Rosenhan’s Experiment

Rosenhan’s experiment was a famous experiment on the validity of the psychiatric diagnosis carried out by the psychologist David Rosenhan between 1968 and 1972. ¹ It was published in 1973 in the journal Science under the heading “On being sane in insane places” ( “To be sane in demented places”). ² The study is considered as an important and influential critique of psychiatric diagnosis. ³

Rosenhan’s study consisted of two parts. In the first part, healthy collaborators or “pseudopatientes” (three women and eight men) simulated acoustic hallucinations to be interned in 12 psychiatric hospitals of five states of the United States . ² All were actually admitted and diagnosed with psychiatric illness. After being hospitalized, the pseudopatientes behaved normally and informed those responsible for establishments that were well and that they had not suffered more hallucinations. Medical managers not only did not detect any of the pseudopatients, but believed that they manifested symptoms of actual mental illness. Several were held for months. ² All were forced to recognize that they had a mental illness and to accept medication with antipsychotics as a condition to be discharged. The second part was carried out when one of the psychiatric facilities challenged Rosenhan to send pseudopatients to her hospital for her staff to detect. Rosenhan accepted and in the following weeks, of the 193 patients the hospital attended, identified 41 as possible pseudopatients, 19 of whom had raised the suspicions of at least one psychiatrist and another staff member. Actually, Rosenhan had not sent anyone to the hospital. ^{4 5}

The study concluded: “It is clear that in psychiatric hospitals we can not distinguish between sane and crazy.” ^{2 He also} illustrated the dangers of depersonalization and labeling in psychiatric institutions. The study suggested that using community mental health facilities to address specific problems rather than establishing psychiatric labels could be a solution and recommended educating workers to make them more aware of the social psychology implicit in those facilities. ²

The experiment of the pseudopacientes

Objective of the experiment

Rosenhan’s goal was to know whether psychiatric diagnoses respond to patients’ existence of symptoms that can be categorized; Or, on the contrary, psychiatric diagnoses are in the minds of the observers and are not valid summaries of the characteristics manifested by the observed.

Participants

Rosenhan himself and seven collaborators with good mental health, the so-called “pseudopatientes”, requested an appointment in a psychiatric hospital through a telephone call claiming to undergo acoustic hallucinations . The hospital staff was not informed of such an experiment. The pseudopatients included a psychology 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 working in professions related to mental health claimed another occupation in order to avoid any special treatment. In addition to giving false names and jobs, no further alterations were made to his biography or personal circumstances.

Initial psychiatric evaluation

During their initial psychiatric assessment, they claimed to hear voices, often confused, that seemed to utter the words “void,” “hollow,” and “off.” The voices were not familiar and were of the same sex as the patient. The choice of these symptoms came from its similarity to existential problems and the lack of literature dealing with psychosis existential. They did not claim any other symptoms. Once admitted to the unit the pseudopaciente had to behave “normally”, to inform that he was well and that he no longer heard voices. Reports obtained after the experiment indicate that all pseudopatients were unanimously rated as “friendly” and “cooperative” by hospital staff.

Observation environment

All were admitted to 12 psychiatric hospitals located in different places in the United States. Including some old and underrated. Some in rural areas, other university hospitals with excellent reputation, and one strictly private. Although pseudopatients presented with identical symptoms, 7 were diagnosed in public hospitals with schizophrenia, and one with manic-depressive psychosis, a more optimistic diagnosis and a better clinical prognosis, in the private hospital. The duration of hospitalization ranged from 7 to 52 days, with an average of 19 days. All were discharged with a diagnosis of schizophrenia “in remission”. A diagnosis that Rosenhan sees as evidence that mental illness is perceived as an irreversible condition that creates a stigma for a lifetime rather than as a curable disease.

Persistence of the psicodiagnóstic labels

Despite consistently and publicly taking notes on the behavior of staff and other patients, none of the pseudopatients were identified as impostors by staff, although many of the other patients appeared to be able to properly identify them as impostors. In the first three hospitalizations, 35 of 118 patients expressed a suspicion that the pseudopatients were sane. Some suggested that they were researchers or journalists investigating the hospital. Hospital records indicate that staff interpreted much of the behavior of pseudopatients as an aspect of their pathological behavior. For example, a nurse labeled the patient taking notes such as “The patient is writing” and considered it pathological. The biographical data of the pseudopatients were inadvertently distorted by the staff to achieve consistency with the dominant theories of schizophrenia at the time.

The experience of psychiatric hospitalization

The pseudopatients were told that they should go out on their own, essentially convincing the staff that they were sane, even though a lawyer was called to be called in case of emergency when he became aware that none of the pseudopatients would be given High in a short period of time. Once admitted and diagnosed, the pseudopatients failed to be discharged until they accepted the psychiatrist’s diagnosis that they were mentally ill and began taking antipsychotic medications that they flushed through the toilet. None of the staff members realized that the pseudopatients were not ingesting their medication and did not report patients doing so.

Conclusions

Rosenhan and the other pseudopatients denounced the dehumanization, invasion of privacy, and the boredom they suffered while hospitalized. Their belongings were checked randomly, and some were observed while they were in the bathroom. They reported that although the staff seemed well-intentioned, they generally objectified and dehumanized patients, they often argued about patients in their presence as if they were not there, and avoided direct contact with patients except when required by their obligations. Some aides displayed verbal and physical abuse of patients when other staff members were not present. The average contact with psychiatrists, psychologists, residents, and physicians, all together, averaged 6 minutes and 48 seconds a day.

“I told my friends, my family, ‘I’ll leave when I have to leave, that’s all. I’ll be there for a couple of days and then I’ll go out. ‘ No one had a clue that he would spend two months there! The only way out was to accept that they were right. ‘They say I’m crazy, I’m crazy, but I’m getting better.’ It was an affirmation of the image they had of me. ”

David Rosenhan on the BBC show “The Trap”. ⁶

The experiment of non-existent patients

For this experiment, Rosenhan turned to a university teaching and research hospital whose staff had heard of her first study but doubted that such an error could occur in her hospital. Rosenhan informed the staff that at some point during the next 3 months one or more pseudopatients would try to be admitted to the psychiatric hospital. Trials were obtained from 193 patients who were admitted to psychiatric treatment. All staff who had sustained contact with the patient or a primary responsibility for him (aides, nurses, psychiatrists, doctors, and psychologists) were asked to make judgments. Forty-one patients were identified, with high confidence, as pseudopatientes by at least one member of the staff. Twenty-three were considered suspects by at least one psychiatrist. Nineteen were suspected by a psychiatrist and another staff member.

In fact, Rosenhan had not sent any genuine pseudo-patients during this period. Rosenhan’s conclusion was that:

“Any diagnostic process that lends itself so easily to massive errors of this kind can not be a very reliable process.” ²

Controversy

Rosenhan published his findings in Science criticizing the reliability of the psychiatric diagnosis as well as the depersonalization and degrading nature of the care undergone by the study participants. His article generated a great controversy. ⁷

Proponents of psychiatry argued that psychiatric diagnosis relies heavily on patients’ reports of their experiences, and pretending to misrepresent diagnosis is no more telling than lying about other medical symptoms. In this sense, psychiatrist Robert Spitzer quotes Seymour Ketty’s critique of Rosenhan’s study:

“If I were to drink a liter of blood and then say nothing about it, I would go to the emergency department of any large hospital vomiting blood, the diagnosis of the medical staff would be absolutely foreseeable.If I were diagnosed and treated for gastroduodenal ulcer , I doubt he could convincingly claim that medical science does not know how to diagnose my symptoms. ” ^{Referring to Fig.}

On the contrary, emergency personnel are not able to question their diagnosis over time and in the absence of other symptoms, is another matter. And it is precisely the tendency to extend a diagnosis, to interpret the following data in order to make them consistent with it, the root of Rosenhan’s criticism. Rosenhan does not criticize that the simulators were admitted, but affirms that the hypothesis of the mental illness was maintained in spite of the apparent good mental health of the patient, with which the diagnosis basically lost its meaning. ²

Impact

The experiment is considered to have boosted the movement of anti- psychiatry and accelerated the movement of reform of psychiatric hospitals and deinstitutionalization of the treatment of the mentally ill as far as possible. ^{Referring to Fig.}

References