The main building of St Elizabeths Hospital (1996), located in Washington, D.C., now boarded up and abandoned, was one of the sites of the Rosenhan experiment
The Rosenhan experiment or Thud experiment was conducted to determine the validity of psychiatric diagnosis.
The experimenters feigned hallucinations to enter psychiatric
hospitals, and acted normally afterwards. They were diagnosed with
psychiatric disorders and were given antipsychotic drugs. The study was conducted by psychologist David Rosenhan, a Stanford University professor, and published by the journal Science in 1973 under the title "On being sane in insane places". It is considered an important and influential criticism of psychiatric diagnosis.
Rosenhan's study was done in eight parts. The first part involved
the use of healthy associates or "pseudopatients" (three women and five
men, including Rosenhan himself) who briefly feigned auditory
hallucinations in an attempt to gain admission to 12 psychiatric
hospitals in five states in the United States. All were admitted and
diagnosed with psychiatric disorders. After admission, the
pseudopatients acted normally and told staff that they felt fine and had
no longer experienced any additional hallucinations. All were forced to
admit to having a mental illness and had to agree to take antipsychotic
drugs as a condition of their release. The average time that the
patients spent in the hospital was 19 days. All but one were diagnosed
with schizophrenia "in remission" before their release.
The second part of his study involved an offended hospital
administration challenging Rosenhan to send pseudopatients to its
facility, whom its staff would then detect. Rosenhan agreed and in the
following weeks out of 250 new patients the staff identified 41 as
potential pseudopatients, with 2 of these receiving suspicion from at
least one psychiatrist and one other staff member. In fact, Rosenhan had
sent no pseudopatients to the hospital.
While listening to a lecture by R. D. Laing, who was associated with the anti-psychiatry movement, Rosenhan conceived of the experiment as a way to test the reliability of psychiatric diagnoses.
The study concluded "it is clear that we cannot distinguish the sane
from the insane in psychiatric hospitals" and also illustrated the
dangers of dehumanization
and labeling in psychiatric institutions. It suggested that the use of
community mental health facilities which concentrated on specific
problems and behaviors rather than psychiatric labels might be a
solution, and recommended education to make psychiatric workers more
aware of the social psychology of their facilities.
In a 2019 popular book on Rosenhan by author Susannah Cahalan, The Great Pretender, the veracity and validity of the Rosenhan experiment has been questioned.
Pseudopatient experiment
Rosenhan himself and seven mentally healthy associates, called
"pseudopatients", attempted to gain admission to psychiatric hospitals
by calling for an appointment and feigning auditory hallucinations. The
hospital staff were not informed of the experiment. The pseudopatients
included a psychology graduate student in his twenties, three
psychologists, a pediatrician, a psychiatrist, a painter, and a
housewife. None had a history of mental illness. Pseudopatients used
pseudonyms, and those who worked in the mental health field were given
false jobs in a different sector to avoid invoking any special treatment
or scrutiny. Apart from giving false names and employment details,
further biographical details were truthfully reported.
During their initial psychiatric assessment,
the pseudopatients claimed to be hearing voices of the same sex as the
patient which were often unclear, but which seemed to pronounce the
words "empty", "hollow", or "thud", and nothing else. These words were
chosen as they vaguely suggest some sort of existential crisis and for the lack of any published literature referencing them as psychotic
symptoms. No other psychiatric symptoms were claimed. If admitted, the
pseudopatients were instructed to "act normally", reporting that they
felt fine and no longer heard voices. Hospital records obtained after
the experiment indicate that all pseudopatients were characterized as
friendly and cooperative by staff.
All were admitted, to 12 psychiatric hospitals across the United
States, including rundown and underfunded public hospitals in rural
areas, urban university-run hospitals with excellent reputations, and
one expensive private hospital. Though presented with identical
symptoms, seven were diagnosed with schizophrenia at public hospitals, and one with manic-depressive psychosis,
a more optimistic diagnosis with better clinical outcomes, at the
private hospital. Their stays ranged from 7 to 52 days, and the average
was 19 days. All were discharged with a diagnosis of schizophrenia "in
remission", which Rosenhan considered as evidence that mental illness is
perceived as an irreversible condition creating a lifelong stigma
rather than a curable illness.
Despite constantly and openly taking extensive notes on the
behavior of the staff and other patients, none of the pseudopatients
were identified as impostors by the hospital staff, although many of the
other psychiatric patients seemed to be able to correctly identify them
as impostors. In the first three hospitalizations, 35 of the total of
118 patients expressed a suspicion that the pseudopatients were sane,
with some suggesting that the patients were researchers or journalists
investigating the hospital. Hospital notes indicated that staff
interpreted much of the pseudopatients' behavior in terms of mental
illness. For example, one nurse labeled the note-taking of one
pseudopatient as "writing behavior" and considered it pathological.
The patients' normal biographies were recast in hospital records along
the lines of what was expected of schizophrenics by the then-dominant
theories of its cause.
The experiment required the pseudopatients to get out of the
hospital on their own by getting the hospital to release them, though a
lawyer was retained to be on call for emergencies when it became clear
that the pseudopatients would not ever be voluntarily released on short
notice. Once admitted and diagnosed, the pseudopatients were not able to
obtain their release until they agreed with the psychiatrists that they
were mentally ill and began taking antipsychotic
medications, which they flushed down the toilet. No staff member
reported that the pseudopatients were flushing their medication down the
toilets.
Rosenhan and the other pseudopatients reported an overwhelming sense of dehumanization,
severe invasion of privacy, and boredom while hospitalized. Their
possessions were searched randomly, and they were sometimes observed
while using the toilet. They reported that though the staff seemed to be
well-meaning, they generally objectified and dehumanized the patients,
often discussing patients at length in their presence as though they
were not there, and avoiding direct interaction with patients except as
strictly necessary to perform official duties. Some attendants were
prone to verbal and physical abuse of patients
when other staff were not present. A group of bored patients waiting
outside the cafeteria for lunch early were said by a doctor to his
students to be experiencing "oral-acquisitive" psychiatric symptoms.
Contact with doctors averaged 6.8 minutes per day.
Non-existent impostor experiment
For
this experiment, Rosenhan used a well-known research and teaching
hospital, whose staff had heard of the results of the initial study but
claimed that similar errors could not be made at their institution.
Rosenhan arranged with them that during a three-month period, one or
more pseudopatients would attempt to gain admission and the staff would
rate every incoming patient as to the likelihood they were an impostor.
Out of 193 patients, 41 were considered to be impostors and a further 42
were considered suspect. In reality, Rosenhan had sent no
pseudopatients; all patients suspected as impostors by the hospital
staff were ordinary patients. This led to a conclusion that "any
diagnostic process that lends itself too readily to massive errors of
this sort cannot be a very reliable one".
Impact and controversy
Rosenhan published his findings in Science,
in which he criticized the reliability of psychiatric diagnosis and the
disempowering and demeaning nature of patient care experienced by the
associates in the study. In addition, he described his work in a variety of news appearances, including to the BBC:
I told friends, I told my family: "I can get out when I can get out. That's all. I'll be there for a couple of days and I'll get out." Nobody knew I'd be there for two months ... The only way out was to point out that they're [the psychiatrists] correct. They had said I was insane, "I am insane; but I am getting better." That was an affirmation of their view of me.
The article generated an explosion of controversy. The experiment is argued to have "accelerated the movement to reform mental institutions and to deinstitutionalize as many mental patients as possible".
Many respondents to the publication defended psychiatry, arguing
that as psychiatric diagnosis relies largely on the patient's report of
their experiences, faking their presence no more demonstrates problems
with psychiatric diagnosis than lying about other medical symptoms. In
this vein, psychiatrist Robert Spitzer quoted Seymour S. Kety in a 1975 criticism of Rosenhan's study:
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.
Kety also argued that psychiatrists should not necessarily be
expected to assume that a patient is pretending to have mental illness,
thus the study lacked realism.
Rosenhan called this the "experimenter effect" or "expectation bias",
something indicative of the problems he uncovered rather than a problem
in his methodology. Others
have pointed out that a competent psychiatrist or psychologist would be
aware of the possibility of transient symptoms and would be willing to
consider other explanations for a seemingly brief symptom, than the
lifelong organic mental illness they instead insisted upon being
acknowledged by the patient.
In a 2019 popular book on Rosenhan by author Susannah Cahalan, The Great Pretender,
the veracity and validity of the Rosenhan experiment has been
questioned; Cahalan argues that Rosenhan never published further work on
the experiment's data, nor did he deliver on a book on it that he had
promised. Moreover, after half a century, she could not find
experiment's subjects, save two—Rosenhan himself, dead since then, and
another volunteer, whose testimony was allegedly inconsistent with
Rosenhan's statements. Susannah concluded that she cannot be completely certain that Rosenhan cheated, despite titling her book 'The Great Pretender'.
Related experiments
In 1887 American investigative journalist Nellie Bly feigned symptoms of mental illness to gain admission to a lunatic asylum and report on the terrible conditions therein. The results were published as Ten Days in a Mad-House.
In 1968 Maurice K. Temerlin
split 25 psychiatrists into two groups and had them listen to an actor
portraying a character of normal mental health. One group was told that
the actor "was a very interesting man because he looked neurotic, but
actually was quite psychotic" while the other was told nothing. Sixty
percent of the former group diagnosed psychoses, most often
schizophrenia, while none of the control group did so.
In 1988, Loring and Powell gave 290 psychiatrists a transcript of
a patient interview and told half of them that the patient was black
and the other half white; they concluded of the results that "clinicians
appear to ascribe violence, suspiciousness, and dangerousness to black
clients even though the case studies are the same as the case studies
for the white clients."
In 2004, psychologist Lauren Slater claimed to have conducted an experiment very similar to Rosenhan's for her book Opening Skinner's Box.
Slater wrote that she had presented herself at 9 psychiatric emergency
rooms with auditory hallucinations, resulting in being diagnosed "almost
every time" with psychotic depression. However, when challenged to
provide evidence of actually conducting her experiment, she could not.
The serious methodologic and other concerns regarding Slater's work
appeared as a series of responses to a journal report, in the same
journal.
In popular media
In 2008, the BBC's Horizon
science program performed a somewhat related experiment over two
episodes entitled "How Mad Are You?". The experiment involved ten
subjects, five with previously diagnosed mental health conditions, and
five with no such diagnosis. They were observed by three experts in
mental health diagnoses and their challenge was to identify the five
with mental health problems solely from their behavior, without speaking
to the subjects or learning anything of their histories.
The experts correctly diagnosed two of the ten patients, misdiagnosed
one patient, and incorrectly identified two healthy patients as having
mental health problems. Unlike the other experiments listed here,
however, the aim of this journalistic exercise was not to criticize the
diagnostic process, but to minimize the stigmatization of the mentally
ill. It aimed to illustrate that people with a previous diagnosis of a
mental illness could live normal lives with their health problems not
obvious to observers from their behavior.
