The Great Pretender (1) is
written as an exposé of a famous experiment conducted by Rosenhan (2) that
purported to discredit psychiatric diagnoses.
The original article was published in in the journal Science in
1973. Whether you we aware of the
original article or not depended on when you were trained and the extent to
which you followed that literature. I was just finishing my undergraduate degree
at that point and did not complete psychiatric training until 1986. We had a community psychiatry seminar for 6
months during my last year that was taught by some of the innovators in the
field. It was common to analyze and
discuss controversial papers of the day.
A good example would have been the paper that suggested that people with
schizophrenia had a much better outcome in the developing countries (3). At no point did we hear about or discuss the
Rosenhan paper. In fact, for the next 24
years the paper never came across my desk. It was only when I started writing a
psychiatry blog that I realized it played a major role in psychiatric criticism
and antipsychiatry rhetoric. At that
point, I read the paper and the associated criticism and concluded
independently that the methodology was extremely weak and that pseudopatients
were not really a good test of medical or psychiatric diagnoses. I thought it would just fade away on that
basis.
I was as surprised as anyone when I heard that investigative
reporter Susannah Cahalan had written a book about this experiment, the author,
and the methods used. The investigation
begins with a visit to one of Rosenhan’s former colleagues. This colleague
shows her a stack of anti-psychiatry books that he thinks “were the key to his
thinking”. There is also a file labeled “pseudopatients” that contain the names
of all eight pseudopatients and details surrounding their hospitalizations. All
the names or aliases and the hospital names had also been changed.
Cahalan’s approach is to write about three parallel
subjects. The most thorough and
objective analysis is about the pseudopatient experiment. She covers everything
from the available remaining data and the problems with it to the likelihood
that the experiment actually occurred the way it was described in the Science
paper. The second broad subject was a
character study of Rosenhan. How did
people describe him? What was he like?
Did people especially his colleagues believe that he conducted the experiment. And finally, the book is a vehicle for
Cahalan to comment on psychiatry. She
comes to this work with the direct experience of having experienced autoimmune
encephalitis and writing about that experience in the book Brain on Fire.
Reading the original paper is a good starting point for
understanding the book. If you do pull
up that article, a few details are immediately evident. The author begins the
introduction using the terms “sane” and “insane” as though this is technical
language used by psychiatrists. That use of language is interesting because he
is listed as a professor of both psychology and law at Stanford. Since the days of my training, insanity is a
strictly legal term and it is without meaning in psychiatry. The use of these legal terms allows him to
point out the unreliability of the “sane”-“insane” dichotomy based on expert
witnesses disagreeing in adversarial court hearings. That has nothing to do with the clinical
diagnoses in psychiatry. To what extent were formal diagnoses used in 1973?
Rosenhan refers to the Diagnostic and Statistical Manual in the body of his
paper. Interestingly, the authors of my
community psychiatry paper (3) reported on the 2-year follow-up of patients
from the International Pilot Study of Schizophrenia (1973) and concluded that
schizophrenia could be reliably diagnosed so that international comparisons and
follow up were possible. A sanity metric
during the same time frame is crude by comparison. There are many additional
examples of a lack of objectivity toward the issue of psychiatric diagnosis in
the introductory section of the paper (paragraphs 4-7) and the discussion.
Excellent critiques of the scientific merit of the paper were available at the
time most notably by Robert Spitzer.
The author describes his pseudopatient experiment as
consisting of 8 people – three women and four men of various occupations. Cahalan
identifies Rosenhan as pseudopatient number 1.
Twelve hospitals in various locations were chosen. One was a private hospital. Pseudopatients were supposed to call the
hospital, present for an intake appointment, and then complain that they were
hearing voices. When asked to elaborate they were supposed to say the voices
were unclear except for the words “empty”, “hollow”, and “thud”. Rosenhan provides a rationalization for this
symptom choice about how on the one hand these symptoms were supposed to have
existential meaning and yet there was not a single report of existential
psychosis in the literature. Once admitted, the patient was supposed to cease
simulating any symptoms and give their actual social history and behave
“normally”. They were to take notes and be as cooperative as possible to get
discharged. The length of stay was 7-52 days with an average of 19 days.
Rosenhan also claims in the body of this paper that a
second experiment occurred at a “research and teaching hospital” where the
staff were informed ahead of time that pseudopatients were going to seek admission
during a 3-month period. Staff were
asked to rate whether a patient was a pseudopatient or not. Of 193 admissions during that time 41 were
ranked as likely being a pseudopatient. In this case, Rosenhan did not send any
pseudopatients to the facility and claims this false experiment represents
“massive errors”.
One of the elements of the paper that is really never
discussed is it structure. The primary data points were eight pseudopatients
were admitted and discharged from psychiatric hospitals without being
discovered. The secondary data points were a series of observations of the
staff that is largely unstructured, highly anecdotal, and contrasted with other
situations that seem to lack relevance. The bulk of Rosenhan’s discussion is
judgmental and there is no discussion of the limitations of the experimental
design or data. Instead the author leaps to clear-cut conclusions that are in
some cases only peripherally connected to the data.
Cahalan expends a lot of effort to try to identify and find
the pseudopatients and ask them what their experience was like. She locates the
records of Rosenhan’s own admission as a pseudopatient. The first real sign of
a departure from the research protocol described in Science, occurs in Rosenhan’s recorded admission
interview. He recited the voices script and said the symptoms had been going on
for four months. He was admitted on an involuntary commitment and discharged
nine days later. The hospitalization ended in 1969 - four years before the
article came out. The first major sign that the experiment described in Science was not quite the way it was
described in the paper occurs when Cahalan looks at the record of the admission
interview. In addition to the vague description of hallucinations, Rosenhan
states that he believes he can “hear what people are thinking”, that he has
tried to “insulate out the noises by putting copper over my ears”, and that he
has “suicidal thoughts”. These are all more serious psychiatric symptoms than
factitious “existential hallucinations”. Rosenhan also altered his occupational
history during one assessment to say that his psychiatric illness led him to
give up a job in economics 10 years earlier. At one point he stated that his
wife is probably unaware of how useless he felt and that “everyone would be
better off if he was not around”.
Considering the seriousness of his fake history, I was surprised that he
was discharged in 9 days.
What about the other 8 pseudopatients? Cahalan was able to locate two – only one of
whom was part of the research protocol and shared Rosenhan’s experience. The
second patient started out as a psychologist and co-authored a couple of papers
with Rosenhan. The author was surprised at how little preparation went into the
pseudopatient role. Patient 2 was taught to cheek medications and spit them
out. He was reassured by Rosenhan that he had filed a writ of habeus corpus to
get him out of the hospital at any time.
When Cahalan tracked down that attorney who said the writs had been
discussed but never prepared and that he did not consider himself to be “on
call” to get pseudopatients immediately released. Patient 2 was also in the
hospital for 9 days and basically released upon his request. There was no reason for discharge given on
the official form but he recalled a psychiatrist approaching him prior to discharge
and making remarks to suggest that there was still some concern that he may
still be suicidal. Despite that concern there was apparently no discharge plan.
The third pseudopatient discovered by Cahalan was
interesting in that he was eliminated from the original protocol and not
counted by Rosenhan. Cahalan discovered
that the ninth uncounted pseudopatient was a research psychologist named Harry
Lando. Dr. Lando is well represented in
the smoking cessation literature and had published an article in the Professional
Psychologist (4) stressing the positive aspects of his pseudopatient
experience. His observations were in
direct contrast to Rosenhan and he states as much in the observation: “My
overall impressions of the hospital are overwhelmingly positive. The
powerlessness and depersonalization of patients so strongly emphasized by Rosenhan
simply did not exist in this setting.” He goes on to suggest that using better
hospitals as models may be a way to improve the quality of care. He also questions the ethics of placing
pseudopatients in “already overcrowded and understaffed institutions”. Lando does express a concern about the
diagnostic process since all three pseudopatients received diagnoses of
schizophrenia.
The key question about why the data of the ninth
pseudopatient was omitted from the original paper is answered as a footnote
number 6 on page 258 of the original paper:
“Data from a ninth pseudopatient are not included in this
study because although his sanity went undetected, he falsified aspects of his
personal history. Including marital status and parental relationships. His
experimental behaviors therefore were not identical to the other
pseudopatients.”
That footnote is exactly what Rosenhan did when he was
admitted as pseudopatient 1 as documented in the existing medical record. Rosenhan’s lapses were discovered and
discussed by Cahalan and are included in the following table.
|
Rosenhan’s Lapses |
|
1. Data was improperly recorded. The two
pseudo-patients interviewed by Cahalan pointed out that their durations of
stay in the hospital were not correctly recorded. |
|
2. His private notes indicated strong
influence by Szasz and Laing. Prior to the pseudopatient experiment he
assigned work to his students describing psychiatric hospitals as
“authoritarian”, “degrading”, and “illness-maintaining”. |
|
3. He told a pseudopatient that a writ of
habeas corpus was prepared and an attorney was on call to get them out of the
hospital if necessary. That was not true. |
|
4. Professional and possibly “unethical”
mistakes (p. 173) about length of stay in pseudopatient number two (7 days
versus 8) and pseudopatient number 9 (26 days versus 9 days), patient
population in the hospital 8,000 vs 1,510), the specific discharge diagnoses
of pseudopatients 2 and 9, and details of staff behavior on the ward. |
|
5. Sending a pseudo-patient into a hospital
that was in disarray because it was closing. |
|
6. Rosenhan at one point lied in
correspondence to Spitzer about his stay in the hospital and said it was part
of a “teaching exercise” that had nothing to do with research(p. 180).
Cahalan describes this as “an outright lie”. |
|
7. During his admission Rosenhan “goes off
script” and gives far more fabricated symptoms and history than the “empty,
hollow, thud” existential hallucinations he described in the protocol.
Additional symptoms suggest a significant psychiatric disorder. He describes
suicidal ideation and significant conflict with his employer – the same
falsification of personal history that led him to eliminate the data of the
ninth pseudopatient. |
|
8. Rosenhan fabricated an excerpted portion of
the medical record and both the original record and the excerpt are published
for A - B comparison on page 190. Cahalan concludes that the facts “were
distorted intentionally by Rosenhan himself.” |
|
9. Inadequate preparation of the research
subjects. Patient 2 ended up taking a dose of chlorpromazine and patient 9
was given liquid chlorpromazine so it could not be cheeked as
instructed. Pseudopatient 9 estimated
the preparation time for hospital admission by Rosenhan was about 15 minutes.
|
|
10. When patient 9 was eliminated from the
study none of the data about pills dispensed or staff contact time in the
paper was changed. |
|
11. In an National Public Radio program that
aired before the publication of his paper (December 14, 1972) he misstated
his time in the hospital as a pseudopatient (several weeks versus 9 days) and
the amount of medications dispensed to pseudopatients (5,000 pills versus
2,000 pills) while building to the conclusion that psychiatric hospitals are
non-therapeutic and should be closed (p.234) |
|
12. Pseudopatient 9 commented that what
Rosenhan had written about him in the experiment was “total fiction” (p.269) |
|
13. Rosenhan did not complete a book about the
pseudopatient experience, despite an advance from the publisher, a subsequent
lawsuit from the publisher and what is described as plenty of publicity
around the time the paper came out in Science. He also never published
on the topic again (p. 295). |
Rosenhan did continue to publish a description
and discussion of his study in the text Abnormal Psychology (5). The
discussion emphasized that the simple hallucinations described with nothing
else being unusual would have been detected outside of a hospital. In the
context dependent setting it was not. In
other words – he maintained one of the same themes as in the original paper.
One of the areas that really piqued my interest was why Science
published this paper in the first place.
Cahalan got the opinion from an academic psychologist that the peer
review in a non-psychology journal would be less rigorous. When she approached the journal she was told
that records were confidential and that they were not kept back that far. Accessing Retraction Watch (6) demonstrated
that there has been a total of 120 papers retracted from Science since
1963. The reasons for the retractions are given as data errors, errors in
methods, result errors, errors in conclusions, errors due to contaminated
experiments, falsification/fabrication of data, irreproducible results,
misconduct by the author, ethical violations by the author, investigation by a
company, institution, or third-party.
Only three of these papers had anything to do with psychiatry and those
papers were primarily about the neurobiology of the brain. Cahalan’s
investigation suggests that several of the reasons for retraction have been
met.
Apart from the details of the Science paper, Cahalan
also does a character study of Rosenhan. We learned that his brother had
bipolar disorder and did well on lithium. It was suggested that was why he
became interested in psychology. He was described as bright and charismatic. He
was clearly influenced by the work of anti-psychiatrists and assigned work to
his students that “describe psychiatric hospitals as authoritarian, degrading,
and illness maintaining among other terms”. (p 73). The title of the book highlights Rosenhan’s
characteristics as a raconteur who would occasionally pretend to be someone who
he was not. His son described an incident in New York City where he introduced
himself as a professor of engineering at Stanford in order to get a tour of an
interesting construction site with his son. In another scene he is joking about
the wig he wore to get into the psychiatric hospital. Cahalan finds the admission photo showing
that he is bald without a wig. The people who knew him the best – acknowledge
the he was difficult to know and just like Rosenhan’s arguments about
psychiatric diagnoses being context dependent – his personality was as well.
Apart from academic books about the history of psychiatry –
most books review sensational history and arguments that by their very nature diminish
the field. This book is intermediate in
that tone with those arguments interspersed through the investigative
journalism about Rosenhan. They touch on the familiar themes of biological
reductionism as opposed to a clinical psychiatry where patients are actually
listened to with no reference to how clinical psychiatrists really practice
every day. Some psychiatrists end up being caricatured and some are
acknowledged as being highly motivated and humanistic. I am probably far too
invested in clinical psychiatry and the good I have seen done to tolerate a
journalist’s approach to the field. I
give Cahalan credit for touching on the current situation that has resulted in
severely rationed care and the transinstitutionalization of patients in jails. The overall concept that psychiatrists have
little to do with the systems of care that are controlled by businesses and
governments is not emphasized even though it was recognized as a problem by two
of the pseudopatients. She also points
out that the pseudopatient experiment is irrelevant to psychiatric practice
today but her resounding theme throughout the book was that it was extremely
relevant irrespective of what actually happened. The book also gives Rosenhan too much credit
for psychiatric criticism. Like many books of this nature – there is little to
no evidence that psychiatrists might be their own best critics or that outrage
might be a legitimate reaction to outrageous criticism rather than
defensiveness.
In conclusion The
Great Pretender identifies very specific problems with the original
Rosenhan paper that have been listed in the narrative and table in this report.
He gained initial celebrity status from the study and signed a book contract.
Even though he was given an advance on the book and wrote a manuscript he never
produced a book. The author suggests
that may have been due to the fact that Robert Spitzer was aware of Rosenhan’s
nonadherence to the research protocol during his admission. As Rosenhan
withdrew from the pseudopatient limelight he also stated that none of his
research should lead to the conclusion that psychiatric hospitals were
unnecessary and that represented a complete turnaround form earlier statements.
The controversy, the original paper and the book could be
the subject of seminars in the history or philosophical aspects of psychiatry.
It touches on a number of themes primarily the ethics of research and how it
should be conducted. It also touches on psychiatric criticism and may be useful
in discussing how future generations of psychiatrists can prepare to deal with
it.
George Dawson, MD, DFAPA
References:
1: Susannah Cahalan. The Great Pretender. Grand Central
Publishing. New York, 2019. 382 p.
2: Rosenhan DL. On being sane
in insane places. Science 1973 Jan 19;179(4070):250-258.
3: Sartorius N, Jablensky A,
Shapiro R. Cross-cultural differences in the short-term prognosis of
schizophrenic psychoses. Schizophr Bull. 1978;4(1):102‐113. doi:10.1093/schbul/4.1.102
4: Lando, H. A. (1976). On
being sane in insane places: A supplemental report. Professional
Psychology, 7(1), 47–52. https://doi.org/10.1037/0735-7028.7.1.47
5: David E. Rosenhan, Martin E.P. Seligman. Abnormal Psychology- 2nd Ed. WW Norton and Company, New York City, 1984, 1989; p
181-183.
6: Retraction Watch: Retractions from Science. Accessed on May 22, 2020: http://retractiondatabase.org/RetractionSearch.aspx#?jou%3dScience
7: Gaudino M, Robinson NB, Audisio K, et al. Trends and Characteristics of Retracted Articles in the Biomedical Literature, 1971 to 2020. JAMA Intern Med. Published online May 10, 2021. doi:10.1001/jamainternmed.2021.1807
The authors cite retracted literature (5209 papers) back to the year 1923. Scientific misconduct like fabrication of data was cited as the most common reason.
Supplementary:
The review was written for Philosophy Special Interest Group of the Royal College of Psychiatrists September 2020 newsletter and it can be found starting on page 8.
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
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