Will the real Rosenhan pseudopatients please stand up?

If you have taken more than a passing interest in psychology, at any level, you have almost certainly come across the Rosenhan Experiment in which 8 pseudopatients claiming to hear a voice were admitted to psychiatric hospitals and diagnosed rapidly and fixedly with various psychotic conditions. Even if some other aspects of your course (like hand calculation of correlation coefficients for example) left you cold, I’m willing to bet this piqued your interest. As a lecturer in mental health I speak about this study to students at least 3-4 times each year, and I have yet to tire of it. If anything, my fascination deepens.

Although most students are familiar with the main thrust of the study and its outcome, it is so familiar that most don’t go and read the original paper in full, which is a pity. They miss some juicy details, like the ways in which the patients’ every behaviour was interpreted as pathological in the medical and nursing notes. “Patient engages in writing behavior” illustrates neatly how context is all important in our perception and interpretation of behaviours as symptoms. The “oral-acquisitive nature of the syndrome” of schizophrenia was the supposed cause of patients loitering outside the canteen before meal times on a ward where there was quite simply nothing else to do.

My favourite detail is that the great Rosenhan makes an error in describing an everyday statistical concept in this paper! There is hope for us all (I will post a lollipop to anyone who can find it).

Although the paper is largely descriptive, there are some interesting numbers in there too. For example, the mean number of minutes per day that the hospitalised patients had contact with psychologists, psychiatrists or physicians was 6.8. This figure includes the admissions and discharge interviews as well as group  and individual psychotherapy sessions. The 8 patients collectively were administered 2,100 pills. Despite all but one of the pseudopatients striving to be released after the first day the length of hospitalisation ranged from 7 to 52 days and many retained a diagnosis of “schizophrenia in remission” on discharge.

Publication of this paper in 1973 caused a lot of controversy, with psychiatrists defending the validity of their diagnostic systems and pointing out that many medical illnesses can be feigned without causing us to doubt their validity.

Psychologists have generally embraced the study as a powerful demonstration of the biasing effect and stickiness of diagnostic labels. For some it may be perceived to bolster the argument that using a medical model to research and treat mental health difficulties just doesn’t work. That it is still being discussed and articles being published on how it is represented in textbooks is testament to the enormity of its influence in this field of psychology.

David Rosenhan passed away in 2012 after a long and successful career, finishing at Stanford. The pseudopatients (“three psychologists, a pediatrician, a psychiatrist, a painter, and a housewife”) have to my knowledge never been identified or come forward. I would love to hear from them, or their friends or relatives in the case that some of them have passed away. There was also a ninth patient who violated the ground rules by giving false information outside the claim to hear a voice in his admission interview.

So is the infamous Rosenhan Experiment a damning indictment of psychiatric diagnostic systems that still exist today, a merely historical embarrassment that serves to demonstrate how far we have come, or a gimmicky but unscientific reminder that doctors are human too, and can be fooled like the rest of us?

What do you think?

Update to this article: In November 2019 Susannah Cahalan published a must-read book (The Great Pretender) for anyone interested in this topic, suggesting aspects of the study were fraudulent. Thanks to the commenter who mentioned this book.