in Educational material, Misc., Thinking about psychiatry

The Rosenhan experiment examined

The ‘Rosenhan experiment’ is a well known experiment examining the validity of psychiatric diagnosis.  It was published in 1975 by David Rosenhan in a paper entitled ‘On being sane in insane places’

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.


Rosenhan concludes:

“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.


Mind changers 27 July 2009 Radio 4: The pseudopatient study

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  1. I find the Rosenham study important and interesting but its results unsurprising. I think at the time of the study a person given a schizophrenia diagnosis was not expected to ever recover, though might go ‘into remission’ for a while. Once given such a diagnosis (even if the ‘evidence’ for it was flimsy) I think it was seldom questioned and changed.

    The medics doing the initial assessment on the pseudo-patients can’t be blamed for believing the claims of these patients that they had heard a voice. I expect they’d been taught that hearing voices points to the strong likelihood of schizophrenia. I think it’s good the way that Rosenham’s experiment challenged the concepts being taught to students of psychiatry. It’s not surprising that it pissed off a lot of pyschiatrists, who rose up in defence of their profession.

    We’re told that once admitted to hospital the researchers behaved normally (perhaps no small feat in the hospital environment!). I’m sure it’s true that psychiatric staff expecting to find symptoms of illness do tend to find abnormality in just about every person they look for it in, often failing to take into account the effects of the hospital and their own behaviour toward the patient.

    I believe that research, and interpretation of research findings, should never be accepted at face-value, and Rosenham’s experiment is no exception to this. But I do think Rosenham’s investigation does still have some truths to teach us, not only about the hospital environment but also about the core concepts underpinning diagnosis and treatment, how some (not all) psychiatrists are quick to make assumptions on insufficient knowledge, and about the ways in which psychiatry was (and is) practised.

  2. Great analysis of Rosenhan. Find myself in agreement with every point you make re the conclusions we can reliably draw from that work.

    I would take issue with one thing you say though:

    “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.”

    Isn’t this the point though? I’m guessing it was rare then, as it is now, to hear psychiatry demonstrating humility about the reliability and validity of psychiatric diagnoses such as schizophrenia. Pick up a standard textbook of psychiatry (particularly a US one) and the certainty that ‘schizophrenia’ is a valid entity which can be reliably measured is quite staggering.

  3. Hi Paul,

    I think that the point is that the test can only expose the weaknesses of psychiatric diagnosis. If some pseudopatients had been sent, and a larger proportion had been identified than would have been expected by chance then this would have challenged Rosenhan’s conclusion.

  4. Yes, but sending pseudopatients when the hospital was expecting it wouldn’t really have produced a generalisable assessment of the actual application of psychiatric diagnosis.

    To be fair to Rosenhan, he’d already made his point with the first experiment. If my memory serves me, he carried out the second round because a nearby hospital tried to attribute the findings to poor clinical practice in the original hospital. They claimed the results were not generalisable.

    You’re right of course; the reliability of psychiatric diagnosis meant they were always going to end up with false positives in the second round. But the doctors at that hospital presumably didn’t think so. They claimed otherwise and paid the price. The question is; how many doctors at the time shared that optimism about diagnostic reliability and validity? And how many doctors today provide their patients with statistics around diagnostic uncertainty (i.e., their risk of being wrong about course and prognosis)? I’d be surprised if very many do. Instead, those patients who challenge their diagnosis are often classified as lacking insight.

    What Rosenhan did do was demonstrate the large role that expectancies play in these diagnoses. That was a pretty big shock to everyone, and rightly challenged the legitimacy of the psychiatric world-view.

    On a slightly separate point, there’s a study just out in the British Journal of Psychiatry claiming that 1 in 5 of us has full-blown personality disorder. A study published last year found the majority of us are going to experience ‘mental illness’ of some sort.* I know you’re skeptical about all this sort of stuff so I’m sure you’ll agree that the validity of psychiatric diagnosis needs to be questioned. Something definitely needs to shift in our way of thinking about all this.

  5. I find it interesting that he found the attendants to be sometimes abusive yet overall very committed and intelligent. I noticed the same thing when I began my job as a mental health tech at a US hospital. At first glance I was impressed by intelligence of my co-workers, especially compared to non-professionals I had worked with at other jobs. The longer I worked there the more I  saw things that were questionable, like denying patients small things off hand, snapping verbally at someone or being rough during a code with a violent patient. I later found out that these experienced techs had a reason for nearly every “mean” thing they did. There were a very few truly abusive techs, but most knew the patients better than the patients knew themselves and were excellent at avoiding outburst or dangerous situations. It’s easy to think denying someone water is cruel unless you also knew they are too confused to know when to quit and often threw up. It’s easy to think that a tech is being overly rough restraining someone unless you also know that the restrained patient likes to beat their head on the ground or broke a techs arm on their last admission. Not to excuse true cruelty, but in my experience people do not deal with the psych population unless they like to and those techs are generally VERY shrewd. They don’t let patients get away with anything because it’s very hard to keep things safe. Until the whole system changes psych techs will continue being this tough on patients. Plus, some patients need that type of tightly controlled order. Sorry to rant. I know psych treatment is not ideal, but psych techs do try their hardest. 

  6. I am sorry, but there are lots of flaws in your article. If you distrust me, I could prove it to you. But I have heard some psychiatrists are biased and arrogant, so it is no point to discuss it with you. I have replicated Rosenhan experiment. You said that if the pseudopatient would reveal that they are pseudopatients to the psychiatric staff, they would surely respect that. But you are wrong. The psychiatrists in my experiment was in denial. The label tends to stick exactly like Rosenhan experiment exposed psychiatry, and there are many flaws in psychiatry diagnostic and treatment

  7. David – please do post your proof here as a comment. The point of this blog is to discuss various viewpoints about psychiatry and if you have replicated the Rosenhan experiment I’m sure that the readers of this blog would be interested to know your methods and results. FP

  8. Hello, My name is Samantha and im currently studying Psychology in the UK. I’ve read through everything posted and some valid poinst have been made that I am definatly going to bring up with my teacher about he validity of the Rosenhan study.
    I was wondering if any of you could help me with something. I know that there were 8 Pseudopatients, but in the case study it says they were trying to be admitted to 12 diferent hospitals and they all achieved it, 7 being diagnosed with schizophrenia and 1 with manic depression. As it says 12 hospitals, I thought there would have been 12 pseudopatients. Or did some of them fail to get into some of the hospitals. And if this is the case, shouldnt it be presented in the actual study.
    please tell me if im being stupid becuase I dont understand.

    thankyou 🙂

  9. Hi Samantha,

    I remember thinking that the numbers didn’t add up, but there was so much to comment on that I didn’t look into this any further.

    Rosenhan is still alive and holds an academic position at Stanford university . Why not try emailing him?

  10. And the neurologists say “Personality Disorder” has an organic basis, and the psychs say it’s deviant behaviour… Still going on today it seems!

  11. The experiment holds validity in certain aspects and rings true in various areas of todays mental health facilities, many psychiatrists are quick to diagnose patients based upon various often flimsy symptoms, but however we must remember they are working with frameworks and nice guidlines etc etc that they have to adhere to, it is difficult to comprehend how one man can “label” another based upon thin evidence, however again we must remember that various service users suffer indescribably from psychotic afflictions and the diagnosis attributed to them is often influential in achieving the correct medication or psychological therapies required. It is unfortunate that in the mundane settings of hospitals that the patients behaviours are consistently attributed to their pathological affliction whereby in most cases this could actually be the individuals general way of life or they could be acting this way due to boredom! i know in this setting i would be bored and would wander the ward environment, this would be construed and documented to correlate with my “diagnosis” as perhaps being restless, wandersome, agitated etc etc. The nurses who document this info are not to blame, they are at the forefront of service user contact and unfortunately have the least qualifications to do so, with a lack of understanding of a term like schizophrenia nurses will try to validate their role and understanding by using terms to describe the service users behaviiours in line with what they expect to be a symptom of the disorder. Nursing assistants play a vital role in recovery, even more so than a psychiatrist, they are the people who offer the therapeutic engagement, assistance with daily living and offer nursing interventions, perhaps the nursing assistants should be afforded further training around disorders etc and understanding of them. I do believe that the majority of psychiatrists will admit and diagnose as appose to not as this is the easier, safer way, its much better to admit a patient on the basis of the initial assessment rather than get sued two weeks later off the patients family because he has commited suicide. This is unfortunate in many ways, the label will inevitably stick, medication will be a more likely route as appose to CBT etc, and the service user will become a part of the system which could be avoided with earlier interventions.

  12. Well, diagnostic systems has improved since then, although not dramatically, so an more up-to-date experiment would be ideal. Nevertheless, the basic point, that such institution are not the way we imagine them to be, is not easily denied. I can sure can understand, however, that if I worked in such an institution, I would definitely not want to appear as the only guy going out of the office (or cage as Rosenhan names it), and joining the crowd. The other staff would comment that “Hmm… George sure fits with them…” and fit me awkward if I did. I am surprised that Rosenhan is surprised of how the staff ignore the patients.

    Also, if I was a staff there and I wouldn’t want to be the first one to claim that some patient is sane… other staff would perceive me as finding wrong behaviors as normal and think about my behaviors.

  13. A psychiatric survivor here. You can lie to yourself all you want but in in the end psychiatry and psychology are just prostitutes of pharmaceutical companies. Have a good day murderers.

  14. Samantha,

    I am a Psychology teacher in the UK and my students have also been asking me about the discrepancy in the numbers – did you manage to get a reply from Rosenhan? I have searched high and low for an answer to this question but have been unable to find anyone who knows.

  15. From my own experience, Rosenhan’s experiment is important in understanding the process of misdiagnosis. At the age of 16, as an intelligent and introverted person interested in science, psychology, and philosophy, I was labelled schizophrenic as I had reported voices (during a quick one day visit to a psychiatrist). I now know that I was referring to my inner monologue, and was misunderstood about how I described other events. After a year of taking anti-psychotics I challenged my diagnosis. I was sectioned and then labelled paranoid schizophrenic. The long-term abuse in my childhood was ignored as a fantasy and quite normal things were seen as a cause or manifestation of the disease. Then, after secretly not taking the medication, I improved dramatically. A recent psychiatric review has accepted that my diagnosis was always uncertain and that the psychiatrist involved became more uncertain over time. I am now being treated for depression. The worst thing is that the diagnosis of psychosis continues to haunt me in many substantial ways, such as being part of my medical history and in colouring the views of others. There is no way for me to prove the misdiagnosis, that I was never psychotic when I was 16 (for the reasons that Spitzer describes).

  16. If I read the original paper correctly, it did not state that all pseudopatients presented at hospital at the same date – possibly the same pseudopatient presented at different hospitals on sequential dates. From experience in UK hospitals (1970-80) some patients moved from hospital to hospital, either because they had nowhere else to go, it was cheap accommodation with reasonable food or because they had become to institutional life – there are possibly other reasons – my argument is that there existed a floating population of ‘continual’ patients – of indeterminate size – not recorded in the statistics but noticed by experienced nurses because of their behaviour patterns though not always by medical staff because of their short exposure to such behavioual patterns – who in their right mind wants to be in a mental hospital??
    Logical criticism has its place but it should be placed in the correct environment! See the Stanley Milgram experiments for unexpected results from ordinary tests.

  17. FYI anyone coming late to this page: Samantha misread the study.

    It says nowhere that 7 were diagnosed with Schizophrenia. It says ” Admitted, except in one case, with a diagnosis of schizophrenia”.

    Assuming there were 12 admissions (I’m doubting that multiple patients were sent to the same hospital), then we can assume that they diagnosed 11 with Schizophrenia.

    That said the non-existence of numbers in the study is worrying. Really would be nice to see all the data, not just the extremes and the average.

  18. This is an interesting article and I wanted to use it as a reference but you don’t list the author. May want to consider doing that.

  19. I’ve worked in medicine for 20 years. This happens. We all know it. The doctors, the nurses, the judges, the lawyers… everyone. The reason we have articles attempting to debunk this study 40 years after the fact is that they can’t produce a study that invalidates it… because that’s how real science works. You form a theory, you test it, if you get repeatable results you report it. If you take issue with such a study, you form your own theory that invalidates it and you prove it. What you don’t do is pick apart a study using logical fallacies… that’s NOT science, it’s politics. Politics is the only reason this field of study has as much credibility as it does.
    Psychiatrists are the ONLY people in this country who can literally ignore a persons rights based solely on his/her opinion, and they do so with virtually no oversight or consequence. I have seen this power abused time after time. Maybe it’s defensive medicine, maybe it’s laziness, maybe it’s greed, in any case it’s a lack of integrity… even if you aren’t the one locking these people up, you sure as hell should be the one blowing the whistle… but you don’t. You don’t because it would damage the public perception of the profession and when it comes right down to it you rely on people trusting you and believing that you can help them to have any hope of having a positive impact.
    Psychiatry is the imperfect tool we have to contend with problems we don’t understand. That’s not to say it’s not a worthwhile endeavor, but we should call a spade a spade instead of trying to artificially inflate the validity of an entirely theoretical field of study.

  20. Since the results of Rosenhan’s study were somewhat replicated by various other authors (until this became unethical to do this kind of psychology study…), I will assume the results are correct to some extent, and that there is a significant issue of misdiagnosis in psychiatric practice.

    Misdiagnosis is a problem that impacts ALL medical fields, but with some being more impacted than others, and in particular some particular diagnoses being more prone to being wrongly attributed. One example is certainly schizophrenia, as demonstrated by this study. Another example is the theory of somatization, which stems from Freud’s concept of hysteria (somatization being the theoretical enabling process for the manifestation of hysteria). Although initially a psychoanalysis diagnosis, it has now crept up through all medical domains, and it’s now not uncommon for patients with real physiological illnesses to be labelled as “somatizing” until they get approriately tested with sensitive enough tests for their illness. Historically, patients with Parkinson’s disease were labelled as somatizing for example, until this illness became better understood and advances in neuroimaging technology allowed to assess unequivocal brain damages that are the hallmarks of this illness. But not only medical practice is impacted, but also research papers, where somatization now randomly pops up in various papers that are totally unrelated to psychoanalysis, showing this concept is now widely well accepted, despite NO evidence it exists.

    Indeed, I think the main issue with somatization, and I would argue with psychiatry at the time of Rosenhan (and up to today to some extent), is the lack of falsifiability. Karl Popper himself criticized the concept of hysteria and somatization on this ground, and I do think he was right. Somatization is based on the logical fallacy that if we can’t find a biological explanation for the symptoms reported by a patient, they must stem from a mental process. Similarly, if a mental illness diagnosis such as schizophrenia cannot be overturned when the pseudopatient is showing no sign of it, then this is also a logical fallacy, because the diagnosis becomes unfalsifiable once it is made. So the emphasis that Rosenhan put on this issue is very logical and acceptable if we accept that falsifiability is a necessary condition for any scientific methodology.

    That’s not to say that psychiatry and psychology are useless or pseudosciences. They certainly led to great discoveries, contributing to neurology, artificial intelligence and so much other domains, and themselves benefiting from progresses in these other domains. But I think that any strongly scientifically grounded medical method need to not only define under what condition a diagnosis can be made, but also under what conditions it can be falsified. And for the moment, it seems psychiatry and psychology (and I won’t mention psycho-analysis) are lagging way behind in that respect unfortunately.

  21. Addendum: to clarify why falsifiability is an issue:
    * for somatization, its existence and diagnosis is admitted on the basis that a biological explanation can NOT be found. But “the absence of proof is not the proof of absence”, as there can be an infinite number of other reasons (eg, tests not sensitive enough, no test available for an emerging or rare disease, intermittently secreting disease that cannot be detected at all times, etc).
    * for schizophrenia and other psychiatric and psychologic diagnoses, if a diagnosis cannot change once it is made, this means that once the diagnosis is made, there is no falsifiability, as there exist no (natural) condition under which the diagnosis can change. I’m expliciting natural condition, meaning that the patient should not have to explicitly tell the personnel (s)he’s a pseudopatient. Why? Because in the case of misdiagnosis, where the patient is a real patient but not a pseudopatient simply with a wrong diagnosis, then the “unnatural condition” of requiring the patient to talk to the staff wouldn’t help at all. Diagnosis should be amendable depending on empirical data. A method that cannot account for updated empirical data can only be dubious.


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  • Quora January 11, 2020

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  • we are young January 11, 2020

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