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Have there been followups to the Rosenhan Experiment?

Have there been followups to the Rosenhan Experiment?



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The famous Rosenhan experiment of 1973 showed that doctors in asylums routinely misdiagnosed normal people with various psychiatric disorders.

Have any followup studies been done to confirm these results? I am particularly interested in any studies in which the pseudopatients did not feign insanity, but act normally during the course of the experiment.


There was a follow-up to Rosenhan (1973). The whole study was revisited by Scribner (2001).

The present study is a replication of sorts, modified to suit the contemporary, postdeinstitutionalization state of mental health care. The findings suggest that a significant shift has occurred in mental health care since 1973. At the time of the original study by Rosenhan (1973), the troubling issue was the ease with which people could receive an unwarranted diagnosis and unnecessary treatment for a nonexistent mental disorder. In today's mental health care environment, the troubling issue is the difficulty involved in obtaining treatment that is warranted for conditions that are present.

References

Rosenhan, D. L. (1973). On being sane in insane places. Science, 179(4070), 250-258. DOI: 10.1126/science.179.4070.250

Scribner, C. M. (2001). Rosenhan revisited. Professional Psychology: Research and Practice, 32(2), 215. DOI: 10.1037/0735-7028.32.2.215


Why the Rosenhan Experiment still matters

One flew east, one flew west, eight shrinks flew into the cuckoo's nest.

  • In 1973, eight experimenters faked insanity to see how easy it was to get into a mental hospital. The hard part was getting out.
  • Their findings sparked a great debate over how psychiatry treated patients and how accurate diagnostic procedures were.
  • In an age marked by a lack of proper mental health care, the finding that it was too easy to get a doctor's attention seems shocking.

In the United States, mental health care can be difficult to come by. One-third of Americans live in a "mental health professional shortage area" and lack access to mental health facilities this probably explains why less than half of the people who need treatment get it. It can almost seem like you have to be at the end of your rope to get help sometimes.

It didn't use to be this way though there was that one time that a psychologist found it was easier to fake your way into a mental hospital than it was to get out.

The Rosenhan experiment

In 1973, after hearing a lecture from the anti-psychiatry figure R.D. Laing the psychologist David Rosenhan decided to test how rigorous psychiatric diagnoses were at modern hospitals by first trying to get into them with fake symptoms and then trying to get out by acting normally.

Eight experimenters participated, including Dr. Rosenhan. All but two of them were somehow involved in medicine, so fake names and occupations were created to both avoid the enhanced scrutiny they expected members of their field to be given when claiming insanity and to prevent the test subjects from facing the stigmas of mental illness after the experiment ended.

The pseudopatients all reported the same symptoms, an auditory hallucination saying the words "empty," "hollow," and "thud." These words were chosen to invoke the idea of an existential crisis. They were also chosen because, at the time, there was no literature on an "existential psychosis."

Much to the pseudopatients' surprise, they were all admitted to all 12 hospitals they went to with little difficulty. In all but one case, they were given a diagnosis of schizophrenia. In the outlier, a private hospital gave them a slightly more optimistic diagnosis of "manic-depressive psychosis."

Once admitted to the hospital, the patients were instructed to act normally and do what they could to be released. This led them all to be "paragons of cooperation" and to fully participate in ward life. They attended therapy, socialized with others, and even accepted their medications which they then disposed of. If asked, they were to say their symptoms had disappeared entirely.

Shockingly, the staff had no idea any of them were faking. Their normal behavior was medicalized into symptoms of their schizophrenia. For example, since all of the pseudopatients were taking notes on the hospital, naturally one of them had the note "patient engages in writing behavior" added to their file. Also, simply lining up early to get food was cited as an example of "oral-acquisitive" psychotic behavior.

The life details of the subjects, all fairly typical for the time, were suddenly signs of pathological behavior. One pseudopatient reported that he had a happy marriage though he occasionally fought with his wife and that he did spank his children on rare occasions. While this might seem like a standard 1960s life, his file read:

"His attempts to control emotionality with his wife and children are punctuated by angry outbursts and, in the case of the children, spankings."

Schizophrenia’s Identity Crisis

Amusingly, while the staff at the hospitals had no idea they had fakers in the ward, the real patients often caught on very quickly. The participants reported dozens of cases of their wardmates coming up to them and accusing them of being either a journalist or professor playing sick in order to take notes about the hospital.

Disturbingly, the fakers also reported that the staff was dehumanizing and often brutal. Conversations with staff were limited by their frequent absence. When the staff did have time to talk, they were often curt and dismissive. Orderlies would often be both physically and verbally abusive when other workers were absent. The pseudopatients reported they often felt invisible, as the staff would act like they weren't even there. These details were made worse by the powerlessness felt by the pseudopatients, which was reinforced both by hospital hierarchy and then current law.

Despite all the evidence that the experimenters were faking it, the shortest stay lasted a week, and the longest was 52 days. The typical stint lasted almost three weeks. All of the patients diagnosed with schizophrenia were deemed "in remission" upon being discharged, leading Dr. Rosenhan to write:

"At no time during any hospitalization had any question been raised about any pseudopatient's simulation. Nor are there any indications in the hospital records that the pseudopatient's status was suspect. Rather the evidence is strong that, once labeled schizophrenic, the pseudopatient was stuck with that label. If the pseudopatient was to be discharged, he must naturally be 'in remission' but he was not sane, nor, in the institution's view, had he ever been sane."

Dr. Rosenhan concluded that, "It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals." He was forgiving, however, and noted that at least some of the problem could be attributed to a desire to err on the side of caution and admit a potential faker with only one reported symptom before letting somebody in serious need of treatment go without.

He went on to explain how another hospital challenged him to send an actor which they would then identify. After presenting him with their lengthy list of suspected actors they had admitted, Dr. Rosenhan revealed that he hadn't sent anybody at all. He saw this as further evidence of his conclusion.

How did people take this report?


The report, published in Science, was a minor bombshell that landed on a profession that was already reevaluating its methods in the wake of a society suddenly coming to grips with the conditions of mental asylums, an increasing number of findings that suggested institutionalization wasn't the only way to treat mental illness, and the discovery by a group of British shrinks that American doctors were handing out diagnoses of schizophrenia left and right when other conditions were really at work.

When the Diagnostic and Statistical Manual of Mental Disorders, the big book of mental illnesses and their symptoms, was updated in 1980 for its third edition, the debate around Rosenhan's experiment likely motivated the authors to make the symptom descriptions used to define various conditions more stringent.

What’s the catch? There has to be a catch with a study like this.

The methods of this experiment were questioned immediately, as they are atypical at best and unscientific at worst.

Physician Fred Hunter pointed out in his letter to Science that if the patients were acting "normally" during their stays, they would have revealed their lie and asked to leave shortly after arriving. He also criticized both the methods and the findings of the stunt. Psychiatrist Robert Spitzer also dismissed the whole thing as pseudoscience in a strongly worded academic article.

There is also the question of whether the conclusion is meaningful at all. Neuroscientist Seymour S. Kety pointed out that a similar stunt in an emergency room would hardly be considered a groundbreaking study, given how important honest reporting is in medicine:

"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."

The continuing problems of dehumanization and deinstitutionalization

The findings of the study on how the mentally ill were treated, even in cases where they were paragons of cooperation, was widely accepted as a valid and needed critique. Even Dr. Hunter admitted that Rosenhan's experiment did a good thing by exposing these horrors. Regrettably, today we still have need of Rosenhan's reports on this subject.

In the United States, sixteen percent of people in jails have a mental illness. This is three times as many people as are seeking care for these conditions in hospitals and is creating new forms of institutionalization. The stigma around mental illness remains as strong as ever. While many people think the mentally ill are dangerous, statistics show they are much more likely to be the victims of violence themselves rather than hurt anybody else.

It seems that Dr. Rosenhan's lament that "The mentally ill are society's lepers" has yet to be made obsolete by progress.

Are there any other experiments like this? Could this have just been a disturbing blip?

Depressingly, this isn't the only experiment to use these methods to conclude that how we treat mental illness needs work. In 1887, almost a century before Rosenhan's article, Nellie Bly faked insanity to enter the Woman's Lunatic Asylum in New York City. The book she wrote about her experience, Ten Days in a Madhouse, revealed the horrific conditions in the hospital and led to an inquiry that resulted in increased funding and more rigorous standards.

Modern attempts to recreate the study have shown some changes in the field of psychiatry. In 2001, seven people who had schizophrenia presented themselves to intake offices in search of treatment all of them were denied care due to lack of resources. In 2004, writer Lauren Slater claimed to have repeated Rosenhan's experiment herself but was only given medication to go with her quick diagnosis. If she actually carried out this experiment remains a subject of debate.

Psychiatry has improved dramatically since the days of One Flew Over the Cuckoo's Nest and David Rosenhan's stings. Studies have shown the objectivity of psychiatric diagnoses remains comparable to that of the rest of medical science while acknowledging that some subjectivity is inevitable. Better methods of integration have made it difficult to tell who has a diagnosed mental illness and who doesn't in normal circumstances. Deinstitutionalization has improved the lives of many people who would otherwise be locked away.

But while asylums are largely gone, there is still much work to be done. Rosenhan's experiment will continue to remind us that being labeled as crazy can lead to a dehumanization with consequences just as isolating as any mental illness.


Real Psychiatry

This is the second book review of this book on my blog. I was asked by the editor of The Philosophy Special Interest Group of the Royal College of Psychiatrists - Dr. Abdi Sanati to write another review for this newsletter. I looked at it as an opportunity to cover some things I may have missed in the first review. I agreed to not put it on my blog until the newsletter came out. The latest review follows:

The Great Pretender (1) is written as an exposé of a famous experiment conducted by Rosenhan (2) that purported to discredit psychiatric diagnoses. The original article was published in in the journal Science in 1973. Whether you we aware of the original article or not depended on when you were trained and the extent to which you followed that literature. I was just finishing my undergraduate degree at that point and did not complete psychiatric training until 1986. We had a community psychiatry seminar for 6 months during my last year that was taught by some of the innovators in the field. It was common to analyze and discuss controversial papers of the day. A good example would have been the paper that suggested that people with schizophrenia had a much better outcome in the developing countries (3). At no point did we hear about or discuss the Rosenhan paper. In fact, for the next 24 years the paper never came across my desk. It was only when I started writing a psychiatry blog that I realized it played a major role in psychiatric criticism and antipsychiatry rhetoric. At that point, I read the paper and the associated criticism and concluded independently that the methodology was extremely weak and that pseudopatients were not really a good test of medical or psychiatric diagnoses. I thought it would just fade away on that basis.

I was as surprised as anyone when I heard that investigative reporter Susannah Cahalan had written a book about this experiment, the author, and the methods used. The investigation begins with a visit to one of Rosenhan’s former colleagues. This colleague shows her a stack of anti-psychiatry books that he thinks “were the key to his thinking”. There is also a file labeled “pseudopatients” that contain the names of all eight pseudopatients and details surrounding their hospitalizations. All the names or aliases and the hospital names had also been changed.

Cahalan’s approach is to write about three parallel subjects. The most thorough and objective analysis is about the pseudopatient experiment. She covers everything from the available remaining data and the problems with it to the likelihood that the experiment actually occurred the way it was described in the Science paper. The second broad subject was a character study of Rosenhan. How did people describe him? What was he like? Did people especially his colleagues believe that he conducted the experiment. And finally, the book is a vehicle for Cahalan to comment on psychiatry. She comes to this work with the direct experience of having experienced autoimmune encephalitis and writing about that experience in the book Brain on Fire.

Reading the original paper is a good starting point for understanding the book. If you do pull up that article, a few details are immediately evident. The author begins the introduction using the terms “sane” and “insane” as though this is technical language used by psychiatrists. That use of language is interesting because he is listed as a professor of both psychology and law at Stanford. Since the days of my training, insanity is a strictly legal term and it is without meaning in psychiatry. The use of these legal terms allows him to point out the unreliability of the “sane”-“insane” dichotomy based on expert witnesses disagreeing in adversarial court hearings. That has nothing to do with the clinical diagnoses in psychiatry. To what extent were formal diagnoses used in 1973? Rosenhan refers to the Diagnostic and Statistical Manual in the body of his paper. Interestingly, the authors of my community psychiatry paper (3) reported on the 2-year follow-up of patients from the International Pilot Study of Schizophrenia (1973) and concluded that schizophrenia could be reliably diagnosed so that international comparisons and follow up were possible. A sanity metric during the same time frame is crude by comparison. There are many additional examples of a lack of objectivity toward the issue of psychiatric diagnosis in the introductory section of the paper (paragraphs 4-7) and the discussion. Excellent critiques of the scientific merit of the paper were available at the time most notably by Robert Spitzer.

The author describes his pseudopatient experiment as consisting of 8 people – three women and four men of various occupations. Cahalan identifies Rosenhan as pseudopatient number 1. Twelve hospitals in various locations were chosen. One was a private hospital. Pseudopatients were supposed to call the hospital, present for an intake appointment, and then complain that they were hearing voices. When asked to elaborate they were supposed to say the voices were unclear except for the words “empty”, “hollow”, and “thud”. Rosenhan provides a rationalization for this symptom choice about how on the one hand these symptoms were supposed to have existential meaning and yet there was not a single report of existential psychosis in the literature. Once admitted, the patient was supposed to cease simulating any symptoms and give their actual social history and behave “normally”. They were to take notes and be as cooperative as possible to get discharged. The length of stay was 7-52 days with an average of 19 days.

Rosenhan also claims in the body of this paper that a second experiment occurred at a “research and teaching hospital” where the staff were informed ahead of time that pseudopatients were going to seek admission during a 3-month period. Staff were asked to rate whether a patient was a pseudopatient or not. Of 193 admissions during that time 41 were ranked as likely being a pseudopatient. In this case, Rosenhan did not send any pseudopatients to the facility and claims this false experiment represents “massive errors”.

One of the elements of the paper that is really never discussed is it structure. The primary data points were eight pseudopatients were admitted and discharged from psychiatric hospitals without being discovered. The secondary data points were a series of observations of the staff that is largely unstructured, highly anecdotal, and contrasted with other situations that seem to lack relevance. The bulk of Rosenhan’s discussion is judgmental and there is no discussion of the limitations of the experimental design or data. Instead the author leaps to clear-cut conclusions that are in some cases only peripherally connected to the data.

Cahalan expends a lot of effort to try to identify and find the pseudopatients and ask them what their experience was like. She locates the records of Rosenhan’s own admission as a pseudopatient. The first real sign of a departure from the research protocol described in Science, occurs in Rosenhan’s recorded admission interview. He recited the voices script and said the symptoms had been going on for four months. He was admitted on an involuntary commitment and discharged nine days later. The hospitalization ended in 1969 - four years before the article came out. The first major sign that the experiment described in Science was not quite the way it was described in the paper occurs when Cahalan looks at the record of the admission interview. In addition to the vague description of hallucinations, Rosenhan states that he believes he can “hear what people are thinking”, that he has tried to “insulate out the noises by putting copper over my ears”, and that he has “suicidal thoughts”. These are all more serious psychiatric symptoms than factitious “existential hallucinations”. Rosenhan also altered his occupational history during one assessment to say that his psychiatric illness led him to give up a job in economics 10 years earlier. At one point he stated that his wife is probably unaware of how useless he felt and that “everyone would be better off if he was not around”. Considering the seriousness of his fake history, I was surprised that he was discharged in 9 days.

What about the other 8 pseudopatients? Cahalan was able to locate two – only one of whom was part of the research protocol and shared Rosenhan’s experience. The second patient started out as a psychologist and co-authored a couple of papers with Rosenhan. The author was surprised at how little preparation went into the pseudopatient role. Patient 2 was taught to cheek medications and spit them out. He was reassured by Rosenhan that he had filed a writ of habeus corpus to get him out of the hospital at any time. When Cahalan tracked down that attorney who said the writs had been discussed but never prepared and that he did not consider himself to be “on call” to get pseudopatients immediately released. Patient 2 was also in the hospital for 9 days and basically released upon his request. There was no reason for discharge given on the official form but he recalled a psychiatrist approaching him prior to discharge and making remarks to suggest that there was still some concern that he may still be suicidal. Despite that concern there was apparently no discharge plan.

The third pseudopatient discovered by Cahalan was interesting in that he was eliminated from the original protocol and not counted by Rosenhan. Cahalan discovered that the ninth uncounted pseudopatient was a research psychologist named Harry Lando. Dr. Lando is well represented in the smoking cessation literature and had published an article in the Professional Psychologist (4) stressing the positive aspects of his pseudopatient experience. His observations were in direct contrast to Rosenhan and he states as much in the observation: “My overall impressions of the hospital are overwhelmingly positive. The powerlessness and depersonalization of patients so strongly emphasized by Rosenhan simply did not exist in this setting.” He goes on to suggest that using better hospitals as models may be a way to improve the quality of care. He also questions the ethics of placing pseudopatients in “already overcrowded and understaffed institutions”. Lando does express a concern about the diagnostic process since all three pseudopatients received diagnoses of schizophrenia.

The key question about why the data of the ninth pseudopatient was omitted from the original paper is answered as a footnote number 6 on page 258 of the original paper:

“Data from a ninth pseudopatient are not included in this study because although his sanity went undetected, he falsified aspects of his personal history. Including marital status and parental relationships. His experimental behaviors therefore were not identical to the other pseudopatients.”

That footnote is exactly what Rosenhan did when he was admitted as pseudopatient 1 as documented in the existing medical record. Rosenhan’s lapses were discovered and discussed by Cahalan and are included in the following table.

1. Data was improperly recorded. The two pseudo-patients interviewed by Cahalan pointed out that their durations of stay in the hospital were not correctly recorded.

2. His private notes indicated strong influence by Szasz and Laing. Prior to the pseudopatient experiment he assigned work to his students describing psychiatric hospitals as “authoritarian”, “degrading”, and “illness-maintaining”.

3. He told a pseudopatient that a writ of habeas corpus was prepared and an attorney was on call to get them out of the hospital if necessary. That was not true.

4. Professional and possibly “unethical” mistakes (p. 173) about length of stay in pseudopatient number two (7 days versus 8) and pseudopatient number 9 (26 days versus 9 days), patient population in the hospital 8,000 vs 1,510), the specific discharge diagnoses of pseudopatients 2 and 9, and details of staff behavior on the ward.

5. Sending a pseudo-patient into a hospital that was in disarray because it was closing.

6. Rosenhan at one point lied in correspondence to Spitzer about his stay in the hospital and said it was part of a “teaching exercise” that had nothing to do with research(p. 180). Cahalan describes this as “an outright lie”.

7. During his admission Rosenhan “goes off script” and gives far more fabricated symptoms and history than the “empty, hollow, thud” existential hallucinations he described in the protocol. Additional symptoms suggest a significant psychiatric disorder. He describes suicidal ideation and significant conflict with his employer – the same falsification of personal history that led him to eliminate the data of the ninth pseudopatient.

8. Rosenhan fabricated an excerpted portion of the medical record and both the original record and the excerpt are published for A - B comparison on page 190. Cahalan concludes that the facts “were distorted intentionally by Rosenhan himself.”

9. Inadequate preparation of the research subjects. Patient 2 ended up taking a dose of chlorpromazine and patient 9 was given liquid chlorpromazine so it could not be cheeked as instructed. Pseudopatient 9 estimated the preparation time for hospital admission by Rosenhan was about 15 minutes.

10. When patient 9 was eliminated from the study none of the data about pills dispensed or staff contact time in the paper was changed.

11. In an National Public Radio program that aired before the publication of his paper (December 14, 1972) he misstated his time in the hospital as a pseudopatient (several weeks versus 9 days) and the amount of medications dispensed to pseudopatients (5,000 pills versus 2,000 pills) while building to the conclusion that psychiatric hospitals are non-therapeutic and should be closed (p.234)

12. Pseudopatient 9 commented that what Rosenhan had written about him in the experiment was “total fiction” (p.269)

13. Rosenhan did not complete a book about the pseudopatient experience, despite an advance from the publisher, a subsequent lawsuit from the publisher and what is described as plenty of publicity around the time the paper came out in Science. He also never published on the topic again (p. 295).

Rosenhan did continue to publish a description and discussion of his study in the text Abnormal Psychology (5). The discussion emphasized that the simple hallucinations described with nothing else being unusual would have been detected outside of a hospital. In the context dependent setting it was not. In other words – he maintained one of the same themes as in the original paper.

One of the areas that really piqued my interest was why Science published this paper in the first place. Cahalan got the opinion from an academic psychologist that the peer review in a non-psychology journal would be less rigorous. When she approached the journal she was told that records were confidential and that they were not kept back that far. Accessing Retraction Watch (6) demonstrated that there has been a total of 120 papers retracted from Science since 1963. The reasons for the retractions are given as data errors, errors in methods, result errors, errors in conclusions, errors due to contaminated experiments, falsification/fabrication of data, irreproducible results, misconduct by the author, ethical violations by the author, investigation by a company, institution, or third-party. Only three of these papers had anything to do with psychiatry and those papers were primarily about the neurobiology of the brain. Cahalan’s investigation suggests that several of the reasons for retraction have been met.

Apart from the details of the Science paper, Cahalan also does a character study of Rosenhan. We learned that his brother had bipolar disorder and did well on lithium. It was suggested that was why he became interested in psychology. He was described as bright and charismatic. He was clearly influenced by the work of anti-psychiatrists and assigned work to his students that “describe psychiatric hospitals as authoritarian, degrading, and illness maintaining among other terms”. (p 73). The title of the book highlights Rosenhan’s characteristics as a raconteur who would occasionally pretend to be someone who he was not. His son described an incident in New York City where he introduced himself as a professor of engineering at Stanford in order to get a tour of an interesting construction site with his son. In another scene he is joking about the wig he wore to get into the psychiatric hospital. Cahalan finds the admission photo showing that he is bald without a wig. The people who knew him the best – acknowledge the he was difficult to know and just like Rosenhan’s arguments about psychiatric diagnoses being context dependent – his personality was as well.

Apart from academic books about the history of psychiatry – most books review sensational history and arguments that by their very nature diminish the field. This book is intermediate in that tone with those arguments interspersed through the investigative journalism about Rosenhan. They touch on the familiar themes of biological reductionism as opposed to a clinical psychiatry where patients are actually listened to with no reference to how clinical psychiatrists really practice every day. Some psychiatrists end up being caricatured and some are acknowledged as being highly motivated and humanistic. I am probably far too invested in clinical psychiatry and the good I have seen done to tolerate a journalist’s approach to the field. I give Cahalan credit for touching on the current situation that has resulted in severely rationed care and the transinstitutionalization of patients in jails. The overall concept that psychiatrists have little to do with the systems of care that are controlled by businesses and governments is not emphasized even though it was recognized as a problem by two of the pseudopatients. She also points out that the pseudopatient experiment is irrelevant to psychiatric practice today but her resounding theme throughout the book was that it was extremely relevant irrespective of what actually happened. The book also gives Rosenhan too much credit for psychiatric criticism. Like many books of this nature – there is little to no evidence that psychiatrists might be their own best critics or that outrage might be a legitimate reaction to outrageous criticism rather than defensiveness.

In conclusion The Great Pretender identifies very specific problems with the original Rosenhan paper that have been listed in the narrative and table in this report. He gained initial celebrity status from the study and signed a book contract. Even though he was given an advance on the book and wrote a manuscript he never produced a book. The author suggests that may have been due to the fact that Robert Spitzer was aware of Rosenhan’s nonadherence to the research protocol during his admission. As Rosenhan withdrew from the pseudopatient limelight he also stated that none of his research should lead to the conclusion that psychiatric hospitals were unnecessary and that represented a complete turnaround form earlier statements.

The controversy, the original paper and the book could be the subject of seminars in the history or philosophical aspects of psychiatry. It touches on a number of themes primarily the ethics of research and how it should be conducted. It also touches on psychiatric criticism and may be useful in discussing how future generations of psychiatrists can prepare to deal with it.

1: Susannah Cahalan. The Great Pretender. Grand Central Publishing. New York, 2019. 382 p.

2: Rosenhan DL. On being sane in insane places. Science 1973 Jan 19179(4070):250-258.

3: Sartorius N, Jablensky A, Shapiro R. Cross-cultural differences in the short-term prognosis of schizophrenic psychoses. Schizophr Bull. 19784(1):102 ‐ 113. doi:10.1093/schbul/4.1.102

4: Lando, H. A. (1976). On being sane in insane places: A supplemental report. Professional Psychology, 7(1), 47󈞠. https://doi.org/10.1037/0735-7028.7.1.47

5: David E. Rosenhan, Martin E.P. Seligman. Abnormal Psychology- 2 nd Ed. WW Norton and Company, New York City, 1984, 1989 p 181-183.

7: Gaudino M, Robinson NB, Audisio K, et al. Trends and Characteristics of Retracted Articles in the Biomedical Literature, 1971 to 2020. JAMA Intern Med. Published online May 10, 2021. doi:10.1001/jamainternmed.2021.1807

The authors cite retracted literature (5209 papers) back to the year 1923. Scientific misconduct like fabrication of data was cited as the most common reason.

The review was written for Philosophy Special Interest Group of the Royal College of Psychiatrists September 2020 newsletter and it can be found starting on page 8.


The Rosenhan Study: On Being Sane in Insane Places

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

The question is neither capricious nor itself insane. However much we may be personally convinced that we can tell the normal from the abnormal, the evidence is simply not compelling. It is commonplace, for example, to read about murder trials wherein eminent psychiatrists for the defense are contradicted by equally eminent psychiatrists for the prosecution on the matter of the defendant's sanity. More generally, there are a great deal of conflicting data on the reliability, utility, and meaning of such terms as "sanity," "insanity," "mental illness," and "schizophrenia" [1]. Finally, as early as 1934, Benedict suggested that normality and abnormality are not universal. [2] What is viewed as normal in one culture may be seen as quite aberrant in another. Thus, notions of normality and abnormality may not be quite as accurate as people believe they are.

To raise questions regarding normality and abnormality is in no way to question the fact that some behaviors are deviant or odd. Murder is deviant. So, too, are hallucinations. Nor does raising such questions deny the existence of the personal anguish that is often associated with "mental illness." Anxiety and depression exist. Psychological suffering exists. But normality and abnormality, sanity and insanity, and the diagnoses that flow from them may be less substantive than many believe them to be.

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? From Bleuler, through Kretchmer, through the formulators of the recently revised Diagnostic and Statistical Manual of the American Psychiatric Association, the belief has been strong that patients present symptoms, that those symptoms can be categorized, and, implicitly, that the sane are distinguishable from the insane. More recently, however, this belief has been questioned. Based in part on theoretical and anthropological considerations, but also on philosophical, legal, and therapeutic ones, the view has grown that psychological categorization of mental illness is useless at best and downright harmful, misleading, and pejorative at worst. Psychiatric diagnoses, in this view, are in the minds of observers and are not valid summaries of characteristics displayed by the observed. [3-5]

Gains can be made in deciding which of these is more nearly accurate by getting normal people (that is, people who do not have, and have never suffered, symptoms of serious psychiatric disorders) admitted to psychiatric hospitals and then determining whether they were discovered to be sane and, if so, how. If the sanity of such pseudopatients were always detected, there would be prima facie evidence that a sane individual can be distinguished from the insane context in which he is found. Normality (and presumably abnormality) is distinct enough that it can be recognized wherever it occurs, for it is carried within the person. If, on the other hand, the sanity of the pseudopatients were never discovered, serious difficulties would arise for those who support traditional modes of psychiatric diagnosis. Given that the hospital staff was not incompetent, that the pseudopatient had been behaving as sanely as he had been out of the hospital, and that it had never been previously suggested that he belonged in a psychiatric hospital, such an unlikely outcome would support the view that psychiatric diagnosis betrays little about the patient but much about the environment in which an observer finds him.

This article describes such an experiment. Eight sane people gained secret admission to 12 different hospitals [6]. Their diagnostic experiences constitute the data of the first part of this article the remainder is devoted to a description of their experiences in psychiatric institutions. Too few psychiatrists and psychologists, even those who have worked in such hospitals, know what the experience is like. They rarely talk about it with former patients, perhaps because they distrust information coming from the previously insane. Those who have worked in psychiatric hospitals are likely to have adapted so thoroughly to the settings that they are insensitive to the impact of that experience. And while there have been occasional reports of researchers who submitted themselves to psychiatric hospitalization [7], these researchers have commonly remained in the hospitals for short periods of time, often with the knowledge of the hospital staff. It is difficult to know the extent to which they were treated like patients or like research colleagues. Nevertheless, their reports about the inside of the psychiatric hospital have been valuable. This article extends those efforts.

PSEUDOPATIENTS AND THEIR SETTINGS

The eight pseudopatients were a varied group. One was a psychology graduate student in his 20's. The remaining seven were older and "established." Among them were three psychologists, a pediatrician, a psychiatrist, a painter, and a housewife. Three pseudopatients were women, five were men. All of them employed pseudonyms, lest their alleged diagnoses embarrass them later. Those who were in mental health professions alleged another occupation in order to avoid the special attentions that might be accorded by staff, as a matter of courtesy or caution, to ailing colleagues.[8] With the exception myself (I was the first pseudopatient and my presence was known to the hospital administration and chief psychologist and, so far as I can tell, to them alone), the presence of pseudopatients and the nature of the research program was not known to the hospital staffs.[9]

The settings are similarly varied. In order to generalize the findings, admission into a variety of hospitals was sought. The 12 hospitals in the sample were located in five different states on the East and West coasts. Some were old and shabby, some were quite new. Some had good staff-patient ratios, others were quite understaffed. Only one was a strict private hospital. All of the others were supported by state or federal funds or, in one instance, by university funds.

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 choice of these symptoms was occasioned by their apparent similarity to existential symptoms. Such symptoms are alleged to arise from painful concerns about the perceived meaninglessness of one's life. It is as if the hallucinating person were saying, "My life is empty and hollow." The choice of these symptoms was also determined by the absence of a single report of existential psychoses in the literature.

Beyond alleging the symptoms and falsifying name, vocation, and employment, no further alterations of person, history, or circumstances were made. The significant events of the pseudopatient's life history were presented as they had actually occurred. Relationships with parents and siblings, with spouse and children, with people at work and in school, consistent with the aforementioned exceptions, were described as they were or had been. Frustrations and upsets were described along with joys and satisfactions. These facts are important to remember. If anything, they strongly biased the subsequent results in favor of detecting insanity, since none of their histories or current behaviors were seriously pathological in any way.

Immediately upon admission to the psychiatric ward, the pseudopatient ceased simulating any symptoms of abnormality. In some cases, there was a brief period of mild nervousness and anxiety, since none of the pseudopatients really believed that they would be admitted so easily. Indeed, their shared fear was that they would be immediately exposed as frauds and greatly embarrassed. Moreover, many of them had never visited a psychiatric ward even those who had, nevertheless had some genuine fears about what might happen to them. Their nervousness, then, was quite appropriate to the novelty of the hospital setting, and it abated rapidly.

Apart from that short-lived nervousness, the pseudopatient behaved on the ward as he "normally" behaved. The pseudopatient spoke to patients and staff as he might ordinarily. Because there is uncommonly little to do on a psychiatric ward, he attempted to engage others in conversation. When asked by staff how he was feeling, he indicated that he was fine, that he no longer experienced symptoms. He responded to instructions from attendants, to calls for medication (which was not swallowed), and to dining-hall instructions. Beyond such activities as were available to him on the admissions ward, he spent his time writing down his observations about the ward, its patients, and the staff. Initially these notes were written "secretly," but as it soon became clear that no one much cared, they were subsequently written on standard tablets of paper in such public places as the dayroom. No secret was made of these activities.

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. The psychological stresses associated with hospitalization were considerable, and all but one of the pseudopatients desired to be discharged almost immediately after being admitted. They were, therefore, motivated not only to behave sanely, but to be paragons of cooperation. That their behavior was in no way disruptive is confirmed by nursing reports, which have been obtained on most of the patients. These reports uniformly indicate that the patients were "friendly," "cooperative," and "exhibited no abnormal indications."

THE NORMAL ARE NOT DETECTABLY SANE

Despite their public "show" of sanity, the pseudopatients were never detected. Admitted, except in one case, with a diagnosis of schizophrenia [10], each was discharged with a diagnosis of schizophrenia "in remission." The label "in remission" should in no way be dismissed as a formality, for at no time during any hospitalization had any question been raised about any pseudopatient's simulation. Nor are there any indications in the hospital records that the pseudopatient's status was suspect. Rather, the evidence is strong that, once labeled schizophrenic, the pseudopatient was stuck with that label. If the pseudopatient was to be discharged, he must naturally be "in remission" but he was not sane, nor, in the institution's view, had he ever been sane.

The uniform failure to recognize sanity cannot be attributed to the quality of the hospitals, for, although there were considerable variations among them, several are considered excellent. Nor can it be alleged that there was simply not enough time to observe the pseudopatients. Length of hospitalization ranged from 7 to 52 days, with an average of 19 days. The pseudopatients were not, in fact, carefully observed, but this failure speaks more to traditions within psychiatric hospitals than to lack of opportunity.

Finally, it cannot be said that the failure to recognize the pseudopatients' sanity was due to the fact that they were not behaving sanely. While there was clearly some tension present in all of them, their daily visitors could detect no serious behavioral consequences -- nor, indeed, could other patients. It was quite common for the patients to "detect" the pseudopatient's sanity. During the first three hospitalizations, when accurate counts were kept, 35 of a total of 118 patients on the admissions ward voiced their suspicions, some vigorously. "You're not crazy. You're a journalist, or a professor (referring to the continual note-taking). You're checking up on the hospital." While most of the patients were reassured by the pseudopatient's insistence that he had been sick before he came in but was fine now, some continued to believe that the pseudopatient was sane throughout his hospitalization [11]. The fact that the patients often recognized normality when staff did not raises important questions.

Failure to detect sanity during the course of hospitalization may be due to the fact that physicians operate with a strong bias toward what statisticians call the Type 2 error [5]. 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.

But what holds for medicine does not hold equally well for psychiatry. Medical illnesses, while unfortunate, are not commonly pejorative. Psychiatric diagnoses, on the contrary, carry with them personal, legal, and social stigmas [12]. It was therefore important to see whether the tendency toward diagnosing the sane insane could be reversed. The following experiment was arranged at a research and teaching hospital whose staff had heard these findings but doubted that such an error could occur in their hospital. The staff was informed that at some time during the following three months, one or more pseudopatients would attempt to be admitted into the psychiatric hospital. Each staff member was asked to rate each patient who presented himself at admissions or on the ward according to the likelihood that the patient was a pseudopatient. A 10-point scale was used, with a 1 and 2 reflecting high confidence that the patient was a pseudopatient.

Judgments were obtained on 193 patients who were admitted for psychiatric treatment. All staff who had had sustained contact with or primary responsibility for the patient -- attendants, nurses, psychiatrists, physicians, and psychologists -- were asked to make judgments. Forty-one patients were alleged, with high confidence, to be pseudopatients by at least one member of the staff. Twenty-three were considered suspect by at least one psychiatrist. Nineteen were suspected by one psychiatrist and one other staff member. Actually, no genuine pseudopatient (at least from my group) presented himself during this period.

The experiment is instructive. It indicates 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 what can be said of the 19 people who were suspected of being "sane" by one psychiatrist and another staff member? Were these people truly "sane" or was it rather the case that in the course of avoiding the Type 2 error the staff tended to make more errors of the first sort -- calling the crazy "sane"? There is no way of knowing. But one thing is certain: any diagnostic process that lends itself too readily to massive errors of this sort cannot be a very reliable one.

THE STICKINESS OF PSYCHODIAGNOSTIC LABELS

Beyond the tendency to call the healthy sick -- a tendency that accounts better for diagnostic behavior on admission than it does for such behavior after a lengthy period of exposure -- the data speak to the massive role of labeling in psychiatric assessment. Having once been labeled schizophrenic, there is nothing the pseudopatient can do to overcome the tag. The tag profoundly colors others' perceptions of him and his behavior.

From one viewpoint, these data are hardly surprising, for it has long been known that elements are given meaning by the context in which they occur. Gestalt psychology made the point vigorously, and Asch [13] demonstrated that there are "central" personality traits (such as "warm" versus "cold") which are so powerful that they markedly color the meaning of other information in forming an impression of a given personality [14]. "Insane," "schizophrenic," "manic-depressive," and "crazy" are probably among the most powerful of such central traits. Once a person is designated abnormal, all of his other behaviors and characteristics are colored by that label. Indeed, that label is so powerful that many of the pseudopatients' normal behaviors were overlooked entirely or profoundly misinterpreted. Some examples may clarify this issue.

Earlier, I indicated that there were no changes in the pseudopatient's personal history and current status beyond those of name, employment, and, where necessary, vocation. Otherwise, a veridical description of personal history and circumstances was offered. Those circumstances were not psychotic. How were they made consonant with the diagnosis modified in such a way as to bring them into accord with the circumstances of the pseudopatient's life, as described by him?

As far as I can determine, diagnoses were in no way affected by the relative health of the circumstances of a pseudopatient's life. Rather, the reverse occurred: the perception of his circumstances was shaped entirely by the diagnosis. A clear example of such translation is found in the case of a pseudopatient who had had a close relationship with his mother but was rather remote from his father during his early childhood. During adolescence and beyond, however, his father became a close friend, while his relationship with his mother cooled. His present relationship with his wife was characteristically close and warm. Apart from occasional angry exchanges, friction was minimal. The children had rarely been spanked. Surely there is nothing especially pathological about such a history. Indeed, many readers may see a similar pattern in their own experiences, with no markedly deleterious consequences. Observe, however, how such a history was translated in the psychopathological context, this from the case summary prepared after the patient was discharged.

This white 39-year-old male. manifests a long history of considerable ambivalence in close relationships, which begins in early childhood. A warm relationship with his mother cools during his adolescence. A distant relationship with his father is described as becoming very intense. Affective stability is absent. His attempts to control emotionality with his wife and children are punctuated by angry outbursts and, in the case of the children, spankings. And while he says that he has several good friends, one senses considerable ambivalence embedded in those relationships also.

The facts of the case were unintentionally distorted by the staff to achieve consistency with a popular theory of the dynamics of a schizophrenic reaction [15]. Nothing of an ambivalent nature had been described in relations with parents, spouse, or friends. To the extent that ambivalence could be inferred, it was probably not greater than is found in all human relationships. It is true the pseudopatient's relationships with his parents changed over time, but in the ordinary context that would hardly be remarkable -- indeed, it might very well be expected. Clearly, the meaning ascribed to his verbalizations (that is, ambivalence, affective instability) was determined by the diagnosis: schizophrenia. An entirely different meaning would have been ascribed if it were known that the man was "normal."

All pseudopatients took extensive notes publicly. Under ordinary circumstances, such behavior would have raised questions in the minds of observers, as, in fact, it did among patients. Indeed, it seemed so certain that the notes would elicit suspicion that elaborate precautions were taken to remove them from the ward each day. But the precautions proved needless. The closest any staff member came to questioning those notes occurred when one pseudopatient asked his physician what kind of medication he was receiving and began to write down the response. "You needn't write it," he was told gently. "If you have trouble remembering, just ask me again."

If no questions were asked of the pseudopatients, how was their writing interpreted? Nursing records for three patients indicate that the writing was seen as an aspect of their pathological behavior. "Patient engaged in writing behavior" was the daily nursing comment on one of the pseudopatients who was never questioned about his writing. Given that the patient is in the hospital, he must be psychologically disturbed. And given that he is disturbed, continuous writing must be behavioral manifestation of that disturbance, perhaps a subset of the compulsive behaviors that are sometimes correlated with schizophrenia.

One tacit characteristic of psychiatric diagnosis is that it locates the sources of aberration within the individual and only rarely within the complex of stimuli that surrounds him. Consequently, behaviors that are stimulated by the environment are commonly misattributed to the patient's disorder. For example, one kindly nurse found a pseudopatient pacing the long hospital corridors. "Nervous, Mr. X?" she asked. "No, bored," he said.

The notes kept by pseudopatients are full of patient behaviors that were misinterpreted by well-intentioned staff. Often enough, a patient would go "berserk" because he had, wittingly or unwittingly, been mistreated by, say, an attendant. A nurse coming upon the scene would rarely inquire even cursorily into the environmental stimuli of the patient's behavior. Rather, she assumed that his upset derived from his pathology, not from his present interactions with other staff members. Occasionally, the staff might assume that the patient's family (especially when they had recently visited) or other patients had stimulated the outburst. But never were the staff found to assume that one of themselves or the structure of the hospital had anything to do with a patient's behavior. 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 behavior 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.

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. When a sufficient amount of time has passed, during which the patient has done nothing bizarre, he is considered to be in remission and available for discharge. But the label endures beyond discharge, with the unconfirmed expectation that he will behave as a schizophrenic again. 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. Eventually, the patient himself accepts the diagnosis, with all of its surplus meanings and expectations, and behaves accordingly [5].

The inferences to be made from these matters are quite simple. Much as Zigler and Phillips have demonstrated that there is enormous overlap in the symptoms presented by patients who have been variously diagnosed [16], so there is enormous overlap in the behaviors of the sane and the insane. The sane are not "sane" all of the time. We lose our tempers "for no good reason." We are occasionally depressed or anxious, again for no good reason. And we may find it difficult to get along with one or another person -- again for no reason that we can specify. Similarly, the insane are not always insane. Indeed, it was the impression of the pseudopatients while living with them that they were sane for long periods of time -- that the bizarre behaviors upon which their diagnoses were allegedly predicated constituted only a small fraction of their total behavior. If it makes no sense to label ourselves permanently depressed on the basis of an occasional depression, then it takes better evidence than is presently available to label all patients insane or schizophrenic on the basis of bizarre behaviors or cognitions. It seems more useful, as Mischel [17] has pointed out, to limit our discussions to behaviors, the stimuli that provoke them, and their correlates.

It is not known why powerful impressions of personality traits, such as "crazy" or "insane," arise. Conceivably, when the origins of and stimuli that give rise to a behavior are remote or unknown, or when the behavior strikes us as immutable, trait labels regarding the behavior arise. When, on the other hand, the origins and stimuli are known and available, discourse is limited to the behavior itself. Thus, I may hallucinate because I am sleeping, or I may hallucinate because I have ingested a peculiar drug. These are termed sleep-induced hallucinations, or dreams, and drug-induced hallucinations, respectively. But when the stimuli to my hallucinations are unknown, that is called craziness, or schizophrenia -- as if that inference were somehow as illuminating as the others.

THE EXPERIENCE OF PSYCHIATRIC HOSPITALIZATION

The term "mental illness" is of recent origin. It was coined by people who were humane in their inclinations and who wanted very much to raise the station of (and the public's sympathies toward) the psychologically disturbed from that of witches and "crazies" to one that was akin to the physically ill. And they were at least partially successful, for the treatment of the mentally ill has improved considerably over the years. 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 [18]. A broken leg does not threaten the observer, but a crazy schizophrenic? There is by now a host of evidence that attitudes toward the mentally ill are characterized by fear, hostility, aloofness, suspicion, and dread [19]. The mentally ill are society's lepers.

That such attitudes infect the general population is perhaps not surprising, only upsetting. But that they affect the professionals -- attendants, nurses, physicians, psychologists and social workers -- 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.

Consider the structure of the typical psychiatric hospital. Staff and patients are strictly segregated. Staff have their own living space, including their dining facilities, bathrooms, and assembly places. The glassed quarters that contain the professional staff, which the pseudopatients came to call "the cage," sit out on every dayroom. The staff emerge primarily for care-taking purposes -- to give medication, to conduct therapy or group meeting, to instruct or reprimand a patient. Otherwise, staff keep to themselves, almost as if the disorder that afflicts their charges is somehow catching.

So much is patient-staff segregation the rule that, for four public hospitals in which an attempt was made to measure the degree to which staff and patients mingle, it was necessary to use "time out of the staff cage" as the operational measure. While it was not the case that all time spent out of the cage was spent mingling with patients (attendants, for example, would occasionally emerge to watch television in the dayroom), it was the only way in which one could gather reliable data on time for measuring.

The average amount of time spent by attendants outside of the cage was 11.3 percent (range, 3 to 52 percent). This figure does not represent only time spent mingling with patients, but also includes time spent on such chores as folding laundry, supervising patients while they shave, directing ward cleanup, and sending patients to off-ward activities. It was the relatively rare attendant who spent time talking with patients or playing games with them. It proved impossible to obtain a "percent mingling time" for nurses, since the amount of time they spent out of the cage was too brief. Rather, we counted instances of emergence from the cage. On the average, daytime nurses emerged from the cage 11.5 times per shift, including instances when they left the ward entirely (range, 4 to 39 times). Later afternoon and night nurses were even less available, emerging on the average 9.4 times per shift (range, 4 to 41 times). Data on early morning nurses, who arrived usually after midnight and departed at 8 a.m., are not available because patients were asleep during most of this period.

Physicians, especially psychiatrists, were even less available. They were rarely seen on the wards. Quite commonly, they would be seen only when they arrived and departed, with the remaining time being spend in their offices or in the cage. On the average, physicians emerged on the ward 6.7 times per day (range, 1 to 17 times). It proved difficult to make an accurate estimate in this regard, since physicians often maintained hours that allowed them to come and go at different times.

The hierarchical organization of the psychiatric hospital has been commented on before [20], but the latent meaning of that kind of organization is worth noting again. Those with the most power have the least to do with patients, and those with the least power are the most involved with them. Recall, however, that the acquisition of role-appropriate behaviors occurs mainly through the observation of others, with the most powerful having the most influence. Consequently, it is understandable that attendants not only spend more time with patients than do any other members of the staff -- that is required by their station in the hierarchy -- but, also, insofar as they learn from their superior's behavior, spend as little time with patients as they can. Attendants are seen mainly in the cage, which is where the models, the action, and the power are.

I turn now to a different set of studies, these dealing with staff response to patient-initiated contact. It has long been known that the amount of time a person spends with you can be an index of your significance to him. If he initiates and maintains eye contact, there is reason to believe that he is considering your requests and needs. If he pauses to chat or actually stops and talks, there is added reason to infer that he is individuating you. In four hospitals, the pseudopatients approached the staff member with a request which took the following 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?"). While the content of the question varied according to the appropriateness of the target and the pseudopatient's (apparent) current needs the form was always a courteous and relevant request for information. Care was taken never to approach a particular member of the staff more than once a day, lest the staff member become suspicious or irritated. In examining these data, remember that the behavior of the pseudopatients was neither bizarre nor disruptive. One could indeed engage in good conversation with them.

The data from these experiments are shown in Table 1, separately for physicians (column one) and for nurses and attendants (column 2). Minor differences between these four institutions were overwhelmed by the degree to which staff avoided continuing contacts that patients had initiated. By far, their most common response consisted of either a brief response to the question, offered while they were "on the move" and with head averted, or no response at all.

The encounter frequently took the following bizarre form: (pseudopatient) "Pardon me, Dr. X. Could you tell me when I am eligible for grounds privileges?" (physician) "Good morning, Dave. How are you today?" (Moves off without waiting for a response.)


It is instructive to compare these data with data recently obtained at Stanford University. It has been alleged that large and eminent universities are characterized by faculty who are so busy that they have no time for students. For this comparison, a young lady approached individual faculty members who seemed to be walking purposefully to some meeting or teaching engagement and asked them the following six questions.
1) "Pardon me, could you direct me to Encina Hall?" (at the medical school: ". . . to the Clinical Research Center?").
2) "Do you know where Fish Annex is?" (there is no Fish Annex at Stanford).
3) "Do you teach here?"
4) "How does one apply for admission to the college?" (at the medical school: ". . . to the medical school?").
5) "Is it difficult to get in?"
6) "Is there financial aid?"
Without exception, as can be seen in Table 1 (column 3), all of the questions were answered. No matter how rushed they were, all respondents not only maintained eye contact, but stopped to talk. Indeed, many of the respondents went out of their way to direct or take the questioner to the office she was seeking, to try to locate "Fish Annex," or to discuss with her the possibilities of being admitted to the university.

Similar data, also shown in Table 1 (columns 4, 5, and 6), were obtained in the hospital. Here too, the young lady came prepared with six questions. After the first question, however, she remarked to 18 of her respondents (column 4), "I'm looking for a psychiatrist," and to 15 others (column 5), "I'm looking for an internist." Ten other respondents received no inserted comment (column 6). The general degree of cooperative responses is considerably higher for these university groups than it was for pseudopatients in psychiatric hospitals. Even so, differences are apparent within the medical school setting. Once having indicated that she was looking for a psychiatrist, the degree of cooperation elicited was less than when she sought an internist.

POWERLESSNESS AND DEPERSONALIZATION

Eye contact and verbal contact reflect concern and individuation their absence, avoidance and depersonalization. The data I have presented do not do justice to the rich daily encounters that grew up around matters of depersonalization and avoidance. I have records of patients who were beaten by staff for the sin of having initiated verbal contact. During my own experience, for example, 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. Nevertheless, they appeared to go unquestioned. 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, "Come on, you m-----f-----s, out of bed!"

Neither anecdotal nor "hard" data can convey the overwhelming sense of powerlessness which invades the individual as he is continually exposed to the depersonalization of the psychiatric hospital. It hardly matters which psychiatric hospital -- the excellent public ones and the very plush private hospital were better than the rural and shabby ones in this regard, but, again, the features that psychiatric hospitals had in common overwhelmed by far their apparent differences.

Powerlessness was evident everywhere.

The patient is deprived of many of his legal rights by dint of his psychiatric commitment [21]. 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 history and anguish is available to any staff member (often including the "grey lady" and "candy striper" volunteer) who chooses to read his folder, regardless of their therapeutic relationship to him. 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. Upon being admitted, I and other pseudopatients took the initial physical examinations in a semipublic room, where staff members went about their own business as if we were not there.

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 behavior, on the other hand, terminated quite abruptly when other staff members were known to be coming. Staff are credible witnesses. Patients are not.

A nurse unbuttoned her uniform to adjust her brassiere in the present of an entire ward of viewing men. One did not have the sense that she was being seductive. Rather, she didn't notice us. A group of staff persons might point to a patient in the dayroom and discuss him animatedly, as if he were not there.

One illuminating instance of depersonalization and invisibility occurred with regard to medication. All told, the pseudopatients were administered nearly 2,100 pills, including Elavil, Stelazine, Compazine, and Thorazine, to name but a few. (That such a variety of medications should have been administered to patients presenting identical symptoms is itself worthy of note.) Only two were swallowed. The rest were either pocketed or deposited in the toilet. The pseudopatients were not alone in this. Although I have no precise records on how many patients rejected their medications, the pseudopatients frequently found the medications of other patients in the toilet before they deposited their own. As long as they were cooperative, their behavior and the pseudopatients' own in this matter, as in other important matters, went unnoticed throughout.

Reactions to such depersonalization among pseudopatients were intense. Although they had come to the hospital as participant observers and were fully aware that they did not "belong," they nevertheless found themselves caught up in and fighting the process of depersonalization. Some examples: a graduate student in psychology asked his wife to bring his textbooks to the hospital so he could "catch up on his homework" -- this despite the elaborate precautions taken to conceal his professional association. The same student, who had trained for quite some time to get into the hospital, and who had looked forward to the experience, "remembered" some drag races that he had wanted to see on the weekend and insisted that he be discharged by that time. Another pseudopatient attempted a romance with a nurse. Subsequently, he informed the staff that he was applying for admission to graduate school in psychology and was very likely to be admitted, since a graduate professor was one of his regular hospital visitors. The same person began to engage in psychotherapy with other patients -- all of this as a way of becoming a person in an impersonal environment.

THE SOURCES OF DEPERSONALIZATION

What are the origins of depersonalization? I have already mentioned two. First are attitudes held by all of us toward the mentally ill -- including those who treat them -- attitudes characterized by fear, distrust, and horrible expectations on the one hand, and benevolent intentions on the other. Our ambivalence leads, in this instance as in others, to avoidance.

Second, and not entirely separate, the hierarchical structure of the psychiatric hospital facilitates depersonalization. Those who are at the top have least to do with patients, and their behavior inspires the rest of the staff. Average daily contact with psychiatrists, psychologists, residents, and physicians combined ranged form 3.9 to 25.1 minutes, with an overall mean of 6.8 (six pseudopatients over a total of 129 days of hospitalization). Included in this average are time spent in the admissions interview, ward meetings in the presence of a senior staff member, group and individual psychotherapy contacts, case presentation conferences and discharge meetings. Clearly, patients do not spend much time in interpersonal contact with doctoral staff. And doctoral staff serve as models for nurses and attendants.

There are probably other sources. Psychiatric installations are presently in serious financial straits. Staff shortages are pervasive, and that shortens patient contact. Yet, while financial stresses are realities, too much can be made of them. I have the impression that the psychological forces that result in depersonalization are much stronger than the fiscal ones and that the addition of more staff would not correspondingly improve patient care in this regard. The incidence of staff meetings and the enormous amount of record-keeping on patients, for example, have not been as substantially reduced as has patient contact. Priorities exist, even during hard times. Patient contact is not a significant priority in the traditional psychiatric hospital, and fiscal pressures do not account for this. Avoidance and depersonalization may.

Heavy reliance upon psychotropic medication tacitly contributes to depersonalization by convincing staff that treatment is indeed being conducted and that further patient contact may not be necessary. Even here, however, caution needs to be exercised in understanding the role of psychotropic drugs. If patients were powerful rather than powerless, if they were viewed as interesting individuals rather than diagnostic entities, if they were socially significant rather than social lepers, if their anguish truly and wholly compelled our sympathies and concerns, would we not seek contact with them, despite the availability of medications? Perhaps for the pleasure of it all?

THE CONSEQUENCES OF LABELING AND DEPERSONALIZATION

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 behavioral 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.

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? On the last point, recall again that a "Type 2 error" in psychiatric diagnosis does not have the same consequences it does in medical diagnosis. 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.

Finally, how 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, one that may be unique to institutions which harbor nether people? Goffman [4] calls the process of socialization to such institutions "mortification' -- an apt metaphor that includes the processes of depersonalization that have been described here. And while it is impossible to know whether the pseudopatients' responses to these processes are characteristic of all inmates -- they were, after all, not real patients -- it is difficult to believe that these processes of socialization to a psychiatric hospital provide useful attitudes or habits of response for living in the "real world."

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.

I do not, even now, understand this problem well enough to perceive solutions. But two matters seem to have some promise. The first concerns the proliferation of community mental health facilities, of crisis intervention centers, of the human potential movement, and of behavior therapies that, for all of their own problems, tend to avoid psychiatric labels, to focus on specific problems and behaviors, and to retain the individual in a relatively non-pejorative environment. Clearly, to the extent that we refrain from sending the distressed to insane places, our impressions of them are less likely to be distorted. (The risk of distorted perceptions, it seems to me, is always present, since we are much more sensitive to an individual's behaviors and verbalizations than we are to the subtle contextual stimuli than often promote them. At issue here is a matter of magnitude. And, as I have shown, the magnitude of distortion is exceedingly high in the extreme context that is a psychiatric hospital.)

The second matter that might prove promising speaks to the need to increase the sensitivity of mental health workers and researchers to the Catch 22 position of psychiatric patients. Simply reading materials in this area will be of help to some such workers and researchers. For others, directly experiencing the impact of psychiatric hospitalization will be of enormous use. Clearly, further research into the social psychology of such total institutions will both facilitate treatment and deepen understanding.

I and the other pseudopatients in the psychiatric setting had distinctly negative reactions. We do not pretend to describe the subjective experiences of true patients. Theirs may be different from ours, particularly with the passage of time and the necessary process of adaptation to one's environment. But we can and do speak to the relatively more objective indices of treatment within the hospital. It could be a mistake, and a very unfortunate one, to consider that what happened to us derived from malice or stupidity on the part of the staff. Quite the contrary, our overwhelming impression of them was of people who really cared, who were committed and who were uncommonly intelligent. Where they failed, as they sometimes did painfully, it would be more accurate to attribute those failures to the environment in which they, too, found themselves than to personal callousness. Their perceptions and behaviors were controlled by the situation, rather than being motivated by a malicious disposition. In a more benign environment, one that was less attached to global diagnosis, their behaviors and judgments might have been more benign and effective.

The author is professor of psychology and law at Stanford University, Stanford, California 94305. Portions of these data were presented to colloquiums of the psychology departments at the University of California at Berkeley and at Santa Barbara University of Arizona, Tucson and Harvard University, Cambridge, Massachusetts.

[1] P. Ash, J. Abnorm. Soc. Psychol. 44, 272 (1949) A. T. Beck, Amer. J. Psychiat. 119, 210 (1962) A. T. Boisen, Psychiatry 2, 233 (1938) N. Kreitman, J. Ment. Sci. 107, 876 (1961) N. Kreitman, P. Sainsbury, J. Morrisey, J. Towers, J. Scrivener, ibid., p. 887 H. O. Schmitt and C. P. Fonda, J. Abnorm. Soc. Psychol. 52, 262 (1956) W. Seeman, J. Nerv. Ment. Dis. 118, 541 (1953). For an analysis of these artifacts and summaries of the disputes, see J. Zubin, Annu. Rev. Psychol. 18, 373 (1967) L. Phillips and J. G. Draguns, ibid. 22, 447 (1971).

[2] R. Benedict, J.Gen. Psychol., 10, 59 (1934).

[3] See in this regard H. Becker, Outsiders: Studies in the Sociology of Deviance (Free Press, New York, 1963) B. M. Braginsky, D. D. Braginsky, K. Ring, Methods of Madness: The Mental Hospital as a Last Resort (Holt, Rinehart & Winston, New York, 1969) G. M. Crocetti and P. V. Lemkau, Amer. Sociol. Rev. 30, 577 (1965) E. Goffman, Behavior in Public Places (Free Press, New York, 1964) R. D. Laing, The Divided Self: A Study of Sanity and Madness (Quadrangle, Chicago, 1960) D. L. Phillips, Amer. Sociol. Rev. 28, 963 (1963) T. R. Sarbin, Psychol. Today 6, 18 (1972) E. Schur, Amer. J. Sociol. 75, 309 (1969) T. Szasz, Law, Liberty and Psychiatry (Macmillan, New York, 1963) The Myth of Mental Illness: Foundations of a Theory of Mental Illness (Hoeber-Harper, New York, 1963). For a critique of some of these views, see W. R. Gove, Amer. Sociol. Rev. 35, 873 (1970).

[4] E. Goffman, Asylums (Doubleday, Garden City, N.Y., 1961).

[5] T. J. Scheff, Being Mentally Ill: A Sociological Theory (Aldine, Chicago, 1966).

[6] Data from a ninth pseudopatient are not incorporated in this report because, although his sanity went undetected, he falsified aspects of his personal history, including his marital status and parental relationships. His experimental behaviors therefore were not identical to those of the other pseudopatients.

[7] A. Barry, Bellevue Is a State of Mind (Harcourt Brace Jovanovich, New York, 1971) I. Belknap, Human Problems of a State Mental Hospital (McGraw-Hill, New York, 1956) W. Caudill, F. C. Redlich, H. R. Gilmore, E. B. Brody, Amer. J. Orthopsychiat. 22, 314 (1952) A. R. Goldman, R. H. Bohr, T. A. Steinberg, Prof. Psychol. 1, 427 (1970) unauthored, Roche Report 1 (No. 13), 8 (1971).

[8] Beyond the personal difficulties that the pseudopatient is likely to experience in the hospital, there are legal and social ones that, combined, require considerable attention before entry. For example, once admitted to a psychiatric institution, it is difficult, if not impossible, to be discharged on short notice, state law to the contrary notwithstanding. I was not sensitive to these difficulties at the outset of the project, nor to the personal and situational emergencies that can arise, but later a writ of habeas corpus was prepared for each of the entering pseudopatients and an attorney was kept "on call" during every hospitalization. I am grateful to John Kaplan and Robert Bartels for legal advice and assistance in these matters.

[9] However distasteful such concealment is, it was a necessary first step to examining these questions. Without concealment, there would have been no way to know how valid these experiences were nor was there any way of knowing whether whatever detections occurred were a tribute to the diagnostic acumen of the staff or to the hospital's rumor network. Obviously, since my concerns are general ones that cut across individual hospitals and staffs, I have respected their anonymity and have eliminated clues that might lead to their identification.

[10] Interestingly, of the 12 admissions, 11 were diagnosed as schizophrenic and one, with the identical symptomalogy, as manic-depressive psychosis. This diagnosis has a more favorable prognosis, and it was given by the only private hospital in our sample. On the relations between social class and psychiatric diagnosis, see A. deB. Hollingshead and F. C. Redlich, Social Class and Mental Illness: A Community Study (Wiley, New York, 1958).

[11] It is possible, of course, that patients have quite broad latitudes in diagnosis and therefore are inclined to call many people sane, even those whose behavior is patently aberrant. However, although we have no hard data on this matter, it was our distinct impression that this was not the case. In many instances, patients not only singled us out for attention, but came to imitate our behaviors and styles.

[12] J. Cumming and E. Cumming, Community Ment. Health 1, 135 (1965) A. Farina and K. Ring, J. Abnorm. Psychol. 70, 47 (1965) H. E. Freeman and O. G. Simmons, The Mental Patient Comes Home (Wiley, New York, 1963) W. J. Johannsen, Ment. Hygiene 53, 218 (1969) A. S. Linsky, Soc. Psychiat. 5, 166 (1970).

[13] S. E. Asch, J. Abnorm. Soc. Psychol. 41, 258 (1946) Social Psychology (Prentice-Hall, New York, 1952).

[14] See also I. N. Mensh and J. Wishner, J. Personality 16, 188 (1947) J. Wishner, Psychol. Rev. 67, 96 (1960) J. S. Bruner and R. Tagiuri, in Handbook of Social Psychology, G. Lindzey, Ed. (Addison-Wesley, Cambridge, Mass., 1954), vol. 2, pp. 634-654 J. S. Bruner, D. Shapiro, R. Tagiuri, in Person Perception and Interpersonal Behavior, R. Tagiuri and L. Petrullo, Eds. (Stanford Univ. Press, Stanford, Calif., 1958), pp. 277-288.

[15] For an example of a similar self-fulfilling prophecy, in this instance dealing with the "central" trait of intelligence, see R. Rosenthal and L. Jacobson, Pygmalion in the Classroom (Holt, Rinehart & Winston, New York, 1968).

[16] E. Zigler and L. Phillips, J. Abnorm. Soc. Psychol. 63, 69 (1961). See also R. K. Freudenberg and J. P. Robertson, A.M.A. Arch. Neurol. Psychiatr. 76, 14 (1956).

[17] W. Mischel, Personality and Assessment (Wiley, New York, 1968).

[18] The most recent and unfortunate instance of this tenet is that of Senator Thomas Eagleton.

[19] T. R. Sarbin and J. C. Mancuso. J. Clin. Consult. Psychol. 35, 159 (1970) T. R. Sarbin, ibid. 31, 447 (1967) J. C. Nunnally, Jr., Popular Conceptions of Mental Health (Holt, Rinehart & Winston, New York, 1961).

[20] A. H. Stanton and M. S. Schwartz, The Mental Hospital: A Study of Institutional Participation in Psychiatric Illness and Treatment (Basic, New York, 1954).

[21] D. B. Wexler and S. E. Scoville, Ariz. Law Rev. 13, 1 (1971).

[22] I thank W. Mischel, E. Orne, and M. S. Rosenhan for comments on an earlier draft of this manuscript.

Originally published in Science, New Series, Vol. 179, No. 4070. (Jan. 19, 1973), pp. 250-258.

Copyright 1973 by the American Association for the Advancement of Science.
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The Rosenhan experiment examined

The study consisted of two parts. The first involved ‘pseudopatients’ – people who had never had symptoms of serious mental disorder – who, as part of the study, briefly reported auditory hallucinations in order to gain admission to psychiatric hospitals across the United States.

After admission, the pseudopatients no longer reported hallucinations and behaved as they ‘normally’ would. Despite this many were confined as inpatients for substantial periods of time and all were discharged with the diagnosis of a psychiatric disorder.

For the second part of the experiment staff at a teaching hospital, whose staff had learned of Rosenhan’s above results, were informed that one or more pseudopatients would attempt to be admitted to their hospital over an ensuing three month period. Many patients were subsequently identified as likely pseudopatients but in fact no pseudopatient had been sent.

‘On being sane…’ also examines, though the experience of the pseudopatients, the patient experience of psychiatric inpatient wards. This part of the paper is discussed often only in passing.

Rosenhan’s conclusion was stark: A psychiatric diagnosis is more a function of the situation in which the observer finds a patient and reveals little about a patient themselves.

“It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals“

Despite being over thirty years old the Rosenhan experiment remains well known and is often cited. Accounts of the experiment are widespread on the internet, but critiques are rarer and many people accept the study’s conclusions at face value.

This was an audacious experiment and the subsequent paper had an extremely good title, but was Rosenhan justified in his conclusion? Anthony Clare, amongst others, wrote that Rosenhan was ‘theorising in the absence of sufficient data’. But if Rosenhan was correct then his experiment remains extremely important as if diagnoses are in ‘the mind of the observer’ and do not reflect a quality inherent a patient, they are of little use.

If you wish to read the original paper it can be found here.

Spitzer’s 1975 critique is: Spitzer, Robert L More on pseudoscience in science and the case for psychiatric diagnosis Arch Gen Psychiatry Vol 33 April 1976

Davis’s critique here. Davis, Douglas A. On being detectably sane in insane places: Base rates and psychodiagnosis. Journal of Abnormal Psychology, Vol 85(4), Aug 1976, 416-422

Clare’s ‘Psychiatry in dissent’ is available in preview here.

Circumstances of diagnosis and the detecting of sanity.

In the experiment eight pseudopatients presented at psychiatric hospitals complaining of hearing a voice. Asked what the voices said, they replied that the voices were often unclear, but as far as they could tell, said “empty,” “hollow,” and “thud.” Beyond alleging this symptom, and falsifying their names and vocations, no other falsehoods were told. Upon admission to the ward the pseudopatients are reported to have ceased to claim symptoms and behaved as they ‘normally’ would.

Length of hospitalization was an average of 19 days during which time no pseudopatients were identified as fraudulent. All pseudopatients except one (diagnosed with bipolar disorder) were discharged with a diagnosis of ‘schizophrenia in remission’. In light of this Rosenhan regards there to have been ‘uniform failure to recognise sanity’. Rosenhan refused to identify the hospitals used on the grounds of his concern for confidentiality. This is laudable in some respects, but it makes it impossible for anyone at the hospitals in question to corroborate or refute this account of how the pseudopatients acted or were perceived.

It is a difficulty that Rosenhan seeks to answer whether patients can be identified as ‘sane’ or ‘insane’, whilst psychiatrists, whose practice he wishes to scrutinize, do not make such distinctions in their practice but instead aim to identify and treat what they view as psychiatric disorders. This objection aside, and working within this terminology, in his 1975 critique Spitzer identifies three possible meanings for ‘detecting of sanity’.

  1. Recognition, when he is first seen, that the pseudopatient is feigning insanity as he attempts to gain admission to the hospital. This would be detecting sanity in a sane person simulating insanity.
  2. Recognition, after having observed him acting normally during his hospitalization, that the pseudopatient was initially feigning insanity. This would be detecting that the currently sane person never was insane.
  3. Recognition, during hospitalization, that the pseudopatient, though initially appearing to be ‘insane’ was no longer showing signs of psychiatric disturbance.

Only the first two involve identifying a pseudopatient as a fraud and Spitzer feels that it is these that Rosenhan implies are all that are relevant to the central research question. He disagrees, writing that when the third definition of detecting of sanity is considered Rosenhan’s conclusions cannot be sustained.

This assertion hinges on Rosenhan’s report that all the pseudopatients were diagnosed as being ‘in remission’, that is recognised as being, currently, without signs of mental disorder or ‘sane’. By this view the data as reported by Rosenhan contradicts Rosenhan’s own conclusion. Spitzer also writes that ‘schizophrenia in remission’ was a diagnosis rarely used by psychiatrists at the time of the experiment, and as such this indicates that the diagnoses given were a function of the patients’ behaviours and not simply of the environment in which they were made.

Should a psychiatrist be able to able to detect that a patient is a fraud? That is, should a psychiatrist be able to detect that, after observing a patient acting normally, that they were initially feigning insanity? Rosenhan reports that this possibility was considered by the pseudopatients’ fellow patients but by no clinical staff:

“It was quite common for the patients to “detect” the pseudopatient’s sanity. During the first three hospitalizations, when accurate counts were kept, 35 of a total of 118 patients on the admissions ward voiced their suspicions, some vigorously. “You’re not crazy. You’re a journalist, or a professor (referring to the continual note-taking). You’re checking up on the hospital.” …. The fact that the patients often recognized normality when staff did not raises important questions.”

Rosenhan reports that the psychiatrists did not spend much time with the pseudopatients. Other patients of course had ample time to formulate their own theories. Whilst the medical staff’s lack of engagement with the pseudopatients is regrettable, it does point towards poor clinical skills rather than an indictment of psychiatric classification. Clare again:

“Rosenhan and those many critics of psychiatry who have greeted his paper with enthusiasm seem in fact to be saying that, since the doctors did not appear to have the faintest idea as to what constitutes the operational concept of ‘schizophrenia’ and yet applied it with haste to people showing virtually no signs or symptoms whatsoever, the whole diagnostic approach should be scrapped!”

Rosenhan later wrote that he considered the patients apparent insight over that of the psychiatrists as due to the ‘experimenter effect’ or ‘expectation bias’. The professionals expected to see a patient with a mental illness, so they looked for reasons to believe it, and eventually they convinced themselves that the pseudopatients were actually suffering from schizophrenia.

People do sometimes simulate mental illness for their own ends and this is a genuine diagnostic problem. It is a situation not unique to psychiatry and how easily a disorder psychiatric or otherwise can be feigned tells us little about the worth of the psychiatric classification system. Kety has something to say on this.

“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”

Clare makes a similar point using the example that the signs and symptoms of diabetes exist independently of whether they are correctly elicited or not.

Rosenhan does consider in his paper that that a mental illness is a life sentence:

“A broken leg is something one recovers from, but mental illness allegedly endures forever”

If a disorder was known to be always chronic and unremitting, it would illogical not to question the original diagnosis if the patient was later found to be asymptomatic and it is at this that Rosenhan is presumably driving. If the pseudopatients ‘recovered’ from an incurable illness whilst under the gaze of their psychiatrists and this did not alter the diagnosis then this would be an example, just as Rosenhan says, of the hospital environment influencing diagnostic decision making. But in stating that mental illness is something that endures forever Rosenhan is taking a very selective view of the wide range of presentations all of which come under the umbrella of ‘schizophrenia’. Schizophrenia has acute subtypes from which full recovery is possible and can also relapse and remit.

As for the non-existent impostor experiment it is surprising that it was agreed to by the teaching hospital in question. The poor reliability of psychiatric diagnoses means that the design of the experiment could only produce an outcome where actual patients were incorrectly identified as pseudopatients.

Conditions on the ward

All of the pseudopatients took extensive notes. Rosenhan makes much of this writing being “seen as an aspect of their pathological behaviour” on the grounds of the nursing entry that read “engages in writing behaviour”. Spitzer argues that was routine for nursing staff to frequently and intentionally comment on non-pathological activities in which a patient engages to enable other staff members to have knowledge of how the patient spends his time. As such, a comment about note taking is therefore inevitable and unremarkable. He is struck by what he sees as Rosenhan’s actual failure to provide data demonstrating where normal hospital experiences were categorized as pathological.

Rosenhan’s account of the conditions on the psychiatric wards is, for me, the most interesting part of the paper. The staff and patients were strictly segregated, the professional staff and especially the psychiatrists being rarely seen and having little patient contact.

“Staff and patients are strictly segregated. Staff have their own living space, including their dining facilities, bathrooms, and assembly places. The glassed quarters that contain the professional staff, which the pseudopatients came to call “the cage,” sit out on every dayroom. The staff emerge primarily for care-taking purposes – to give medication, to conduct therapy or group meeting, to instruct or reprimand a patient. Otherwise, staff keep to themselves, almost as if the disorder that afflicts their charges is somehow catching.”

This description bears resemblance to modern UK psychiatric wards. Psychiatrists spend little time with the patients in their care and nurses are occupied for a great deal of their time sitting in a locked room doing paperwork. The healthcare staff members with the most patient contact are the least qualified. This is far from ideal, and a target for improvement, but it should be noted that within healthcare this distance between staff and patients is not restricted to psychiatric wards and the pressures on staff due to the number of patients in their care means that a more desirable personal service is something with which the NHS struggles in all its domains.

Rosenhan’s description of the depersonalising effect of a long stay on the wards is also powerful. Despite their commitment to the experiment in which they are taking part, their wish to resist the powerlessness they experience leads several of them to jeopardise the study.

“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 history and anguish is available to any staff member (often including the “grey lady” and “candy striper” volunteer) who chooses to read his folder, regardless of their therapeutic relationship to him. His personal hygiene and waste evacuation are often monitored. The water closets have no doors.”

Attendants were reported to deliver verbal and occasional physical abuse to patients, something that can in no way be justified. Rosenhan’s report of this leads to an interesting inconsistency. Despite initial descriptions of abusive staff behaviour, in his conclusion Rosenhan describes the staff as overwhelmingly ‘committed and … uncommonly intelligent’. Spitzer considers that this is because of Rosenhan does not wish to direct attention toward shortcomings of the staff, rather wishing to concentrate on diagnostic labels.

Validity of diagnosis.

There are two issues here. Where the psychiatrists who met his pseudopatients wrong to make a diagnosis of schizophrenia within the DSM II diagnostic framework? And are psychiatric diagnoses of use or should they be replaced by an alternative?

The ease with which the pseudopatients gained admission on the basis of what are reported to be mild symptoms was remarked upon by Anthony Clare in Psychiatry in Dissent.

“It is a matter of some interest that a solitary complaint of a hallucinatory voice in the absence of any other unusual experience or personal discomfort should actually persuade certain American hospitals to open their doors. Such is the current demand for a psychiatric bed within the National Health Service and the prevailing emphasis on treating patients outside hospitals and in the community that the average admitting doctor in Britain is likely to find himself under strict instructions to avoid admitting any patient who can see, speak, and do all of these things without bothering himself or others to an significant extent. On suspects that, in Britain, Professor Rosenhan might well be advised to go home like a good man, get a decent night’s rest and come back again in the morning.”

And many people have been critical of the way the pseudopatients were diagnosed with schizophrenia on the basis of hallucinations – a single symptom and not even essential for the diagnosis. Anthony Clare again:

“…the doctors did not appear to have the faintest idea as to what constitutes the operational concept of ‘schizophrenia’ and yet applied it with haste to people showing virtually no signs or symptoms whatsoever…”

Spitzer remarks that the doctors should have been wary of making a diagnosis of schizophrenia in a previously unknown patient presenting without any history of insidious onset. However he is more lenient toward the pseudopatients’ psychiatrists, writing that, given the information available, schizophrenia was the most reasonable diagnosis. Davis and Weiner agree, respectively arguing from statistical and attribution theory standpoints that schizophrenia was the most likely diagnosis. Rosenhan himself presents no differential diagnosis.

Hunter takes exception to Rosenhan’s assertion that the pseudopatients acted ‘normally’ in the hospital:

“The pseudopatients did not behave normally in the hospital. Had their behaviour been normal, they would have talked 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”.

We in fact learn very little about the diagnostic process beyond the initial presentations of the pseudopatients. It should be noted that the pseudopatients would likely not have been, unlike Rosenhan’s assertion, admitted on the basis of their hallucinations solely. Their presentation to hospital and request for admission may also have carried diagnostic weight as it suggested much greater distress. However, whatever the fine detail, throughout their stay, the pseudopatients do not appear to have been assessed in detail.

The poor diagnostic skills and apparent lack of curiosity of the psychiatrists that the pseudopatients met is not an indictment of the classification per se, rather its application. The Rosenhan paper offers no insight as to why psychiatric classification had developed into the shape that he found it in 1973.

The purpose of a disease classification system is that it allows healthcare professionals to:

  • Communicate with each other about the subject of their concern
  • Avoid unacceptable variations in diagnostic practice
  • Predict their outcome disorders and suggest a treatment.
  • Conduct research

Amongst others Richard Bentall has made a career out of pointing out that psychiatric diagnosis is neither particularly valid nor reliable. However in Spitzer’s view the historical precedent is that classification in medicine has always been preceded by clinicians using imperfect systems. These have then improved on the basis of clinical and research experience. The clinician is forced to do the best he/she can until something better comes along.

In contrast to psychiatric disorders, the diagnosing of physical medical conditions is often portrayed as being solid and dependable. This does not bear close inspection, as many medical conditions are at least as vaguely described as psychiatric disorders. Although it is true that by-and-large a physical illnesses diagnosis rests on biological ‘facts’, the accompanying negative impact on person is the most important factor and this is highly subjective. For instance we all have bacteria in the back of our throats, but do not consider ourselves to have an infection.

In light of his experiment, rather than the syndromal classification system, Rosenhan would favour a classification system based on behaviours:

“It seems more useful … to limit our discussions to behaviours, the stimuli that provoke them, and their correlates”

Yet despite this early on in the paper he writes that “Anxiety and depression exist”, suggesting he favours an ad-hoc classification system at least.

“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.”

There are sufficient objections to the design of Rosenhan’s experiment – not least that his study consisted of only eight subjects- to doubt whether he is justified in writing his initial sentence. Rosenhan’s observational study of conditions on psychiatric wards – to which the rest of the above paragraph alludes – still has relevance today and remains a note of caution for anyone who works in mental health.


The Experience of Psychiatric Hospitalization.

Before patients were called `Mentally ill', over 200 years ago, they were thought to be possessed by evil spirits. The classification of being mentally ill should have put mental illnesses on a par with physical illnesses. Unfortunately, mental illness, unlike physical illness is still treated with little sympathy, and believed to be a chronic (long lasting) affliction. The general public seem to avoid mentally ill people. It is surprising to find, however, that medical staff who work with mentally ill people also seem to avoid them. Medical staff spent much of their time in their own areas, where patients were not allowed. Psychiatrists spending even less time than nurses, and nurses spent less time with patients than attendants. Attendants, who are supposed to be in contact with the patients much of the time, spent nearly all of their time in the staff area!

An experiment was conducted to test for the level of student and staff interaction. The Pseudo-patients asked staff "Pardon me, Mr [or Dr or Mrs] X, could you tell me when I will be presented at the staff meeting?" or ". when am I likely to be discharged?". As can be seen from the table, many psychiatrists ignored the question, or failed to respond to it sympathetically. Even more worrying, is the fact that even more nurses and attendants were as unhelpful.

As a control, a young person approached faculty members at a university asking for directions. She was helped on every occasion. This means we can discount the explanation that psychiatrists are too important to talk to the patients. The young person was helped on every occasion when she asked for a doctor whilst in the university medical centre. However, when she asked for a psychiatrist, 22% gave a minimal amount of interaction.


As part of the Mad World exhibition which examined missing voices from the story of psychiatry. The word ‘Madness’ is a rich word, and in its labyrinths are held important stories of humanity. It means a lot of different things to different people, and for me it has come to be a word which sometimes symbolises the best qualities in humans. Billy, a man who is part of ‘the old and the bold’ that keep our ambulance service running told me:

“A man needs a little madness or else he never dares cut the rope and be free.”


The quote is from Zorba the Greek by Nikos Kazantzakis – and holds in it the message – make of it what you will… So starts the exploration of Mad People’s History, a degree course developed in Ryerson University, Toronto Canada…

…More importantly, it is the history of people who have lived under this label and it is a history which belongs to the people – and as a part of the public domain – rather than the potentially dusty vaults of academia.

As short a time ago as the 1960s in Britain homosexuality was treated as both a crime and a mental illness. This medicalizing of a natural form of sexuality was a narrow, and dangerous ideological stand.

People were driven mad by a culture which told them they were unnatural and either opted or were forced into aversion therapy. Peter Price talked about his experiences of this in The Independent newspaper in August 1996:

“The treatment he was to undergo was intended to “cure” him of his homosexuality. Within a day of his arrival, Price was confined to one room, pumped full of nausea-inducing drugs, kept in a bed smeared with his own vomit and faeces. His fear tipped into paranoia. ‘It was like being in a horror movie'”

We must question our fear of otherness and make an inquiry into any development which offers ‘scientific treatment’ that acts upon an alienated group. This notion of being self critical as a culture is imperative if a sane (healthy) society is to be reached towards. In an open society which is based upon rational enquiry, there should be no fear of raising questions about the failings that precipitate cultural behaviour that strips people of voice, agency and dominates their physical presence.

In this examination, we should have the honesty to approach the sociology as a contextualizing body of knowledge for psychology, and understand psychology as a primary tool to approach psychiatry. The medical model of pharmacy seems to impose itself on every other field and overshadow decades of observation and study that has value in understanding mass behavioural data.

When we look at how different ethnic groups have varying rates and experiences of mental health problems, it prompts deeper investigation. Our social circumstances no doubt affect how we feel, and how we feel no doubt affects how we behave. How we measure behaviour is no doubt affected by who measures it, and what they are attempting to measure behaviour with. Different diagnoses rates of different ethnic groups reflect their different cultural and socio-economic contexts and there are issues around people gaining access to culturally appropriate treatments.

The Mental Health Foundation has done a lot of work in this area, and has found that, in general, people from black and minority ethnic groups living in the UK are:

  • more likely to be diagnosed with mental health problems
  • more likely to be diagnosed and admitted to hospital
  • more likely to experience a poor outcome from treatment
  • more likely to disengage from mainstream mental health services, leading to social exclusion and a deterioration in their mental health.

These differences may be explained by a number of factors, including poverty and racism. The differences may also be because the same social supports and mental health services often fail to understand or provide services which are acceptable and accessible to non-white British communities, and some argue everyone. People can be culturally alienated and isolated from the most basic and fundaments of human needs – community, company and care.

It is more likely that mental health problems go unreported and unaddressed because people who feel pushed to the peripheries of society and those who are marginalized may see what support there is as repellant for they have been made to feel an outsider. It is suggested that it is also likely that mental health problems are over-diagnosed in people whose first language is not English.

It is clear that when a prevalent culture deems something to be a threat to its dominant norms, it outlaws it and structures it out. More worrying is the propensity for human civilisations to create thought crime. Culture’s can become decided by relatively few people without considering the many and the madness of crowds can inflict upon the few as we find Arthur Miller writing about in The Crucible – in cultures if people can find distaste in something, then it can lead to interpret people using two instruments the penal and medical system.

The abuses of medicine are like that of any institution – a type of unquestioned expertism which fails to value expertise beyond its borders. It is important to be able to publicly analyse the failings and abuses of our most precious institutions, because humans are simply capable of injustices/inequities as are structures.

It is well documented and understood that in Victorian times women who did not yield to the mantle and trappings of the patriarchal culture were often declared mad and committed to an insane asylum. The person who had the power was the husband or father or nearest male, and the right to be heard was non-existent.

We would like to think that these dark days are behind us, but there is still a power differential today which exists and plays a significant role in who gets to decide who gets the attention of the physician. Kate Millet wrote The Loony Bin Trip as a deconstruction of when she was involuntarily committed to an Asylum between 1982 and 1985:

“Kate Millett, the feminist author and maverick intellect, sips her coffee in the plush hotel bar and considers a question: Were you truly insane? “No,” she said. “I think I’ve had unusual experiences, happy and unhappy ones. But I was not mad. Madness is manufactured when psychiatry intervenes.”

As a society, we cannot allow the notion that gendered abuses do not go on in these modern times. I have heard accounts of women having been sectioned by their husbands for wanting to separate or get a divorce. Indeed, wherever there exists a power differential, there exists the potential danger of abuse of the power that one human being can wield over another.

Children lack agency. I recall a boy being sectioned by his parents when I was in high school. He had gone out, got drunk, returned home and called his Dad an asshole – or words that effect. He was swiftly deposited in the hospital and went through a diagnosis, period of interment and medication before release. Is this mad ? I can hear a voice in my head saying – this cannot happen, not in modern medicine not in this great and just society – but this voice we must guard against by analyses and open discussion…

But really – that little voice in my head goes – there must have been something that he had done to warrant being locked up and medicated. These things dont happen for no reason… And then I read Sir Ken Robinson’s The Element and happen across an account of Paulo Coelho’s experience of psychiatry courtesy of his parents:

“This is what happened to Paulo Coelho. Mind you, his parents went further than most to put him off. They had him committed repeatedly to a psychiatric institution and subjected to electroshock therapy because they loved him.

The next time you feel guilty about scolding your children, you can probably take some comfort in not resorting to the Coelho parenting system.The reason Coelho’s parents institutionalized him was that he had a passionate interest as a teenager in becoming a writer.

Pedro and Lygia Coelho believed this was a waste of a life. They suggested he could do a bit of writing in his spare time if he felt the need to dabble in such a thing, but his real future lay in becoming a lawyer. When Paulo continued to pursue the arts, his parents felt they had no choice but to commit him to a mental institution to drive these destructive notions from his head.

‘They wanted to help me,’ Coelho has said. ‘They had their dreams. I wanted to do this and that but my parents had different plans for my life. So there was a moment when they could not control me anymore and they were desperate.’ Coelho’s parents put Paolo in an asylum three times…. Coelho’s novel The Alchemist was a major international best seller, selling more than forty million copies around the world.”

Various factors affect how we feel and how we behave – malnutrition, physical damage, drugs, heavy metals, endocrine disorders, poverty, trauma – these can all influence how we interact with the world and how the world interacts with us. It is important to acknowledge the vital advances in understanding and health benefits which the medical establishment has brought about its project always a work in progress. The Mad World Exhibition and archive is an opportunity for people to add to the conversation what they think should be a part of how we perceive the word Madness.

Now, in the UK and western world, the dominant perspective is one which medicalizes behaviour, and the medical world has become the overriding voice which gets to speak about what meanings are attributed to these phenomena, and what they represent.

This exhibition invites the world to come into the exhibition, look at what is on view and try to decide who is ‘sane’ and who is ‘crazy’ by looking at the art and exhibits. The idea reformulates psychologists David Rosenhan and Martin Seligman’s famous work ‘On Sane People in Insane Places’.

Click to Download a copy of ‘On Being Sane in Insane Places’ by David Rosenhans

Here we have brought together work from a number of artists, and woven a panorama of histories revealing perspectives around ‘madness’ which are not commonly found in the rhetoric of the medical institutions.

Historiographer, Michel-Rolph Trouillot suggests that everywhere a fact is created, so too is a silence. You are warmly invited to come and peer in on the silences of the mental asylum, and discover the histories, organisations, and individuals who have dared have a perspective of their own revealing the alternative and sometimes uncomfortable.

Dr Diamond photographed the patients in his asylum

Concepts and Themes:

The idea was to create an art exhibition with a collection of named or anonymous artists and artworks (themed and unthemed) – some of which would have a medical ‘diagnosis’ and some of which do not. The works are to be interspersed with information on pivotal concepts and histories of psychology/psychiatry written in potted form.

The public viewers were asked to make judgements about who was ‘diagnosed’ and who was not before witnessing the solution to the logic problem posed to ‘Inspector Rosenhan’, which suggests that a rethinking of the way the idea has been approached needs to take place.

The premiss of the idea is adapted from a logic problem which Raymond Smullyan created. It is themed with the famous experiment by David Rosenhan and Martin Seligman which produced the paper ‘On Sane People In Insane Places’, the textbook ‘Abnormal Psychology’ and contributed to ‘Learned Helplessness’.

Raymond Depardon photographed mental patients in Italy producing the book Manicomio

Premiss: The Asylum of Doctor Rosenhan

Inspector Michel of Direction Générale de la Sécurité Extérieure was called over to Britain to investigate eleven insane asylums where it was suspected that something was wrong. In each of these asylums, the only inhabitants were patients and doctors – the doctors constituted the entire staff.

Each inhabitant of each asylum, patient or doctor, was either sane or insane. Moreover, the sane ones were totally sane and a hundred percent accurate in all their beliefs all true propositions they know to be true and all false propositions they knew to be false.

The insane ones were totally inaccurate in their beliefs all true propositions they believed to be false and all false propositions they believed to be true. It is to be assumed also that all the inhabitants were always honest – whatever they said, they really believed. In the first asylum Michel visited, he spoke separately to two inhabitants whose last names were Jones and Smith.

“Tell me,” Craig asked Jones, “what do you know about Mr. Smith”

“You should call him Doctor Smith,” replied Jones. “He is a doctor on our staff”

Sometime later, Michel met Smith and asked, “What do you know about Jones ? Is he a patient or a doctor ?”

“He is a patient,” replied Smith.

The inspector mulled over the situation for a while and then realized that there was indeed something wrong with this asylum: either one of the doctors was insane, hence shouldn’t be working there, or, worse still, one of the patients was sane an shouldn’t be there at all.

Photography of people in asylum

Theme: On Sane People In Insane Places

Rosenhan’s study was done in two parts the first involved the use of 8 healthy associates (pseudopatients) including David Rosenhan himself. They went into 12 mental hospitals in five different states pretending to have a single symptom: They heard voices that said ’empty’, ‘meaningless’ and ‘thud’. From the start, these pseudopatients acted the way ‘normal’ people did, but however, they were labelled as ‘crazy’ and treated as such.

Each person was admitted and diagnosed with psychiatric disorders. After their admission, the pseudopatients acted normally and told staff that they felt fine and no longer experienced any hallucinations. Martin Seligman and David Rosenhan assumed false names and wound up in the locked men’s ward of a state mental hospital in October of 1973. In that time the two psychologists discussed:

  • How they and other patients were being treated
  • Their personal and academic lives
  • The legal rights of mental patients
  • How to choose a therapist
  • The dehumanizing effects of labelling
  • The diagnosis of schizophrenia
  • The misdiagnosis of schizophrenia
  • Depression
  • Suicide
  • The experience of psychopathology of hospitalisation
  • Therapy
  • Diagnosis
  • The range of psychological miseries which could be communicated

All the ‘pseudopatients’ were forced to admit to having a mental illness and agree to taking anti-psychotic 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 the study involved a hospital administration challenging Rosenhan to send pseudopatients to their 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.

You can read the paper which David Rosenhan wrote following the famous experiment by clicking the link:

David Rosenhan’s Paper: On Being Sane In Insane Places

Here is a quote from his paper: “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?.

At the time, the study concluded “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 behaviour can easily be misunderstood. The consequences to patients hospitalized in such an environment – the powerlessness, depersonalization, segregation, mortification, and self- labelling – seem undoubtedly counter-therapeutic.”

Raymond Smullyan

Arrangement and Organisation

The people who want their identity protected will at no time will have their identities revealed – thus it will remain as a thought experiment without impacting on peoples personal territory anonymity is big here, where it is wanted.

Getting the public to guess who is diagnosed and who is ‘sane’ giving their thoughts on sanity, madness, psychiatry, and psychology will be a critical part of the exhibition which provides a process which aggregates the thoughts and perspectives together as part of the exhibition.

There is no correct or incorrect, thus there will be no finite answers given so that it brings people into the territory of the original Rosenhan’s experiment more important is the journey through the concepts involved.

The purpose is to promote more enlightened attitudes of the complexities of state of mind and the perception of behaviour. Discussion is going to be fostered through events/happenings in the gallery and debates are opened out in the light of everyone’s contributions.

All practical formats will be welcomed and included in the display. There is a film room which will be displaying several films, there will be an audio loop for spoken word and sound pieces. Paintings, drawings, photographs and sculptures are all going to hold a place in the exhibition.

The written word will play a prominent role as hidden narratives will be revealed in the mix. There will also be a whole section of the exhibition where people will be invited to contribute their personal comments, stories and thoughts on the themes by hanging them on hooks and clips provided.

Digital will also play a role, where an interactive website will be set out for people to contribute to electronically. Performance art will be used to open the exhibition, along with some short talks.

Each artist who is involved is encouraged to write something on the theme of madness/mental health/sanity – however, their work of art can be themed in whatever way they choose. Writing about their encounters with mental health is optional but not compulsory.

Historically many artists were labelled mentally ill because of their art at various times – for example under Hitler’s reign of terror many great creative minds were interred as producers of deviant art, and in the jazz community of the united states those who dared to speak out about racism were jailed, medicalised or worse. This is why the very notion of madness and normality need to be healthily questioned.

The key thing is that the work does not have to be focused on the theme of mental health because the theme is about normality and questioning ideas of norms. The art creates it’s own context within the premiss and theme of Rosenhan visits the asylum by asking the public to work out who is mad and who is sane. By the time they leave the gallery, the public will realise that the question is insane and that it is not a valid way of looking at the world, nor people.

How people identify their own experience is too often left out in this area of life. The labels which people suffer are usually imposed from one person to another reducing the person who is labelled to a process of definition outside of their control. Placing definitions on people is a hazardous thing when one account is ruled out or over ruled. I recall a friend who had Parkinson’s disease being put on a section order and locked inside a psychiatric ward as a doctor had decided that they were experiencing delusions.

My friend, an elderly investigative journalist in his earlier years had worked in Vietnam, North Africa and America in this role. He had been telling accounts of the dark histories which happened in industry in short conspiracies. The doctor had failed to check the facts and historical veracity to what he had been saying. My friend understood himself as a writer and journalist the doctor saw him as a mental patient because he was in a psychiatric hospital…

As my friend said: “The doctor sees disease, the police see criminals and the journalist sees conspiracy…” sometimes it is a professional psychosis that we encounter.

The snippets of history and thinkers – such as R.D. Laing, Thomas Sasz, Ken Robinson – who challenge the medical and orthodox models of viewing behaviour and mental health, illustrate the history of ‘madness’ along with the emergence of critical perspectives. We need to be critical or else we are all lost.

A short film made documenting the first Mad World exhibition:

Click Here For The Mad World Archive

This is an ongoing and open project. If you have anything which you want to contribute to the Mad World Archive – which came of the exhibition, please get in touch. Two large exhibitions have taken place over the past three years and more will come based on the above premiss. The archive is there to create a public resource of authentic and uncut perspectives which talk about issues surrounding mental health that are less often voiced.

Visit Asylum Magazine for open access to 30 years back catalogue of critical psychiatry and a continuing platform for those who have something to publish about their experiences and thoughts:


Have there been followups to the Rosenhan Experiment? - Psychology

In 1973, Dr. D. L. Rosenhan, a professor of psychology and law at Stanford University, published a ground-breaking psychiatric study in the January 19 issue of Science magazine. The article exposed a serious short-coming in the psychiatric hospital system at the time, and therefore it became very controversial. Dr. Rosenhan designed the study to try to answer the question in the title of this article: “If sanity and insanity exist, how shall we know them?”

The now famous (some of the offended or embarrassed psychiatrists preferred to call it “infamous”) experiment that was carried out involved 12 different psychiatric hospitals and 8 different people, mostly professionals (including the author). Each of the eight were totally and certifiably sane “pseudo-patients”.

Each one secretly gained admission to one or two different mental hospitals by falsely complaining to a psychiatrist that they had been hearing voices over the past few weeks. The “voices” in each case were saying only the three words “empty,” “hollow,” and “thud.” No visual hallucinations or other psychological abnormalities were relayed to the examining psychiatrist. Except for the fake “chief complaint”, the intake histories relayed by the patients were entirely truthful. Each individual was immediately admitted to the target psychiatric hospital, much to the surprise of most of the pseudo-patients.

All but one of the admitted “patients” were given a diagnosis of “schizophrenia”. The other one was labeled “manic-depressive”. When they were discharged, the eleven had discharge diagnoses of “schizophrenia, in remission,” despite the fact that absolutely no psychotic or manic behaviors had been observed during their stays.

After admission, the pseudo-patients all acted totally sane, each emphasizing to the hospital staff member that the voices had disappeared. When given the chance, each also asked about when they could be discharged. Those questions were largely ignored by staff.

Despite the fact that each one acted totally normally throughout, hospital stays averaged 19 days, ranging from 7 to 52 days.

The patients engaged in all the normal ward activities except for the fact that they never swallowed the variety of antipsychotic pills that had been prescribed for them. The only obvious difference between the behaviors of the experimental group and the regular patients was that each of them took notes during their hospitalizations. On several occasions, a staff member wrote in the patient’s chart: “the patient engages in note-taking behavior”. Otherwise none of the staff seemed interested in any of the patient’s behaviors.

Although the pseudo-patients planned to secretly smuggle out their daily notes, they eventually stopped trying to hide the fact that they were recording their impressions of their stays, and they soon stopped the smuggling operations – with no consequences.

The average daily contact with the therapeutic staff averaged only 6.8 minutes per day (mean 3.9 – 25.1 minutes) and that included the admission interviews, ward meetings, group and individual psychotherapy contacts, case conferences and discharge meetings.

The group observed that attendants only came outside the locked “cage” 11.5 times per 8-hour shift but usually the staff only interacted minimally with the patients when doing so. The staff psychiatrists rarely interacted meaningfully with any patient. If any interaction occurred, it was usually rather patronizing.

None of the professional therapeutic staff ever suspected that any of the 12 were pseudo- patients, whereas many of the actual patients knew for certain that they were faking. These patients (who were probably actually swallowing their medications) often said things like: “You’re not crazy. You’re a journalist or a professor. You’re checking up on the hospital.” The therapeutic staff never tumbled to the subterfuge. The only people who recognized normality were those who themselves had been labeled “insane”.

Upon the publication of the Rosenhan paper, there arose an enormous uproar from the psychiatric community about the “ethics” of performing such a study. Rosenhan was attacked viciously by those who had been fooled or had themselves jumped to erroneous psychiatric diagnoses in the past.

Because of the controversy, Rosenhan announced that a follow-up study would be done in a certain research and teaching hospital whose staff had heard about the first stu but doubted that such errors could occur in their own hospital. The staff was led to believe that sometime in the next 3 months there would be one or more pseudo-patients attempting to be admitted. However, by design, no pseudo-patients actually attempted admission.

Among the total of 193 patients that were admitted for psychiatric treatment during the 3-month period, 41 genuine patients (20 % of the total) were suspected, with high confidence, of being pseudo-patients by at least one member of the staff. 23 of the 41 were suspected of being fake patients by a psychiatrist, and 19 were suspected by both a psychiatrist and one other staff member. On the bright side, their heightened vigilance saved 41 normal people from receiving a diagnosis of permanent mental illness and the prescribing of brain-altering drugs.

Among the conclusions the reader can draw from these two experiments are these important and quite logical ones:

1] The sane are not “sane” all of the time, nor are those labeled “insane” actually insane all of the time

Therefore, definitions of sanity or insanity may often be erroneous.

2] Sanity and insanity have cultural variations

What is viewed as normal in one culture may be seen as quite aberrant in another. As just one example, there was a famous experiment contrasting American and British psychiatrists and each country’s diagnostic differences. The two groups studied identical video-taped interviews of a group of psychiatric patients. In that series of cases, American psychiatrists diagnosed “schizophrenia” far more often than did British psychiatrists.

3] Bizarre behaviors in people constitute only a small fraction of total behavior

For example, violent, even homicidal people are nonviolent most of the time.

4] Psychiatric diagnoses, even those made in error, carry with them personal, legal and social stigmas that can be impossible to shake and which often last a lifetime

It is a fact that hallucinations can occur in up to 10% of normal people. Vivid flashbacks in patients with PTSD (posttraumatic stress disorder) have, in the past, been commonly and tragically misdiagnosed as “hallucinations”. Therefore, those unfortunate patients can be permanently labeled (and then permanently over-drugged) as a chronic “schizophrenic of undetermined etiology rather than as an otherwise normal patient with a history of psychological trauma that was having temporary “flashbacks”. (Note that combat-traumatized war veterans prior to the 1990s were often mis-diagnosed – and therefore mis-treated – as schizophrenics.).

Hallucinations can normally occur during certain phases of sleep, half-waking states, sleep deprivation, or from drug effects – either because of neurotoxic or psychotoxic effects from brain-altering, psycho-stimulating prescription (or illicit) drugs or from withdrawal from sedating antipsychotic drugs. It is not uncommon for Novartis’s Ritalin cocaine Shire’s Adderall speed or Eli Lilly’s Prozac Pfizer’s Zoloft Sandoz/Novartis’s Paxil Forest Lab’sLexapro Solvay/Abbott’s Luvox to cause (drug-induced) psychotic episodes.

It is also well known that drug-induced mania (and thus a false diagnosis of bipolar disorder “of unknown etiology”) can occur from even standard doses of most psycho-stimulating antidepressant drugs, especially the SSRIs (“selective” serotonin reuptake inhibitors). But mania can also occur during withdrawal from “minor” tranquilizer drugs (such as the Valium-type benzodiazepines) or “major” tranquilizers (such as antipsychotics like Pfizer’sGeodon Smith Kline & French’s (GSK) Thorazine Janssen’s (& Johnson) Haldol Janssen/J & J) RisperdalEli Lilly’s Zyprexa Bristol-Myers Squibb’s (GSK) Abilify AstraZeneca’s Seroquel Sandoz’s (Novartis) Clozaril etc.)

One well-done study showed that a significant percentage of patients admitted from one psychiatric hospital emergency room was ultimately discharged with a diagnosis SSRI-induced mania and not “bipolar disorder of unknown etiology”. The cause of those ER visits was not a mental disorder but rather a drug-induced neurological disorder that was self-limited and best treated by stopping or tapering-down the offending drug.

Rosenhan rightly points out, reminding readers of Jack Nicholson’s and the Chief’s characters in “One Flew Over the Cuckoo’s Nest”:

“How many people…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 or of handling their own accounts? How many have feigned insanity in order to avoid the consequences of their behavior and, conversely, how many would rather stand trial for a crime than live interminable in a psychiatric hospital because they were wrongly thought to be mentally ill? How many have been stigmatized by well-intentioned, but nevertheless erroneous, diagnoses?”

To those concerns, I would add, how many patients have suffered the brain-disabling and neurotoxic and neurodegenerative consequences of dangerous, dependency-inducing, and very powerful psychiatric drugs that, if used long enough can easily produce dementia as well as deadly withdrawal effects when the dosages are cut down or stopped?

Rosenhan’s study has far more implications for our society today than in 1973. Back then there was only small numbers of relatively untested psychiatric drugs to be concerned about compared to the hundreds of even more toxic drugs that are being given to more and more people. Both the old “obsolete” drugs and the “modern”, over-hyped drugs in the current psychiatrist’s armamentaria have been discovered to be brain-damaging and often addictive.

However, today there are scores and scores of what the psychiatric and pharmaceutical industries euphemistically call “second and third generation”, “novel” or “atypical” psychostimulants, anti-depressants or anti-psychotics (see lists above) that were never tested for long-term safety or efficacy before they were granted marketing approval by the FDA. Many of them are commonly used in hugely expensive cocktail combinations which likewise have never been tested for long-term OR short-term safety in the animal labs, much less thoroughly tested in human long-term clinical trials.

All of these psychiatric drugs enter the blood stream and then go everywhere the blood goes, including liver, kidneys, heart, brain, etc. Psych drugs are bio-accumulative substances that are considered hazardous materials by professional waste management crews at manufacturing sites. Such chemicals need to be handled with extreme care – unless, of course, they are prescribed by unaware physicians or nurse practitioners for lifetime use by poorly-informed, obedient patients who may not have adequate liver detoxification capabilities and who might also be taking other prescription drugs with unknown drug-drug interactions. The irony of that reality should give us all pause.

Choice quotes from Rosenhan’s original article entitled “On Being Sane in Insane Places”. (Science magazine 1973, Vol. 179 p. 250 – 258)

“It is commonplace, for example, to read about murder trials wherein eminent psychiatrists for the defense are contradicted by equally eminent psychiatrists for the prosecution on the matter of the defendant’s sanity.”

“Psychological suffering exists…but do the salient characteristics that lead to diagnoses reside in the patients themselves or in the environments and contexts in which observers find them?… Psychiatric diagnosis betrays little about the patient but much about the environment in which an observer finds him.”

“The view has grown that psychological categorization of mental illness is useless at best and downright harmful, misleading, and pejorative at worst.”

“Despite their public ‘show’ of sanity, the pseudo-patients were never detected, and each was discharged with a diagnosis of schizophrenia ‘in remission.’”

“Once labeled schizophrenic, the pseudo-patients (in the study group) were stuck with that label. If the pseudo-patient was to be discharged, he must naturally be ‘in remission’ but he was not sane, nor, in the institution’s view, had he ever been sane.”

“It was quite common for fellow patients to ‘detect’ the pseudo-patient’s sanity. The fact that fellow patients could recognize normality when staff did not raises important questions.”

“Physicians are more inclined to call a healthy person sick (a false positive) than a sick person healthy (a false negative). 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.”

“’Patient engaged in writing behavior’ was the daily nursing comment on one of the pseudo-patients who was never questioned about his writing. Given that the patient is in the hospital, he must be psychologically disturbed. And given that he is disturbed, continuous writing must be a behavioral manifestation of that disturbance, perhaps a subset of the compulsive behaviors that are sometimes correlated with schizophrenia.”

“One tacit characteristic of psychiatric diagnosis is that it locates the sources of aberration within the individual and only rarely within the complex of stimuli that surrounds him.”

“Often enough, a patient would go ‘berserk’ because he had, wittingly or unwittingly, been mistreated by, say, an attendant.”

“Never were the staff found to assume that they themselves or the structure of the hospital had anything to do with a patient’s behavior.”

“A psychiatric label has a life and an influence of its own. 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. Eventually, the patient himself accepts the diagnosis, with all of its surplus meanings and expectations and behaves accordingly.”

“There is enormous overlap in the behaviors of the sane and the insane. The sane are not ‘sane’ all of the time. Similarly, the insane are not always insane. It makes no sense to label (anyone as)permanently depressed on the basis of an occasional depression…”

“I may hallucinate because I am sleeping, or I may hallucinate because I have ingested a peculiar drug. These are termed sleep-induced hallucinations (or dreams) and drug-induced hallucinations, respectively. But when the stimuli to my hallucinations are unknown, that is called craziness, or schizophrenia.”

“The average amount of time spent by attendants outside of the cage was 11.3 percent (range, 3 to 52 percent). It was the relatively rare attendant who spent time talking with patients…”

“Those with the most power have the least to do with patients, and those with the least power are the most involved with them.”

“Neither anecdotal nor ‘hard’ data can convey the overwhelming sense of powerlessness which invades the individual as he is continually exposed to the depersonalization of the psychiatric hospital.”

“Heavy reliance upon psychotropic medication tacitly contributes to depersonalization by convincing staff that treatment is indeed being conducted and that further patient contact may not be necessary.”

“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.”

“Finally, how many patients might be ‘sane’ outside the psychiatric hospital but seem insane within it…”

“It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals.”

This article was originally published by Duluth Reader in September 2010, updated version on Global Research on January 11, 2021.


Molivam42's Weblog

Last week in my article on race I referred to the famous Jane Elliot. “blue-eyed/brown-eyed” exercise. That gave me the idea to do a piece about some of the most famous psychological experiments in the last 100 years. Some of them may not have been very ethical but they make fascinating reading. I hope all the details are accurate because you often get contradictory information when you research them online. Anyway here is a list of five of my favourites:

Nuns behaving badly

In the 1960s in California William Coulson and a group of radical psychotherapists were able to convince a group of nuns to become guinea pigs in a bizarre psychological experiment. The Convent of the Immaculate Heart in Los Angeles, one of the largest seminaries in America, was the place chosen. Quite why the convent approved of this experiment is beyond me but I suppose they wanted to appear hip and trendy. The nuns were going to be put in an encounter group. This is defined as “a typically unstructured psychotherapy group in which the participants seek to increase their sensitivity, responsiveness, and emotional expressiveness, as by freely verbalizing and responding to emotions”. They most certainly did that.

The convent was transformed. This quote from one of the nuns indicated that strange things were happening:

You are trying to assert yourself, trying to find out who you are, who you are becoming, at the same time you are trying to live a life of dedication of service and you are trying to make all of these things fit into who you are, and it’s such a turmoil at times that you just blow a gasket and do silly crazy things. Running around the orchard and stealing oranges and taking Cokes out of the refrigerator, crazy things.

The nuns voted to discard their habits but that was nothing compared to what was about to happen. These sessions unleashed forces previously that had previously lain dormant – sex. Nuns started seducing each other. It may sound like a Larry Flynt production but it really happened.

Within a year 300 nuns, more than half the convent, had petitioned the Vatican to be released from their vows and six months later the convent closed its doors. All that was left was a small group of radical lesbian nuns.

‘I am insane but I am getting better.’

David Rosenhan created a dramatic experiment that gets at the very heart of how we conduct psychiatric diagnosis. There were two elements to Rosenhan’s study:

The first involved the use of eight normal people, including Rosenhan himself, none of whom had ever had any psychiatric problems. They briefly simulated auditory hallucinations so that they would be admitted to various psychiatric hospitals in the USA. In the psychiatric assessment they said they could hear voices saying single words such as “empty”, “hollow” “thud or “dull”. These were the only psychiatric symptoms which they exhibited. During their stay, hospital notes indicated that staff misinterpreted much of the pseudopatients’ behaviour in terms of mental illness. For example, the note-taking of one individual was listed as “writing behaviour” and considered pathological – the patient had a compulsion to write. The hospital staff was unable to detect a single pseudopatient seven were diagnosed with schizophrenia and the other one with bipolar disorder. All were given powerful psychotropic drugs and there was nothing they could to convince the doctors that they were sane. The only way out for them to get out was to agree that they were mentally ill and then pretend that they were getting better.

Rosenhan’s experiment provoked outrage and he was challenged to repeat it. The second part involved asking staff at a psychiatric hospital to detect non-existent ‘fake’ patients. The staff detected large numbers of patients as impostors. There was just one problem Rosenhan hadn’t actually sent any fake patients. These patients were genuinely ill. The study, published under the title “On Being Sane in Insane Places”, is considered a landmark study of psychiatric diagnosis.

The experiment requires that you go on.

The Milgram Experiment was created to explain how people often obey orders even if those orders were palpably bad. This is what many concentration camp guards had claimed. For this experiment Milgram created a phoney but very impressive-looking electric ‘shock generator’ with 30 clearly marked switches representing 15-volt increments. The machine went from 15 to 450 volts. At the low end there was a label slight shock at the end was DAMGER: SEVERE SHOCK and beyond that simply XXX He then recruited 40 male subjects, who believed they were going to participate in an experiment about the effects of punishment on learning. When they arrived they met the chief experimenter, who was dressed in a white coat to lend him an air of scientific authority. Milgram then manipulated a draw so that the candidates chosen would be the “teachers” administering the shock the “learners”, who were Milgram’s accomplices, were actors. The “teachers” saw that the “learner” being strapped to a chair. Then electrodes were attached. The “teacher” then had to sit down in another room in front of the shock generator, unable to see the “learner”. He had to teach word-pairs to the “learner”. If the “learner” made a mistake or didn’t answer, the “teacher” was instructed to give the “learner” a shock, upping the charge 15 volts higher for each error. Of course the “learner” didn’t actually receive the shocks, but pre-taped audio of screams was triggered when a shock-switch was pressed. If the “teacher” had second thoughts, they would be told in an increasingly authoritarian tone such things as:

The experiment requires that you go on.

You have no other choice, you must go on

Although most subjects did express reservations, all 40 of them obeyed up to 300 volts and 25 of the 40 subjects continued giving shocks until the maximum level was reached. The conclusion that Milgram arrived at was obedience to instructions can make us engage in morally questionable behaviour.

Six days in “prison”

Philip Zimbardo devised this experiment to examine that behaviour of individuals when placed into roles of authority and submission – prisoner or guard respectively. Twenty-five paid volunteers were selected for these roles in a simulated prison. The “prisoners” were put into a situation specifically designed to make them feel degraded, disoriented and dehumanised. To begin with they were arrested, charged and made to undergo all the usual procedures. They were then strip-searched, deloused, given a number and a uniform and had a manacle placed on one ankle. The “guards” too were given the real stuff including military-style uniforms, and reflective sunglasses to avoid eye contact and look cool They also had whistles handcuffs and keys. They were not given special training or very specific instructions on how to carry out their roles. However both “prisoners” and “guards” quickly settled into their roles and things soon degenerated. By the second day of the experiment the “prisoners” had staged a rebellion, which was brutally repressed by the “guards”. The latter’s behaviour became increasingly paranoid and they sought to control every aspect of the “prisoners’” lives these began to experience depression, mental problems and what is known in psychology as learned helplessness. After five days Zimbardo had to abandon the experiment, which had been scheduled for two weeks, because it was rapidly getting out of hand. The lesson of this experiment is how people can get drunk on power and abuse the authority they have been given,

Good Samaritans

Darley and Batson Batson did a study examining bystander intervention in theology students at Yale Divinity School. 40 students were asked to present a talk on either the Good Samaritan story or their future job prospects for seminary students. The students were told that due to space limitations they would have to give their talk in a nearby building. Then they gave each participant one of three time constraints:

1) Oh, you’re late. They were expecting you a few minutes ago. We’d better get moving. The assistant should be waiting for you so you’d better hurry. It shouldn’t take but a minute.

2) The assistant is ready for your, so please go right over.

3) It’ll be a few minutes before they’re ready for you, but you might as well head on over. If you have to wait over there, it shouldn’t be long.

On their way to the new building they would see a man sitting slumped in doorway. The “beggars” would moan and cough twice as the students walked by. Around 40% offered some help to the victim. What had more impact on the willingness to stop and help was the amount of time the students thought they had. The students who were giving the Good Samaritan did not seem to take its message to heart Thus these divinity students’ beliefs could be easily manipulated by instructions from an unknown person in authority. They faced a conflict between helping the victim and meeting the needs of the experimenter. Conflict rather than callousness can explain the failure to stop.


How has psychiatry changed since the Rosenhan experiment?

I've just read the write up of the Rosenhan experiment, in which 9 mentally healthy people initially feigned symptoms and then acted normally inside of mental hospitals. Their treatment there was worrying from a human rights and a medical point of view, as normal things were seen as pathology, and pseudopatients asking to be released were given anti-psychotics.

Information on the response of psychiatry to the findings of the paper is patchy, so I was wondering- how has it impacted the field, if at all?

I definitely would, thanks for your input. If you don't mind me asking, do you think the findings were all that damning? There seems to be some disagreement over their significance.

Have you thought about joining the /r/askscience panel?

I knew I was missing something, thanks!

I love how when he sent the new batches, they found 83/192 "imposters" when he never sent any.

I am a mental health professional who works in outpatient or in community settings. The biggest impact I have seen has been the requirements by many states to have a patient bill of rights and more regulation. As well as periodic re-evaluation of a patients condition. This however is from my experience in the field since 2008, professionals in the field who have been practicing from time periods closer to the 73 experiment will probably have seen more of a change.

Ever since reading that paper myself, I have thought a good manner in which to reassess patients would involve an outside psychiatrist. This psychiatrist would not know if they were evaluating a sane person, or an inpatient. Something like a single-blind study. This may be difficult to implement, however.

Sadly, even if the institutions are improving, the outside world is still rather ignorant in regards to mental health.

I believe (correct me if I'm wrong) but there is a law (in the 70s I believe) that says you can't commit a person in a psychiatric hospital against his will unless he poses a danger to himself and no one else can take care of him, and even if that is the case, they can only be held for three days?

out of curiosity. I am going into psychiatry, and my take is that a large majority of psychological illnesses, particularly the types that increase in prevalence when a society becomes affluent, can be explained through evolutionary psychology. Is there professional discussion about this possibility right now?

for example, when we become affluent, we eat a lot of calories but not enough nutrition. then we feel weak, but we don't know why. the same example can be said for psychological needs. we spend a lot of time with people, but we won't get the real relationship nourishment that has always been prehistorically intrinsic. thus we feel depressed and we don't know why. so our body's natural "sensory" systems like feeling hungry and feeling lonely aren't up to the task of giving us explicit feedback on how to live in this much more complicated world.

so my main take on psychiatry would be looking at lifestyle as well as medications. but the problem is also that people lose psychological plasticity as they get older, so lifestyle choices will prevent it from getting worse, but you'll still need medications to treat it as it is right now.

One big difference is the growth of the field of counseling, which still doesnt get the recognition it deserves as its own field. In counseling we use the "wellness model," in which the client (as opposed to patient) is viewed as functinoing on a continuum of wellness. You are not a depressed person, waiting to be cured. You are a person, dealing with some level of depression and related symptoms, and the idea is to help the person cope with that, increasing wellness. Does that make sense?

How does that particular paradigm shift affect treatment? Wouldn't the things you would have done to help them relieve their depression (and achieve "healing") also improve their wellness?

Except that use of counseling as a therapeutic approach is decreasing, not increasing.

Going to assume you're a counsellor. I'm a psych undergrad and I've been thinking about the future recently. How did you get to that point? Did you have to do several postgrad degrees?

I would spend all of about one session with that counselor and then leave feeling like I was part of some television special.

Can't be cured, not a normal person, yeah. It's about accepting who you are, not defining yourself as everybody else with "some level of psychotic features, impulses, brain degeneration, impaired prefrontal cortex features." It minimizes what we suffer through.

I also hated that stupid bullshit they made me go over in the hospital. Mindfulness. What a joke.

You might be interested in these follow-ups to the Rosenhan study.

In 2003-4, a psychologist named Lauren Slater attempted to re-create the Rosenhan experiment herself, for her book "Opening Skinner's Box." She presented to 9 psychiatric ERs complaining of a single auditory hallucination (hearing the word "thud", as in the original experiment). Hospitalization was not recommended by any psychiatrist, but Slater was given the diagnosis of depression with psychotic features and offered medication (antidepressants and/or antipsychotics) in most cases. Notably, Slater states that she did not shower, groom herself, or even brush her teeth for at least 3 days before showing up at the ERs, and she showed up voluntarily, suggesting that she was interested in obtaining some relief of her 'symptoms'. Other things that are also notable are that (1) she actually does have a very strong history of depression (I believe with psychotic features) and (2) she also sometimes engages in ɼreative non-fiction', and has written a non-true memoir(?) about her history of pseudoneurological symptoms and her compulsion to lie ("Lying: A Metaphorical Memoir").

In 2005, Lilienfield and colleagues conducted an experiment to challenge the veracity of Slater's claims (Scott Lilienfield is a leading authority on science/pseudoscience in psychology his work, such as this chapter on issues in diagnosis from the text "Psychopathology: History, Diagnosis, and Empirical Foundations" is pretty much required reading for psych grad students, and for the interested reader, this particular chapter does a nice job of outlining how the field of psychology thinks about diagnosis and the various controversies related to diagnosis, including the Szasz argument).

In their 2005 study, Lilienfeld and colleagues presented a detailed vignette to 74 ER psychiatrists and asked them what they would diagnose and recommend, and then asked them questions about how they arrived at their diagnosis. As you can see from the abstract, only 3 of the 74 psychiatrists offered a diagnosis of depression with psychotic features, and only about 1/3 recommended medication.


Watch the video: The Rosenhan Experiment - Infographics about the Psychiatric Study (August 2022).