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Key Study: On Being Sane
in Insane Places

David Rosenhan, 1973



AIMS:  “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 not valid summaries of characteristics displayed by the observed” (‘On Being Sane in Insane Places’ in Science #179, 1973).

Rosenhan aimed to investigate if psychiatrists could distinguish the difference between people who are genuinely mentally ill and those who aren’t, using DSM.  He aimed to find out if “the salient characteristics that lead to diagnoses reside in the patients themselves or in the environments and contexts in which the observers find them?”

Rosenhan also wanted to learn more about what it was like on a psychiatric ward from the patient’s viewpoint.


PROCEDURE (METHOD): A group of 8 ‘normal’ people attempted to gain admission to 12 different hospitals in 5 different states on the American east and west coasts. The hospitals varied from old to new; some had good staff-patient ratios while others were understaffed; some were research based and one was a private hospital.

The ‘pseudopatients’ consisted of 3 women and 5 men - a 20-year-old graduate, 2 psychologists, a paediatrician, a psychiatrist, a painter and a housewife, with the eighth being Rosenhan himself. (Rosenhan reputedly recruited the pseudopatients by ringing around his friends who included the noted psychologist Martin Seligman.)

The pseudopatients called the hospital for an appointment, stating that they were hearing voices, which were of the same sex and, whilst slightly unclear, seemed to be saying, ‘empty’, ‘hollow’ and ‘thud’. These symptoms were purposefully chosen for their similarity to existential symptoms (the alleged meaninglessness of life) and their absence in the psychiatric literature. Apart from falsifying symptoms, name and employment, no further pretences were made.

They all employed pseudonyms and those in the mental health profession gave another occupation to avoid embarrassment to colleagues. They described their childhoods, life events, relationships and, for those who weren’t involved in mental health, occupations accurately (both good and bad).  None of them had any prior history of pathological behaviour.

The pseudopatients, very much as a true psychiatric patient, entered a hospital with no knowledge of a discharge date.  (Each had been told that they would have to get out by convincing the staff that they were sane.)

Following admission to hospital no further symptoms were ‘acted out’ and, other than some understandable nervousness and tension of being found out, the pseudopatients behaved perfectly normal. As all but one found the experience stressful and wanted to be released, they co-operated with staff and obeyed instructions. If asked how they felt, they said they felt fine and no longer experienced any symptoms. In some cases the pseudopatients approached staff and said: “Pardon me, can you tell me when I am likely to be discharged?” (Care was taken never to approach a particular member of staff more than once a day to avoid irritating them or arousing their suspicions.)

The pseudo-patients spent their time talking to the other patients and making notes of observations of patients and staff on the ward. Initially the notes were done in secret but it soon became apparent that the staff did not really care. (The closest to being questioned about the note-taking was when one doctor told the pseudopatient making a note of his medication: “You needn’t write it. If you have trouble remembering, just ask me again.”)

Rosenhan was the first pseudopatient to be admitted, having confided only to the hospital administrator and the chief psychologist there. In all other 11 cases the hospital authorities were not informed.


After the results of this research were publicised, staff in a research & teaching hospital that had not received any pseudopatients claimed that it could not happen in their hospital. They were informed that in the next 3 months, one or more pseudopatients would present themselves.

The staff were asked to rate, on a 10-point scale, their confidence level that the participant was genuine. Judgements were obtained on 193 patients admitted for psychiatric treatment.


FINDINGS (RESULTS): All pseudopatients were admitted, except in one case, with a diagnosis of Schizophrenia. The 12th diagnosis was Manic Depression.

The length of hospitalisation ranged from 7 to 52 days, with an average of 19 days.

Average daily contact with the psychiatrists was an average of 6.8 minutes per day (based on data from 6 patients over 129 days of hospitalisation)

Whilst at the hospital the ‘real’ patients regularly voiced their suspicions. 35 30%) out of 118 patients made statements such as you’re not crazy - you’re a journalist’” or “you’re a professor checking up on the hospital”. However, in no case did doctors or nurses notice there was nothing wrong with the pseudopatients. This lack of insight may have been influenced by the fact that doctors (71%) and nurses (88%) mostly ignored the pseudopatients when they they tried to speak to them. The staff at the hospitals tended to interact only minimally with patients - for caretaking purposes, to issue medication, conduct therapy or group meetings, instruct and reprimand patients. According to Rosenhan, staff on average only spent 11.3% of their time outside their glassed quarters patients referred to as ‘the cage’ - the nurses interacted  with the patients 6.7 times on average per day. The table below shows the full results of attempts by pseudopatients to initiate interaction with staff. (The table also includes data from Stanford University where Rosenhan, for comparison purposes, had a young woman approach individual busy-looking faculty members and medical centre staff to ask them 6 questions, including how to get to various parts of the campus. All the questions were answered fully, without being rushed and with good eye contact.)

twelfth discharge diagnosis was Manic Depression-in-Remission!)

It was clear from comments made by staff and from records viewed retrospectively that perceptions of behaviour were coloured by the diagnosis of the pseudopatient’s condition Having once been labelled schizophrenic, there was nothing the pseudopatients could do to overcome the label.  Eg: one pseudopatient was described by Rosenhan as: “...had had a close relationship with his mother, but was rather remote from his father during early childhood. But during adolescence and beyond, his father became a close friend while his relationship with his mother cooled. His present relationship with his wife was close and warm; apart from occasional angry exchanges, friction was minimal. The children had rarely been spanked.” Yet the hospital record described him as: “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 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 these relationships also....”

Many normal behaviours were overlooked completely or profoundly misinterpreted. Eg: waiting outside the canteen before lunch was interpreted by one psychiatrist as ‘Oral-Acquisitive Syndrome’. Pacing the corridors out of boredom was seen as ‘nervousness’.

Rosenhan’s pseudopatients also recorded a number of instances of maltreatment, ranging from lack of privacy - eg: initial examination in a semi-public room and records available to anyone who wanted to look at them - to verbal abuse to physical beatings (in front of other patients but not other staff). The pseudopatients felt this treatment led to feelings of powerlessness and a loss of identity which could again be interpreted as symptoms of their ‘illness’ rather than a response to the social role they had been given.


In the follow-up study, of 193 admitted patients 23 were thought to be a pseudopatient by at least one psychiatrist. In fact, Rosenhan did not send any pseudopatients to the hospital. 41 patients were thought to be pseudopatients by at least one member of staff and 19 by one psychiatrist and one other member of staff.


CONCLUSIONS: Rosenhan 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 hospitalised in such an environment - the powerlessness, depersonalisation, segregation, mortification and self-labeling - seem undoubtedly counter-therapeutic...Once labeled schizophrenic there is nothing the pseudopatient can do to overcome the tag.

“Any diagnostic process that lends itself so readily to massive errors of this sort cannot be very reliable.”

Rosenhan concluded that the failure to detect sanity during the course of hospitalisation may be due to the fact that the doctors were showing a strong Type 2 error - that is the physicians were more inclined to call a healthy person sick (a false positive, Type 2) than a sick person healthy (a false negative, Type 1).


With regard to the 23 patients thought to be sane in the follow-up study, Rosenhan speculated that, in the course of avoiding a Type 2 error, the staff may have made a Type 1 error and called “crazy people sane” ?


CRITICISMS (EVALUATION): The investigation was carried out in real hospitals, using real staff who were unaware of the study, thus giving it high ecological validity.

As a range of hospitals were used from around the United States, it was reasonable to generalise the results to other psychiatric hospitals at the time.

The study yielded both quantitative data – eg: the number of days the pseudopatients were kept in hospital – and qualitative data – eg: the notes the pseudopatients made about life on the wards.

For validity purposes, Rosenhan attempted to ensure the conduct of his participants conformed to their brief. Data from a 9th pseudopatient was not included in Rosenhan’s report because, amongst other things, he did not stick closely enough to his brief.

However, Seymour Ketty (1974) criticised Rosenhan’s deception from a validity perspective, saying: “If I were to drink a quart of blood and, concealing what I had done, had come to the emergency room of any hospital vomiting blood, the behaviour of the staff would be quite predictable. If they labelled and treated me as having a bleeding peptic ulcer, I doubt that I could argue convincingly that medical science did not know how to diagnose that condition.” (‘From Rationalization to Reason’ in American Journal of Psychiatry #131)

Ketty’s point was that psychiatrists will hardly expect someone to carry out a deception in order to be admitted to a psychiatric hospital. In other words, the study lacked mundane realism.

The fact that 11 of the 12 diagnoses were consistent - Schizophrenia - may actually indicate reliability - present the same symptoms, get the same diagnosis!

Robert Spitzer (1976) notes that the diagnosis ‘Schizophrenia-in Remission’ is extremely rare. He examined the records of discharged schizophrenic patients in both of his own hospital and 12 other American hospitals and found that in 11 cases ‘Schizophrenia-in-Remission’ was either never used or used only for a handful of patients each year. Therefore, Spitzer claims the psychiatrists’ discharge diagnosis was, in fact, due to how the pseudopatients behaved and not to the fact the psychiatrists couldn’t tell they were normal.

Although the pseudopatients attempted to record their observations objectively, almost inevitably there would be some subjectivity influenced by their emotions.

There are significant ethical problems with the study as the hospital staff were deceived about the patients’ symptoms. Consequently they could neither give their consent nor exercise their right to withdraw. However, Rosenhan did protect confidentiality - no staff or hospitals were named, thus minimising the risk of identification.

Another ethical issue with Rosenhan’s study is the crisis of public confidence in the American mental health system it caused - which may have prevented people who genuinely needed help from seeking it.

Psychiatrists point out that the DSM has been revised several times since Rosenhan’s study and that diagnostic criteria have been tightened considerably. Rosenhan set himself and his pseudopatients against DSM-II (1968); it is much less likely his pseudopatients could have fooled psychiatrists steeped in DSM-III (1980) as a characteristic hallucination was now required to be repeated several times. In DSM-IV (1994) hearing voices must be experienced for over a month before a diagnosis of Schizophrenia can be made.

Lauren Slater (2004) reported that she had attempted to replicate Rosenhan’s study by presenting herself at 9 psychiatric emergency rooms with the lone complaint of an isolated auditory hallucination (hearing the word ‘thud’). In almost all cases Slater was given a diagnosis of ‘Psychotic Depression’ and prescribed antipsychotics or antidepressants. (Ironically Slater had once been diagnosed with Depression!) Robert Spitzer, Scott Lilienfeld & Michael Miller (2005) sought to challenge Slater’s findings by giving 74 emergency room psychiatrists her detailed case description and asking questions about diagnosis and treatment recommendations. Only 3 psychiatrists diagnosed ‘Psychotic Depression’ and only a third recommended medication.

G Langweiler & M Linden (1993) sent a trained pseudopatient to 4 physicians, each with a different professional background. Although the pseudopatient presented the exact same symptoms to the physicians, 4 different diagnoses were offered along with 4 different treatments.



Psychiatrists

Nurses & Attendants

Faculty

“Looking for a psychiatrist”

“Looking for an internist”

No additional comments

% moves on, head averted

71

88

0

0

0

0

% makes eye contact

23

10

0

11

0

0

% pauses and chats

2

2

0

11

0

10

% stops and talks

4

0.5

100

78

100

90

Mean number number of questions answered (out of 6)

N/a

N/a

6

3.8

4.8

4.5

No of respondents

13

47

14

18

15

10

No of attempts

185

1283

14

18

15

10

Some notice was taken, though, as nursing records for 3 pseudopatients indicate that their writing was seen as an aspect of their pathological behaviour (‘patient engages in writing behaviour”).

During the research the pseudopatients were given a total of 2,100 tablets - including Elavil, Stelazine and Compazine - which they did not swallow.

Each was discharged with a diagnosis of Schizophrenia-in-Remission. (The