were ordinary patients. This led to a conclusion that "any diagnostic process that lends itself too readily to massive errors of this sort cannot be a very reliable one". Studies by others found similarly problematic diagnostic results.
Impact and controversy
Rosenhan published his findings in Science, criticizing the reliability of psychiatric diagnosis and the disempowering and demeaning nature of patient care experienced by the associates in the study. His article generated an explosion of controversy.
Many defended psychiatry, arguing that as psychiatric diagnosis relies largely on the patient's report of their experiences, faking their presence no more demonstrates problems with psychiatric diagnosis than lying about other medical symptoms. In this vein, psychiatrist Robert Spitzer quoted Kety in a 1975 criticism of Rosenhan's study :
- 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.
Rosenhan replied that if they continue thinking that you still have an ulcer during x weeks despite having no other symptoms of ulcer, that makes for a big problem.
Kety also argued that psychiatrists should not necessarily be expected to assume that a patient is pretending to have mental illness, thus the study lacked realism. Rosenhan called this the "experimenter effect" or "expectation bias", something indicative of the problems he uncovered rather than a problem in his methodology.
The Roman comedian Plautus wrote a play c. 200 BC, titled Menaechmi, in which a character feigns symptoms of mental illness. He successfully deceives a psychiatrist, who interprets his every reaction as symptomatic of mental illness.
American investigative journalist Nellie Bly feigned symptoms of mental illness to gain admission to a lunatic asylum in 1887 and report on the terrible conditions therein. The results were published as Ten Days in a Mad-House.
Maurice K. Temerlin split 25 psychiatrists into two groups and had them listen to an actor portraying a character of normal mental health. One group was told that the actor "was a very interesting man because he looked neurotic, but actually was quite psychotic" while the other was told nothing. Sixty percent of the former group diagnosed psychoses, most often schizophrenia, while none of the control group did so.
In 1988, Loring and Powell gave 290 psychiatrists a transcript of a patient interview and told half of them that the patient was black and the other half white; they concluded of the results that "clinicians appear to ascribe violence, suspiciousness, and dangerousness to black clients even though the case studies are the same as the case studies for the white clients".
The science writer Lauren Slater may have conducted an experiment very similar to Rosenhan's for her 2004 book Opening Skinner's Box. She claims to have presented herself at 9 different psychiatric emergency rooms with auditory hallucinations, resulting in being diagnosed "almost every time" with psychotic depression. However, when challenged to provide evidence of actually conducting her experiment, she could not.
In 2008, the BBC's Horizon science program performed a somewhat related experiment over two episodes entitled "How Mad Are You?". The experiment involved ten subjects, five living with previously-diagnosed mental health conditions, and five with no such diagnosis. They were observed by three experts in mental health diagnoses and their challenge was to identify the five with mental health problems. The experts correctly diagnosed two of the ten patients, misdiagnosed one patient, and incorrectly identified two healthy patients as having mental health problems.
- Confirmation bias
- Involuntary commitment
- Nellie Bly, author of Ten Days in a Mad-House (1887)
- Norah Vincent, author of Voluntary Madness
- Shock Corridor
- The Trap
- Rosenhan DL (January 1973). "On being sane in insane places". Science 179 (4070): 250–8. doi:10.1126/science.179.4070.250. PMID 4683124. Archived from the original on 2004-11-17.
- Slater, Lauren (2004). Opening Skinner's Box: Great Psychological Experiments of the Twentieth Century. W. W. Norton. ISBN 0-393-05095-5.
- Spitzer, Robert L. 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; 1975; vol. 84 no. 5; pp 442-452.
- An excerpt from the BBC program with this statement by David Rosenhan can be viewed here.
- Spitzer, Robert L. (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.
- "The Rosenhan experiment examined", Frontier Psychiatrist
- 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.
- Temerlin, 1968. "Suggestion Effects in Psychiatric Diagnosis"; Journal of Nervous & Mental Disease: October 1968 - Volume 147 - Issue 4 - p. 349-353.
- Loring M, Powell B (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 (April 7, 2006). "Writer Ignites Firestorm With Misdiagnosis Claims". Psychiatric News (American Psychiatric Association) 41 (7): 10–12. ISSN 1559-1255, Print 0033-2704 Online 1559-1255, Print 0033-2704. Retrieved 2009-12-30.
- BBC Headroom Horizon: How Mad Are You?
- How Mad Are You? - Spotlight
- On being sane in insane places
- Rosenhan experiment summary
- Clip from the BBC's The Trap, 11th March 2007
- BBC Radio 4, "Mind Changers", Series 4 Episode 1: The Pseudo-Patient Study