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In 1973, a study published in the preeminent research journal Science shook the mental health community. The study tested a provocative question: “Could psychiatrists at 12 different U.S. hospitals distinguish the sane from the insane?” In one of the most controversial findings published in the field, Stanford psychology and law professor David Rosenhan showed that mental health professionals were remarkably bad at detecting completely sane individuals amongst the patient population of psychiatric hospitals. His article, “On Being Sane in Insane Places,” highlighted some of the problems with the nation’s psychiatric hospitals.
For the study, Rosenhan had eight people gain admittance into 12 different psychiatric hospitals by feigning auditory hallucinations; these “pseudo-patients” arrived at the admissions office complaining that they were hearing voices. When asked by psychiatrists what the voices were saying to them, they replied “empty,” “hollow,” and “thud”—possible indications of some kind of existential psychosis. All 12 hospitals admitted these completely sane individuals, eleven under the diagnostic label of ‘schizophrenia’ and one as ‘manic depressive psychosis.’ Once these pseudo-patients were admitted, they behaved normally without any symptoms of abnormality. Rosenhan wanted to see how long it would take for the psychiatrists and hospital staff to realize that these individuals were not disturbed in the least.
So how long did it take? The average length of the pseudo-patients’ stay was 19 days, with one patient staying as long as 52 days. All the pseudo-patients were eventually discharged with the label of their admitted condition ‘in remission.’ It was a dramatic failure of detection in the mental health system.
Aside from the extended lengths of stay, several other interesting observations emerged from the study. While the hospital staff failed to distinguish sanity from insanity, real patients in the ward were often very suspicious of the pseudo-patients. For example, the real patients frequently exclaimed, “You’re not crazy. You’re a journalist” or “You’re checking up on the hospital.” But by far the most disturbing finding was that anything the pseudo-patients did was viewed in the context of their “illness.” When pseudo-patients were seen taking notes on their writing pads, it was viewed as a symptom of their pathological condition; not once was a pseudo-patient asked about what they were writing. And after they were admitted and labeled as mentally ill, their requests and questions were routinely ignored. On one occasion a pseudo-patient asked a psychiatrist if he might gain ground privileges; the doctor’s reply was “Good morning, Dave. How are you today?” after which he walked away without waiting for a response. Psychiatrists, nurses, and attendants avoided eye-contact or moved along with their heads averted on over 71% of the instances where the pseudo-patient tried to initiate a conversation. Not surprisingly, all of the pseudo-patients disliked their stays and wanted to be discharged as quickly as possible, and who could blame them? They found themselves in a setting where they were essentially invisible to the staff and there was remarkably little to do. It was an environment where a sane person might actually be driven insane by the quality of treatment.
Intriguing as it was, Rosenhan’s study had some major weaknesses. He used a very small sample size of only eight psuedo-patients tested at 12 different hospitals. Moreover it’s unclear whether the ability to detect “malingerers” (those that feign illness) is a critical trait of a good psychiatric hospital. But despite these shortcomings, the study’s strength lied in revealing how patients, fake and real, are sometimes treated by their caretakers.
The pseudo-patients were not treated as individual human beings; they were seen as their labeled illnesses. It’s something we are all guilty of doing at some point or another, categorizing people under tidy and convenient labels to simplify our own lives. The difference is that a label like “schizophrenic” sticks with someone for a long time and it is difficult for others to see past it.
If we are to learn anything from Rosenhan’s 1973 study, it’s that even though someone is diagnosed and subsequently labeled with a mental illness, it does not diminish their human need for attention, recognition, or respect. The challenge for today’s psychiatrists and hospital staff is to see patients as distinct individuals, not as a collection of symptoms or as mere labels. That alone would do wonders for our collective sanity.