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