Podcast Transcript
In 1973, one of the most influential and frightening experiments in psychology was published.
It was an experiment designed to test how mental health professionals identified and diagnosed mental illnesses and their inherent biases.
The results were jarring enough to completely change how doctors handle psychiatric care.
Learn about the Rosenhan experiment on this episode of Everything Everywhere Daily.
I want you to imagine the following nightmare scenario: you are a perfectly sane person who has been committed to a psychiatric ward involuntarily, perhaps even maliciously.
Would the doctors be able to tell that you shouldn’t be there, or would they keep you committed regardless?
This exact situation was subjected to an experiment in the early 1970s, and the results were terrifying.
The man behind the study was David Rosenhan, a professor of Psychology and law at Stanford University from 1971 to 1989.
While working at Stanford, Rosenhan was known for applying psychological principles to legal topics such as witnesses and juries. He also published over 80 research papers and books.
Despite his background in law, Rosenhan is best known for his 1973 paper, which is the subject of this episode. It focused on psychiatric hospitals and how expectations of mental illness led to misdiagnosis.
Rosenhan took the perspective that psychological abnormality has seven features: maladaptiveness, suffering, unconventionality, observer discomfort, violation of moral standards, unpredictability, and irrationality.
Rosenhan’s experiment was designed to determine the validity of psychiatric diagnoses. His key question was whether the characteristics people show that determine diagnosis come from the patients themselves or from the environment or context around them.
To test this, Rosenhan recruited eight students with no history of psychiatric illness to go to different mental hospitals. The students were sent to five different US states between 1969 and 1972, and some participated more than once.
These students can also be referred to as pseudopatients, meaning people pretending to be patients, or impostors.
Each pseudopatient was told to go to a psychiatric hospital and falsely report a single symptom: vaguely hearing auditory hallucinations. To keep the experimental variables equal, the imposters all reported hearing words such as hollow, thought, and empty. All other aspects of their life were reported honestly.
Once they reported the auditory hallucinations, the students were given extensive admission interviews, which determined whether they were to be admitted and remain in the hospital. Despite none of them expressing any other psychiatric symptoms that would justify admission, all were admitted.
All of the pseudopatients were admitted despite experiencing no other psychiatric symptoms. Once in the hospital, they were also given extensive interviews and tests to determine their sanity.
Once admitted, the imposters claimed they no longer heard voices, were honest about their significant life events, and acted normally with the staff. Despite this, the staff still did not see them as sane.
Among the 12 hospitals tested, none of the staff recognized that the pseudo-patients didn’t belong there.
Despite only complaining about auditory hallucinations once, the impostors were kept in the hospital for 7 to 52 days, with an average stay of 19 days.
Based on the behavior the staff claimed to have observed in the hospital, while they were acting normally, each pseudopatient was diagnosed with a serious mental abnormality.
The main diagnosis given was schizophrenia. Schizophrenia is a severe mental disorder in which a person experiences psychosis, including hearing voices, which is considered an auditory hallucination.
There are many symptoms of schizophrenia beyond auditory hallucinations. People diagnosed with the disorder may also experience visual hallucinations, exhibit disorganized speech, experience illusions, show diminished emotional expression, struggle with memory and focus, and have catatonic behavior, among other symptoms.
To be diagnosed with schizophrenia, a person needs to experience at least two of its symptoms over most of a month-long period. If fewer than two symptoms are present, the diagnosis would not apply. While this specific criterion wasn’t officially developed until 1980, the point is to show that psychiatrists should have been able to identify that the patients did not exhibit enough traits to warrant a diagnosis.
As the patient in Rosenhan’s experiment reported auditory hallucinations only once, and they went away, a diagnosis of schizophrenia would not be adequate or accurate, as they weren’t a persistent condition. However, when the pseudopatients were discharged, many were given the label “schizophrenia in remission.”
It actually gets more shocking. Although the hospital staff did not identify the impostors, there were people who did. The patients. Many fellow patients approached the impostors and told them they were likely journalists or professors checking up on the hospital.
Other patients were able to identify the ruse because the impostors openly took notes about their experiences in the psychiatric ward.
These notes were telling, providing insight into how a psychiatric ward functions. The notes themselves resembled participant observation research, in which researchers recorded their opinions and experiences of the hospital staff.
A common thread in these observations was that the hospital staff spent little time interacting with their patients. On average, the staff spent only 6.8 minutes with the impostors per day.
Every pseudopatient reported that the staff segregated themselves away from the patients. They typically stood behind a glass enclosure, where they could see the patient but could not respond to behavior.
The impostors’ notes highlighted that staff interactions with patients were inadequate. Patients were often treated impersonally, meaning they were ignored when they had questions, while the staff behaved in an authoritarian manner.
Many of the pseudopatients reported feeling bored, invisible, and powerless. The staff noticed these feelings but identified them as symptoms of a mental disorder rather than signs of mistreatment.
For example, when patients were pacing in their rooms to pass the time, the observers interpreted it as a sign of nervousness rather than boredom. The note-taking was viewed by hospital staff as a sign of obsession rather than a way of recording their treatment.
Many impostors felt that most of the real patients’ behavior was similar to their own, leading them to believe that people with genuine mental illness often act like quote-on-quote normal people most of the time.
Rosenhan’s findings were published in the prestigious journal Science in 1973 under the title “On Being Sane in Insane Places.”
Rosenhan later conducted a follow-up experiment. He told hospital staff that one or more pseudopatients would be admitted to their care.
He directed the staff to rate each potential patient on a scale of 1 to 10. If a person was rated a 1 or 2, the staff believed they were likely a pseudopatient and were healthy. If they were ranked higher, they were believed to truly be mentally ill.
The experiment lasted three months. During this period, the staff reported that 41 of the 193 admitted patients received a score of 1 or 2, accounting for 21.24% of all patients.
After the three-month period, Rosenhan revealed that no pseudopatients had been sent to the hospital. This offered further evidence of the previous biases at mental health institutions.
Following the publication of Rosenhan’s study, other psychologists conducted related experiments that focused on internal biases. While the experiments tested different phenomena, all showed internal biases in the general population and among mental health professionals.
For example, in an exercise conducted in 2008 by the BBC science program Horizon, two episodes of the show, titled “How Mad Are You?”, followed three experts as they studied 10 different subjects.
The experts were told that five of the subjects were previously diagnosed with a mental health condition, while the other five had never had one. Their challenge was to identify the five subjects with behavior-based diagnoses.
The experts were not allowed to speak to the subjects or learn about their history. They simply observed whether each person appeared to have a mental health diagnosis based on looks and behavior.
The experts only managed to identify 2 of the five patients based on their behavior, incorrectly claimed that two others had a mental health diagnosis, and misdiagnosed one patient.
The purpose of this experiment was different from what Rosenhan was testing. Instead of offering a critique of mental health professionals and diagnoses, it aimed to bring awareness to the public stigmatization of mental health.
The goal was to show the audience that Mental illness isn’t always obvious, and those who are diagnosed can, in many cases, behave like everyone else.
Despite Rosenhan’s experiment leading to a revolution in psychiatry, it has also been controversial. It remains debated because psychiatrists challenged his findings and argued that diagnoses relied on patients’ own reports of symptoms and experiences.
By lying about their symptoms, psychiatrists argued that the issue was not the diagnoses themselves but the patients’ false reports of their symptoms.
One psychiatrist compared the experiment to drinking a quart of blood and going to the emergency room, and reporting throwing up blood. If the patient did not report drinking their blood, the doctor would believe they had a serious internal issue. The idea is that psychiatrists can only work with the information they were given about the patient.
It was also pointed out that psychiatrists don’t expect their patients to be faking their symptoms, so the real-life implications of the experiment lacked a basis in reality.
Rosenhan’s study revealed glaring weaknesses of mental health institutions. It revealed that the label of “schizophrenia” warped how hospital staff would view patients and their symptoms.
Rosenhan concluded that hospitals are uniquely positioned to misdiagnose behavior because of personal attitudes and biases, which can lead to mistakes.
This led to critical discussions occurring around psychiatric institutions. This led to improvements in diagnostic reliability, most evident in updates to the Diagnostic and Statistical Manual of Mental Disorders, otherwise known as the DSM.
When Rosenhan’s experiments were being conducted, only two versions of the DSM had been released. At this time, the Manual put more trust in the ability of psychiatrists to determine who had mental disorders.
Rosenhan’s experiment led to the third version of the DSM, which incorporated criteria checklists to more accurately evaluate patients.
Additionally, the newfound lack of trust in psychiatric hospitals led to many of them being closed.
The revelations in the Rosenhan experiment also led to psychiatric institutions reforming themselves. Institutions began to treat patients with more respect. They also challenged how they labeled the behavior of patients, like note-taking, as something normal, rather than a sure-fire sign of mental abnormality.
Almost 50 years after the paper was published, there was dramatic twist in the story. Accusations arose that that the results of Rosenhan’s experiment may have been fraudulent.
In the 2019 book, The Great Pretender, Susannah Cahalan questions the validity of the experiment after examining documents Rosenhan left behind when he died in 2012.
While analyzing the data, Cahalan noticed a potential distortion in the results. She found that there were misleading descriptions, fabricated and inaccurate quotes from psychiatric records, and inconsistent data.
Another concern Cahalan noted was that she could identify only two of the eight pseudopatients. The two she managed to identify were Rosenhan and one of his graduate students.
Given that the graduate student’s testimony was inconsistent with Rosenhan’s presentation of his research and the inability to find the six other pseudopatients, Cahalan posits that Rosenhan may have fabricated the six other participants to further his experiment’s agenda.
A review of Cahalan’s book was later published in the journal The History of Psychology. The review agreed with Cahalan’s findings and suggested that Rosenhan’s experiment was fraudulent.
The interesting thing is that the reason why Calahan even bothered to investigate the study is that she was misdiagnosed with a mental illness.
If it is indeed true that Rosenhan fabricated his study, that doesn’t mean his conclusions were wrong. It just means someone needs to replicate the study, although the results 50 years later might be totally different given the different climate.
Regardless of whether Rosenhan faked his results, the experiment itself led to many positive reforms in the field of psychology. It led to doctors changing how they care for their patients, reforms in how we diagnose mental illness, and more awareness of internal biases around mental health.
