Introduction to the study

Rosenhan's (1973) study, titled 'On being sane in insane places', explored fundamental questions about mental health. It questioned whether sanity and insanity truly exist as distinct states, and how we can reliably tell them apart. The research focused on whether the key factors leading to diagnoses of abnormality lie within the individuals themselves or in the surrounding environments and contexts where they are observed.

This study challenged the reliability of psychiatric diagnoses by testing if mentally healthy people could be admitted to psychiatric hospitals and, if so, whether their sanity would be recognised. It highlighted potential flaws in how mental health professionals distinguish between normal and abnormal behaviour, using real-world hospital settings to gather evidence.

Aims of the study

Rosenhan aimed to investigate the validity of psychiatric diagnoses. Specifically, he wanted to determine if the characteristics that lead to a diagnosis of mental illness are inherent to the patients or influenced by the hospital environment.

Key research questions

• Do sanity and insanity exist as clear, detectable states?
• If mentally healthy individuals try to gain admission to psychiatric hospitals, will they be identified as sane?
• How might the hospital context affect the perception of a person's mental state?

These aims were tested by simulating admissions to see if 'normal' people would be misdiagnosed, revealing potential biases in diagnostic processes.

Participants in the study

The study involved eight mentally healthy individuals, referred to as pseudopatients, who pretended to have symptoms to gain hospital admission.

Background of the pseudopatients

• One graduate student (in psychology)
• Three psychologists
• One psychiatrist
• One paediatrician (a doctor specialising in children's health)
• One painter
• One housewife

These participants were diverse in background but all confirmed to be sane before the study. They were chosen to represent ordinary people without genuine mental health issues, allowing Rosenhan to test if sanity could be detected in a psychiatric setting.

Method and procedures

Rosenhan designed the study as a field experiment, using real psychiatric hospitals to observe natural behaviours and diagnostic practices. This approach allowed for an authentic examination of how mental health professionals respond to perceived symptoms.

Selection of hospitals

The pseudopatients targeted 12 different hospitals across five US states.

These varied in type to ensure broad representation:

• Old and shabby facilities
• New and modern ones
• Research-oriented hospitals
• Well-staffed and poorly staffed institutions
• Funding sources including private, federal, and university-funded

This variety helped test if diagnostic errors were consistent across different environments.

Procedure for admission

1. Each pseudopatient telephoned a hospital to request an appointment at the admissions office.
2. Upon arrival, they reported hearing unfamiliar voices of the same sex as themselves, which were unclear but said words like 'empty', 'hollow', or 'thud'.
3. These symptoms were deliberately chosen to mimic an existential crisis – a state of distress arising from feelings that life is meaningless – without matching clear signs of any specific mental disorder.

Pseudopatients provided false names and jobs to protect their identities but gave truthful details about their personal lives, including everyday ups and downs. Once admitted, they immediately stopped pretending to have symptoms, behaving normally except for possible nervousness due to fear of being discovered. They participated in ward activities, took notes on staff and patients, and had to convince staff of their sanity to be discharged, as they were instructed to secure their own release.

Results of the study

The study's findings revealed significant issues in psychiatric diagnosis and hospital treatment. All pseudopatients were admitted and misdiagnosed, highlighting how normal behaviours were misinterpreted in a hospital context.

Admission and diagnosis

• Every pseudopatient was admitted, and all but one was diagnosed with schizophrenia.
• Diagnoses occurred despite the absence of clear symptoms of these disorders.
• Hospital stays ranged from 7 to 52 days, with an average of 19 days.
• All were discharged with schizophrenia 'in remission', implying they were still considered mentally ill.

Visitors observed no serious behavioural issues in the pseudopatients, but hospital staff failed to detect their sanity. However, 35 out of 118 real patients suspected the pseudopatients were not truly ill.

Misinterpretation of behaviours

Normal actions were often seen as pathological (abnormal or indicative of illness).

Examples of misinterpretation

• Note-taking was recorded in nursing notes as 'patient engages in writing behaviour', interpreted as a symptom.
• Waiting outside the cafeteria before meals was labelled by a psychiatrist as 'oral-acquisitive syndrome', when it was likely just routine behaviour due to boredom.

Experiences of depersonalisation and powerlessness

The pseudopatients reported feeling depersonalised and powerless.

Key observations included

• Deprivation of rights, such as restricted movement and lack of privacy (e.g., open medical records, monitored hygiene, toilets without doors).
• Brutality from some orderlies, who mistreated patients but stopped when other staff approached, showing patients were not seen as credible witnesses.
• Limited staff interaction: Nurses spent about 90% of time in offices; medical staff visited wards infrequently, averaging 7.2 minutes per day with patients.

All pseudopatients disliked the experience and sought immediate discharge, but none were released until staff decided they were 'in remission'.

Conclusions and implications

Rosenhan concluded that psychiatric hospitals struggle to distinguish between sanity and insanity. The study demonstrated that diagnostic labels, once applied, can stick, leading to misinterpretation of normal behaviours as symptoms of illness.

Key takeaways

• The hospital environment itself may contribute to perceptions of abnormality, as sane individuals were not detected.
• Experiences of depersonalisation and powerlessness in hospitals can harm patients, depriving them of basic rights and dignity.
• While the pseudopatients had negative experiences, Rosenhan noted that real patients, who lack the knowledge that their diagnosis is false, might suffer even more.

These findings raised ethical questions about psychiatric practices and emphasised the need for more reliable diagnostic methods.