On Being Sane in Insane Places

David Rosenhan’s “pseudopatient experiment” is a classic study for both sociologists and psychologists, that raises a range of interesting questions relating to areas like mental illness, labelling theory and ethics.

Rosenhan’s research was designed to discover if doctors could correctly diagnose mental illness. If they couldn’t, this would tell us something very important about the relationship between mental illness and labelling – that mental illness is not an objective category but a subjective condition; it is, in other words, whatever medical professionals claim it to be – a situation that has hugely-important ramifications for contemporary ideas about crime and deviance, for example.

Rosenhan and seven of his students became pseudopatients: they pretended to be suffering from some form of ‘mental illness’. They got themselves admitted to 12 hospitals on the basis that they were hearing a voice saying ‘hollow, empty, thud’. This was interpreted by the hospital staff as a symptom of schizophrenia and, as Taylor (2011) notes:

“Once admitted to the hospital the pseudopatients stopped faking the symptom and behaved normally. When asked by the staff how they were feeling, they said they were fine, the symptom had disappeared and could they please be released… [However,] the pseudopatients remained in hospital for between 7 and 52 days. It seemed behaving normally was not enough to get out of a mental hospital, you had to accept the diagnosis first…and they were all finally released with a diagnosis of schizophrenia in remission”.

Labelling Mental Illness

The implication here is that ‘mental illness’ only exists because we begin with a label (and a set of characteristics we associate with it) that we then apply to particular forms of behaviour. This process reverses cause and effect:

rather than a cause (mental illness) coming before the label (the effect),

the effect (labelling) comes before the cause.

In other words, we only know behaviour is mental illness because that’s how medical professionals label it. Rather than an objective, quantifiable medical condition producing a specific label (‘schizophrenia’), the label defines the condition.

These broad claims have historically been associated with both the “Anti-Psychiatry” movement in psychology that developed in the 1960’s around critical theorists such as R.D. Laing and Thomas Szasz and labelling theories in sociology. These, in their slightly different ways, focused on “mental illness” as a form of labelling process which, as in the case of schizophrenia, was highly-dependent on a behavioural diagnosis – hence the significance of Rosenhan’s Experiment.

Here, the “self-diagnosis” of the pseudopatients was, Rosenhan claimed, accepted by medical professionals as evidence of possible schizophrenia and led to a vicious-circle from which “the mentally ill” found it difficult – and sometimes impossible – to escape: to conform to the medical definition led to being labelled “mentally ill” (with all it concomitant personal and social problems), while to confront the label – to claim, as Rosenhan’s pseudopatients did that the “symptoms had disappeared” – was merely to confirm it. To claim not to be mentally ill was part of the illness…

Over the past 50 years, however, our knowledge of the causes of the various conditions we call “mental illness” has developed somewhat – particularly with the emergence of neuroscience and the ability to image brain functions – such that with a condition like schizophrenia we no-longer rely on simple behavioural diagnoses.

It’s important to remember, however, that the main target of psychologists like Rosenhan and Szasz was not “the medical profession”, per se, but rather psychiatry – particularly as it was, and arguably still is in many cases, practiced in America.

While labelling theory generally and Rosenhan’s research specifically (see, for example Cahalan’s The Great Pretender) has been increasingly questioned and criticised over the past half century, it’s interesting to note that behavioural diagnoses of both mental and physical illness remain a source of controversy. A good example here is Attention-Deficit / Hyperactivity Disorder (ADHD) and its application to school children, initially in America and increasingly in the UK.

Here, the “problem of misbehaviour” in schools appears to have been increasingly diagnosed in terms of ADHD and medicalised through the use of “pharmacological solutions”, such as Ritalin (US Schools and the Astounding Rise in ADHD).

Increasingly, however, behavioural diagnoses of ADHD have been questioned, with a recent (2018) Harvard University study arguing that such diagnoses consistently overlook much simpler – and more-convincing – explanations: young children born towards the end of summer, for example, suffer from educational behavioural problems because they are around a year younger than their autumn-born classroom peers (“Summer-born struggle: Why August children suffer at school”).

Ethics

Rosenhan’s study was a little different to many forms of sociological and psychological research in that the relationship between researcher (Rosenhan) and respondents (medical professionals) was broadly mediated through a third-party (the pseudopatients), rather than there being a direct relationship between the two. Nevertheless, a major ethical question here relates to the extent to which a researcher is justified in either deceiving the objects of their study (in this case doctors) or misrepresenting the nature of their research. The ethical question to resolve in this instance might be the extent to which such research is justified if it exposes professional practices that might be detrimental to the public?

You can explore Rosenhan’s research further in a number of ways:

• Text – the complete text of “On Being Sane in Insane Places”
• PowerPoint – covers the basics of the study.
• Video – a new film we’ve made on Rosenhan’s experiment called, with a remarkable lack of invention: “On Being Sane in Insane Places“