Rosenhan Uncovered

I have been on record for many years regarding the Rosenhan experiment. To briefly recap, that was a paper published in Science in 1973 (1). In the paper the author described how eight pseudopatients were admitted to psychiatric hospitals and the treatment they received. He describes their varied backgrounds. He says that they were admitted to 12 hospitals in five states on the East and West Coast. The hospitals also varied from research institutions to institutions with much fewer resources. Most importantly he describes the script that each pseudo-patient is supposed to adhere to in order to get admitted and how they are supposed to behave post admission. 

Specifically:

“After calling the hospital for an appointment, the pseudopatient arrived at the admissions office complaining that he had been hearing voices. Asked what the voices said, he replied that they were often unclear, but as far as he could tell they said "empty," "hollow," and "thud." The voices were unfamiliar and were of the same sex as the pseudopatient. The choice of these symptoms was occasioned by their apparent similarity to existential symptoms.” (p. 251)

Apart from the false symptoms, false name, false vocation, and false employment the social history provided by the pseudopatients was supposed to be identical to their real social history. After gaining admission so patient was supposed to “cease simulating any symptoms of abnormality.”

From the purported data, Rosenhan pointed out that none of the pseudo-patients were discovered, they were hospitalized for varying lengths of time, they were given medications that they may have been trained to not take and spit out, and they made a number of observations inside the hospital. Rosenhan concluded that “It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals”.  He also uses at least half of the article for highly speculative observations on powerlessness, depersonalization, and labeling none of which really pertain to the study.

I just finished reading Susannah Cahalan’s new book The Great Pretender. It is about Rosenhan’s study and Rosenhan himself.  She has quite a lot to say about him including how this paper changed the face of psychiatric care and was a major factor in closing down psychiatric institutions.

Let me start by describing what I experienced at that time. In 1973, I was just finishing an undergraduate degree and although I was a science major - heard nothing about this paper. I was reading Science and Nature at the time. I did medical school and residency training between the years 1978 and 1986 and again heard nothing about Rosenhan - even during psychiatry rotations and seminars. That was a controversial time in psychiatry because of the tension between biological psychiatry and psychotherapy. The controversy seemed to be largely from the psychotherapy side of the equation. Psychiatry residents were pulled to one side or the other. It was always clear to me that both modalities were critical. I got what I consider to be good psychotherapy training at two different Midwest residency programs.

A unique aspect of my training happened at the University Wisconsin training program. Community Psychiatry was a mandatory six-month rotation that consisted of an outpatient clinic, crisis intervention training, and an active seminar every week. One of the leaders of that seminar was Len Stein MD. Dr. Stein was a major force and originator of Assertive Community Treatment (ACT) and other forms of community treatment that were focused on maintaining people with severe mental illness in the community. To this day I can recall a slide from one of his presentations that showed a gymnasium sized room at the local state mental hospital. In that room were cots arranged edge to edge across the entire floor. Rows and rows of these cots covering the entire floor. The men who slept on those cots were standing in the foreground. They were all wearing the same pajamas. After showing that slide, Dr. Stein would point out that this was one of the motivators that led him to help people get out of hospitals into their own apartments.  His goal at the time of Rosenhan’s paper, was to develop a way to help people with severe mental illnesses live independently in the community.  He was not only successful at it – he trained psychiatry residents how to do it. After completing my training, I went to a community mental health center and helped run an ACT team for three years.  We were highly successful at maintaining people outside of the hospital and helping them function independently.

My introduction here is to illustrate that one of the main theses of The Great Pretender, namely that Rosenhan’s experiment was one of the main forces in deinstitutionalization and closing down psychiatric hospitals is something that I disagree with. It seems to be a good theory if you want to suggest that psychiatry only changes from the outside and the change happens by people who are not psychiatrists. You can probably make that argument if you don’t know psychiatrists like Len Stein and all of the other community psychiatrists out there who were highly motivated to maintain people outside of state hospitals because it was the right thing to do. It was the right thing to do because states ration resources to the mentally ill. They always have and they always will.  Politicians don't really care about anyone with severe mental illness. Community psychiatrists know that. They know the only way to provide good treatment to those patients is to make sure that public funds follow the individual patient.

In her book Susannah Cahalan, spends a lot of time describing how seminal the Rosenhan study was. She has numerous testimonials from important psychiatrists at the time. There is even a suggestion that Robert Spitzer, MD used the study politically to advance his own agenda in writing more precise diagnostic criteria for the DSM-III. I can state unequivocally that I had not heard of this experiment until I started encountering anti-psychiatrists. That didn’t happen much until I started this blog in 2012.

What did I like about the book? I was impressed with the investigative aspects of the book. She carefully details how Rosenhan’s original description in Science does not accurately reflect what actually happened. There is not enough information available to verify whether or not the entire pseudoexperiment was completed as written. In addition to that research, she has detailed impressions of Rosenhan from fellow faculty members, coworkers, friends, and family members who knew him well. Many of these people had reservations about him and his work. Many believed that there were problems with the original paper. Many had concerns about his character that are clearly described in this book. In brief, there is plenty of circumstantial evidence in addition to the direct evidence that something was wrong with this paper.  I take this circumstantial and character evidence with a grain of salt. In any clinical or academic settings, there are always plenty of personality conflicts and politics. There is one scene in the book where Rosenhan is throwing a party and tells a colleague that he had a wig made for the pseudopatient role (Rosenhan was bald). Cahallan confirms by photo and the attending psychiatrist’s notes that he was bald and not wearing a wig during the hospitalization. I also do not consider that to be a big deal. He was described as a raconteur who liked to hear himself talk. Making up stories at parties to keep people engaged is what raconteurs and extroverts do.  

She also builds a careful case of additional red flags along the way. Rosenhan apparently achieved celebrity status for brief period of time. When that occurs he got a book deal and was advanced substantial sum of money. He also wrote several chapters that were read by Cahalan. He never finished the book even when he was sued by the publisher.  He never did any further research on the subject of pseudopatients getting into psychiatric hospitals or psychiatric hospitals at all. He had an active correspondence with Spitzer and one point recruited psychiatrists to convince Spitzer not to publish criticisms of his paper. Spitzer was very content with his criticism, but Cahalan points out that he may have had direct information at the time to refute the paper entirely. Rosenhan clearly broke the protocol that he described as evidenced by the medical record. The treating psychiatrist apparently sent Spitzer a copy of those records showing that as the original pseudo-patient, Rosenhan broke protocol. In addition to describing vague auditory hallucinations he added historical data that would have resulted in him being hospitalized anywhere.  Excerpts from the exact medical record are included in the book on pages 184 and 190. The author concludes (and any reader can do the same) that the facts were intentionally distorted by Rosenhan primarily with more elaborate delusional material and suicidal thoughts including the statement “everyone would be better off if he were not around.” What is recorded in the actual medical record is a person feigning a much more serious mental illness than “existential symptoms.”

Cahalan was able to locate two more pseudopatients, but one of them was not included in the study. Cahalan was unable to locate any of the other six pseudo-patients described in the Science paper despite an intensive effort.  Rosenhan also removed the data from the ninth pseudo-patient. The data from the ninth pseudo-patient was inconsistent with the others in that this patient liked his experience in the psychiatric hospital and in fact found to be very positive. He liked it so much that he published that positive experience in Professional Psychology in February 1976 (2) including the following conclusion “He recommends stressing the positive aspects of existing institutions in future research.” (p 213).

Cahalan approached Science directly. She asked them directly why they published this article in the first place given the concerns she outlined in her book. They refused to discuss their editorial process. A psychologist speculated that the submission to Science would be less rigorously reviewed because they probably did not have the top peer reviewers in the field. Although Cahalan uses a fair amount of anti-psychiatry rhetoric in her book, and seems to talk authoritatively about that field, there is no speculation that bias against psychiatry may have been involved in publishing this article.  Given what we know about general bias against psychiatry, that would seem to be a real possibility to me.

I am already on record saying that there is enough information in this book to retract the original article. I admit I don’t know the criteria for retractions or whether there is any time limit. Having been a Science subscriber for decades I know that it certainly does not meet their typical standards. I will happily go back and read articles from medicine and psychiatry in their 1973 editions to illustrate that fact if there is a shot at retraction.

Retraction would certainly create a furor in the anti-psychiatry community. Their arguments rest almost entirely on false premises and pseudoscience. As I noted in my post from seven years ago, anyone can walk into a medical facility and lie about a condition for any number of motives. In my current field, I have talked with hundreds of people who tell me they asked for a second or third opioid prescription when they did not need it for pain. They were taking it to get high. Before that I did consults in a general hospital, we were often asked to see people with factitious disorders who are feigning some medical illness. We also saw significant numbers of people who had medical symptoms but were not consciously feigning illness. The author mentions some of this but is usually quick to make it seem like psychiatry is the wildcard relative to the rest of medicine. 

I have had several people ask me if they should buy this book. I have also been asked to write a book review for newsletter.  My response is consistently, buy the book if you want to see the clear evidence that the Rosenhan experiment was more than seriously flawed – the protocol was violated by the author himself and the evidence is there black on white. A second protocol violation occurred when the Rosenhan decided to eliminate the experience of the pseudopatient who enjoyed being in the hospital and found it to be useful. I will say again that I am not an expert in retractions but believe that papers are retracted today for violations of data integrity.

Don’t buy this book if you are expecting to read a valentine to psychiatry. The author's previous book was about her episode of inflammatory encephalitis that was misdiagnosed as a psychiatric disorder. She mentions it several times to point out her credibility as a person who has experienced severe psychiatric symptomatology. At one point in the book she undergoes a SCID (Structured Clinical Interview for DSM-IV) evaluation by a psychiatrist who had a lot of input into DSM-5. After a tedious exchange he tells her that his going charge for the exam is $550. When I read that, I asked myself why would this psychiatrist go along with a SCID when he knew it was irrelevant to Cahalan’s diagnosis? Several other prominent psychiatrists are quoted in the book in a way that fits Cahalan’s thesis that psychiatry is in fact a weak link in medicine and even though Rosenhan’s pseudoexperiment was grossly flawed there is a still some valuable lesson there.

I would suggest that is really not the case. I don’t know why anyone would want to try to resuscitate this work and I sure don’t know why Science wants to keep it in a reputable journal.  The original responses over 40 years ago pointed that out. I would highly recommend reading the  original responses by Spitzer.

George Dawson, MD, DFAPA

References:

1: Rosenhan DL. On being sane in insane places. Science. 1973 Jan 19;179(4070):250-8. PubMed PMID: 4683124.

2: Lando H. On being sane in insane places: a supplemental report. Professional Psychology, February 1976: 47-52.

Additional Reference posted on July 17, 2021:

Justman, Stewart, "Below the Line: Misrepresented Sources in the Rosenhan Hoax" (2021). Global Humanities and Religions Faculty Publications. 13. https://scholarworks.umt.edu/libstudies_pubs/13

This author fact checks Rosenhan's references and footnotes and finds they do not support his points.