The Rosenhan experiment or Thud experiment was an experiment regarding the validity of psychiatric diagnosis. For the experiment, participants submitted themselves for evaluation at various psychiatric institutions and feigned hallucinations in order to be accepted, but acted normally from then onward. Each was diagnosed with a psychiatric disorder and given antipsychotic medication. The study was arranged by psychologist David Rosenhan, a Stanford University professor, and published by the journal Science in 1973 with the title On Being Sane In Insane Places. [1] [2]
It is considered[ by whom? ] an important and influential criticism of psychiatric diagnosis, and broached the topic of wrongful involuntary commitment. [3] The experiment is said to have "accelerated the movement to reform mental institutions and to deinstitutionalize as many mental patients as possible". [4] Rosenhan claimed that he, along with eight other people (five men and three women), entered 12 hospitals in five states near the west coast of the US. Three of the participants were admitted for only a brief period of time, and in order to obtain sufficient documented experiences, they re-applied to additional institutions.
Respondents defended psychiatry against the experiment's conclusions, saying that as psychiatric diagnosis relies largely on the patient's report of their experiences, faking their presence no more demonstrates problems with psychiatric diagnosis than lying about other medical symptoms. [5] It has been alleged that at least part of the published results were distorted or falsified. [6] [7]
While listening to a lecture by Ronald D. Laing, a psychiatrist associated with anti-psychiatry claims, Rosenhan conceived of the experiment as a way to test the reliability of psychiatric diagnoses. [8] The study concluded "it is clear that we cannot distinguish the sane from the insane in psychiatric hospitals" and also illustrated the dangers of dehumanization and suggestion in psychiatric institutions. It suggested that the use of community mental health facilities which concentrated on specific problems and behaviors rather than psychiatric terminology might be a solution, and recommended education to make psychiatric workers more aware of the social psychology of their facilities.
Rosenhan himself and seven mentally healthy associates, termed "pseudopatients", attempted to gain admission to psychiatric hospitals by telephoning for an appointment and feigning auditory hallucinations. The hospital staff were not informed of the experiment. The pseudopatients included a psychology graduate student aged in his twenties, three psychologists, a pediatrician, a psychiatrist, a painter, and a housewife. None had a history of mental illness. Pseudopatients used pseudonyms, and those who were mental health professionals were given false jobs in a different sector to avoid invoking any special treatment or scrutiny. Apart from giving false names and employment details, further biographical details were reported truthfully.
During their initial psychiatric assessment, the pseudopatients claimed to be hearing voices of the same sex as the patient which were often unclear, but which seemed to pronounce the words "empty", "hollow", or "thud", and nothing else. These words were chosen as they vaguely suggest some sort of existential crisis and for the lack of any published literature referencing them as psychotic symptoms. No other psychiatric symptoms were claimed according to Rosenhan's publication, but medical records have indicated that, at least in the case of one pseudopatient, more were shared to the hospital such as not being able to sleep, feeling cold all over, being unable to work for six months, being sensitive to radio signals, having suicidal thoughts, etc. Grimacing and twitching were also observed by the doctor who examined one of the pseudopatients. [6] If admitted, the pseudopatients were instructed to "act normally", reporting that they felt fine and no longer heard voices. Hospital records obtained after the experiment indicate that all pseudopatients were characterized as friendly and cooperative by staff.[ citation needed ]
All were admitted, to 12 psychiatric hospitals across the United States, including underfunded public hospitals in rural areas, urban university-run hospitals with excellent reputations, and one expensive private hospital. Though presented with identical symptoms, seven were diagnosed with schizophrenia at public hospitals, and one with manic-depressive psychosis, a more optimistic diagnosis with better clinical outcomes, at the private hospital. Their stays ranged from 7 to 52 days, and the average was 19 days. All but one were discharged with a diagnosis of schizophrenia "in remission", which Rosenhan considered as evidence that mental illness is perceived as an irreversible condition creating a lifelong stigma rather than a curable illness.
Despite openly and frequently taking extensive notes on the behavior of the staff and other patients, none of the pseudopatients were identified as impostors by the hospital staff, although many of the other psychiatric patients seemed to be able to correctly identify them as impostors. In the first three hospitalizations, 35 of the total of 118 patients expressed a suspicion that the pseudopatients were sane, with some suggesting that the patients were researchers or journalists investigating the hospital. Hospital notes indicated that staff interpreted much of the pseudopatients' behavior in terms of mental illness. For example, one nurse labeled the note-taking of one pseudopatient as "writing behavior" and considered it pathological. The patients' normal biographies were described in hospital records consistent with what was expected of schizophrenics by the then-dominant theories of its cause.
The experiment required the pseudopatients to get out of the hospital on their own by getting the hospital to release them, though a lawyer was retained to be on call for emergencies when it became clear that the pseudopatients would not ever be voluntarily released on short notice. Once admitted and diagnosed, the pseudopatients were not able to obtain their release until they agreed with the psychiatrists that they were mentally ill and began taking antipsychotic medications, which they flushed down a toilet. No staff member reported that the pseudopatients were flushing their medication down the toilets.
Rosenhan and the other pseudopatients reported an overwhelming sense of dehumanization, severe invasion of privacy, and boredom while hospitalized. Their possessions were searched randomly, and they were sometimes observed while using the toilet. They reported that though the staff seemed to be well-meaning, they generally objectified and dehumanized the patients, often discussing patients at length in their presence as though they were not there, and avoiding direct interaction with patients except as strictly necessary to perform official duties. Some attendants were prone to verbal and physical abuse of patients when other staff were not present. A group of patients waiting outside the cafeteria half an hour before lunchtime were said by a doctor to his students to be experiencing "oral-acquisitive" psychiatric symptoms. Contact with doctors averaged 6.8 minutes per day. [9]
For this experiment, Rosenhan used a well-known research and teaching hospital, the staff of which had learned of the results of the initial study but claimed that similar errors could not be made at their institution. Rosenhan arranged with them that during a three-month period, one or more pseudopatients would attempt to gain admission and the staff would rate every incoming patient as to the likelihood they were an impostor. Of 193 patients, 41 were considered to be impostors and a further 42 were considered suspect. In reality, Rosenhan had sent no pseudopatients; all patients suspected as impostors by the hospital staff were ordinary patients. This resulted in a conclusion that "any diagnostic process that lends itself too readily to massive errors of this sort cannot be a very reliable one". [2]
Rosenhan published his findings in Science , in which he criticized the reliability of psychiatric diagnosis and the disempowering and demeaning nature of patient care experienced by the associates during the study. [2] Additionally, he described his work in a variety of news appearances, including to the BBC:
I told friends, I told my family: "I can get out when I can get out. That's all. I'll be there for a couple of days and I'll get out." Nobody knew I'd be there for two months ... The only way out was to point out that they're [the psychiatrists are] correct. They had said I was insane, "I am insane; but I am getting better." That was an affirmation of their view of me. [10]
The experiment is said to have "accelerated the movement to reform mental institutions and to deinstitutionalize as many mental patients as possible". [4]
Many respondents to the publication defended psychiatry, saying that as psychiatric diagnosis relies largely on the patient's report of their experiences, faking their presence no more demonstrates problems with psychiatric diagnosis than lying about other medical symptoms. In this vein, psychiatrist Robert Spitzer quoted Seymour S. Kety in a 1975 criticism of Rosenhan's study: [5]
If I were to drink a quart of blood and, concealing what I had done, come to the emergency room of any hospital vomiting blood, the behavior of the staff would be quite predictable. If they labeled and treated me as having a bleeding peptic ulcer, I doubt that I could argue convincingly that medical science does not know how to diagnose that condition.
Kety also said that psychiatrists should not necessarily be expected to assume that a patient is pretending to have mental illness, thus the study lacked realism. [11] Instead of considering realistic problems in diagnosis, such as comorbidity or differential diagnosis between disorders with similar symptoms, Rosenhan dismissed the criticism as further examples of the "experimenter effect" or "expectation bias," and evidence for his interpretation that he had discovered genuine problems of diagnosis rather than being fooled by his method. [12]
In The Great Pretender, a 2019 book on Rosenhan, author Susannah Cahalan questions the veracity and validity of the Rosenhan experiment. Examining documents left by Rosenhan after his death, Cahalan finds apparent distortion in the Science article: inconsistent data, misleading descriptions, and inaccurate or fabricated quotations from psychiatric records. Moreover, despite an extensive search, she is only able to identify two of the eight pseudopatients: Rosenhan himself, and a graduate student whose testimony is allegedly inconsistent with Rosenhan's description in the article. Due to Rosenhan's seeming willingness to alter the truth in other ways regarding the experiment, Cahalan questions whether some or all of the six other pseudopatients might have been simply invented by Rosenhan. [7] [13] In February 2023, Andrew Scull of the University of California at San Diego published an article in the peer-reviewed journal History of Psychiatry in support of Cahalan's allegations. [6]
In 1887, American investigative journalist Nellie Bly feigned symptoms of mental illness to gain admission to a lunatic asylum and report on the terrible conditions therein. The results were published as Ten Days in a Mad-House . [14]
In 1968, Maurice K. Temerlin split 25 psychiatrists into two groups and had them listen to an actor portraying a character of normal mental health. One group was told that the actor "was a very interesting man because he looked neurotic, but actually was quite psychotic" while the other was told nothing. Sixty percent of the former group diagnosed psychoses, most often schizophrenia, while none of the control group did so. [15] [16]
In 1988, Loring and Powell gave 290 psychiatrists a transcript of a patient interview and told half of them that the patient was black and the other half white; they concluded of the results that "clinicians appear to ascribe violence, suspiciousness, and dangerousness to black clients even though the case studies are the same as the case studies for the white clients." [17]
In 2004, psychologist Lauren Slater claimed to have performed an experiment very similar to Rosenhan's for her book Opening Skinner's Box . [3] Slater wrote that she had presented herself at 9 psychiatric emergency rooms with auditory hallucinations, resulting in being diagnosed "almost every time" with psychotic depression. However, when challenged to provide evidence of actually performing her experiment, she could not. [18] The serious methodological and other concerns regarding Slater's work appeared as a series of responses to a journal report, in the same journal. [19]
In 2008, the BBC's science television series Horizon performed a similar experiment for two episodes entitled "How Mad Are You?". The experiment involved ten subjects, five with previously diagnosed mental health conditions, and five with no such diagnosis. They were observed by three experts in mental health diagnoses and their challenge was to identify the five with mental health problems solely from their behavior, without speaking to the subjects or learning anything of their histories. [20] The experts correctly diagnosed two of the ten patients, misdiagnosed one patient, and incorrectly identified two healthy patients as having mental health problems. Unlike the other experiments listed here, however, the purpose of this journalistic exercise was not to criticize the diagnostic process, but to minimize the stigmatization of the mentally ill. It was intended to show that people with a previous diagnosis of a mental illness could live normal lives with their health problems not obvious to observers from their behavior. [21] [22]
One of the main claims of the Rosenhan experiment was that clinicians could be negatively biased in their first clinical impression, which would negatively affect further clinical decisions. Christoph Flückiger and colleagues conducted two experiments in 2024 (N = 56 and 64) in which psychotherapists were asked to give their first clinical impressions in two consecutive cases after a brief presentation of the case (case description and video excerpt) and a short recall task on the information provided. The attentional focus in the recall task served as an independent variable: therapists had to adopt either a symptom-focused or a strength-focused attentional focus to recall the cases, i.e. therapists rated their first case in either the symptom-focused or the strength-focused condition and the second case in the opposite condition. In both studies, the therapists in the symptom-focused conditions rated the patients as slightly more distressed, less resilient and less psychosocially integrated compared to the strength-focused conditions. However, these effects, although statistically significant, were rather small to clinically negligible. These preliminary results suggest that the first clinical impressions of contemporary psychotherapists in both experiments may be slightly, but not as dramatically, distorted as the Rosenhan experiment suggested at the time [23] .
The Diagnostic and Statistical Manual of Mental Disorders is a publication by the American Psychiatric Association (APA) for the classification of mental disorders using a common language and standard criteria. It is an internationally accepted manual on the diagnosis and treatment of mental disorders, though it may be used in conjunction with other documents. Other commonly used principal guides of psychiatry include the International Classification of Diseases (ICD), Chinese Classification of Mental Disorders (CCMD), and the Psychodynamic Diagnostic Manual. However, not all providers rely on the DSM-5 as a guide, since the ICD's mental disorder diagnoses are used around the world, and scientific studies often measure changes in symptom scale scores rather than changes in DSM-5 criteria to determine the real-world effects of mental health interventions.
Involuntary commitment, civil commitment, or involuntary hospitalization/hospitalisation is a legal process through which an individual who is deemed by a qualified person to have symptoms of severe mental disorder is detained in a psychiatric hospital (inpatient) where they can be treated involuntarily. This treatment may involve the administration of psychoactive drugs, including involuntary administration. In many jurisdictions, people diagnosed with mental health disorders can also be forced to undergo treatment while in the community; this is sometimes referred to as outpatient commitment and shares legal processes with commitment.
A mental disorder, also referred to as a mental illness, a mental health condition, or a psychiatric disability, is a behavioral or mental pattern that causes significant distress or impairment of personal functioning. A mental disorder is also characterized by a clinically significant disturbance in an individual's cognition, emotional regulation, or behavior, often in a social context. Such disturbances may occur as single episodes, may be persistent, or may be relapsing–remitting. There are many different types of mental disorders, with signs and symptoms that vary widely between specific disorders. A mental disorder is one aspect of mental health.
A psychiatric hospital, also known as a mental health hospital, a behavioral health hospital, or an asylum is a specialized medical facility that focuses on the treatment of severe mental disorders. These institutions cater to patients with conditions such as schizophrenia, bipolar disorder, major depressive disorder, and eating disorders, among others.
Anti-psychiatry, sometimes spelled antipsychiatry, is a movement based on the view that psychiatric treatment can be often more damaging than helpful to patients. The term anti-psychiatry was coined in 1912, and the movement emerged in the 1960s, highlighting controversies about psychiatry. Objections include the reliability of psychiatric diagnosis, the questionable effectiveness and harm associated with psychiatric medications, the failure of psychiatry to demonstrate any disease treatment mechanism for psychiatric medication effects, and legal concerns about equal human rights and civil freedom being nullified by the presence of diagnosis. Historical critiques of psychiatry came to light after focus on the extreme harms associated with electroconvulsive therapy and insulin shock therapy. The term "anti-psychiatry" is in dispute and often used to dismiss all critics of psychiatry, many of whom agree that a specialized role of helper for people in emotional distress may at times be appropriate, and allow for individual choice around treatment decisions.
Insanity, madness, lunacy, and craziness are behaviors caused by certain abnormal mental or behavioral patterns. Insanity can manifest as violations of societal norms, including a person or persons becoming a danger to themselves or to other people. Conceptually, mental insanity also is associated with the biological phenomenon of contagion as in the case of copycat suicides. In contemporary usage, the term insanity is an informal, un-scientific term denoting "mental instability"; thus, the term insanity defense is the legal definition of mental instability. In medicine, the general term psychosis is used to include the presence of delusions and/or hallucinations in a patient; and psychiatric illness is "psychopathology", not mental insanity.
Schizoaffective disorder is a mental disorder characterized by symptoms of both schizophrenia (psychosis) and a mood disorder - either bipolar disorder or depression. The main diagnostic criterion is the presence of psychotic symptoms for at least two weeks without prominent mood symptoms. Common symptoms include hallucinations, delusions, disorganized speech and thinking, as well as mood episodes. Schizoaffective disorder can often be misdiagnosed when the correct diagnosis may be psychotic depression, bipolar I disorder, schizophreniform disorder, or schizophrenia. This is a problem as treatment and prognosis differ greatly for most of these diagnoses. Many people with schizoaffective disorder have other mental disorders including anxiety disorders.
Sluggish schizophrenia or slow progressive schizophrenia was a diagnostic category used in the Soviet Union to describe what was claimed to be a form of schizophrenia characterized by a slowly progressive course; it was diagnosed even in patients who showed no symptoms of schizophrenia or other psychotic disorders, on the assumption that these symptoms would appear later. It was developed in the 1960s by Soviet psychiatrist Andrei Snezhnevsky and his colleagues, and was used exclusively in the USSR and several Eastern Bloc countries, until the fall of Communism starting in 1989. The diagnosis has long been discredited because of its scientific inadequacy and its use as a means of confining dissenters. It has never been used or recognized outside of the Eastern Bloc, or by international organizations such as the World Health Organization. It is considered a prime example of the political abuse of psychiatry in the Soviet Union.
Adjustment disorder is a mental and behavioral disorder defined by a maladaptive response to a psychosocial stressor. The maladaptive response usually involves otherwise normal emotional and behavioral reactions that manifest more intensely than usual, causing marked distress, preoccupation with the stressor and its consequences, and functional impairment.
David L. Rosenhan was an American psychologist. He is known best for the Rosenhan experiment, a study challenging the validity of psychiatry diagnoses.
The classification of mental disorders, also known as psychiatric nosology or psychiatric taxonomy, is central to the practice of psychiatry and other mental health professions.
Child and adolescent psychiatry is a branch of psychiatry that focuses on the diagnosis, treatment, and prevention of mental disorders in children, adolescents, and their families. It investigates the biopsychosocial factors that influence the development and course of psychiatric disorders and treatment responses to various interventions. Child and adolescent psychiatrists primarily use psychotherapy and/or medication to treat mental disorders in the pediatric population.
A psychiatric assessment, or psychological screening, is the process of gathering information about a person within a psychiatric service, with the purpose of making a diagnosis. The assessment is usually the first stage of a treatment process, but psychiatric assessments may also be used for various legal purposes. The assessment includes social and biographical information, direct observations, and data from specific psychological tests. It is typically carried out by a psychiatrist, but it can be a multi-disciplinary process involving nurses, psychologists, occupational therapist, social workers, and licensed professional counselors.
Psychiatry is the medical specialty devoted to the diagnosis, prevention, and treatment of deleterious mental conditions. These include various matters related to mood, behaviour, cognition, perceptions, and emotions.
The word schizophrenia was coined by the Swiss psychiatrist Eugen Bleuler in 1908, and was intended to describe the separation of function between personality, thinking, memory, and perception. Bleuler introduced the term on 24 April 1908 in a lecture given at a psychiatric conference in Berlin and in a publication that same year. Bleuler later expanded his new disease concept into a monograph in 1911, which was finally translated into English in 1950.
Political abuse of psychiatry, also known as punitive psychiatry, refers to the misuse of psychiatric diagnosis, detention, and treatment to suppress individual or group human rights in society. This abuse involves the deliberate psychiatric diagnosis of individuals who require neither psychiatric restraint nor treatment, often for political purposes.
Depression, one of the most commonly diagnosed psychiatric disorders, is being diagnosed in increasing numbers in various segments of the population worldwide. Depression in the United States alone affects 17.6 million Americans each year or 1 in 6 people. Depressed patients are at increased risk of type 2 diabetes, cardiovascular disease and suicide. Within the next twenty years depression is expected to become the second leading cause of disability worldwide and the leading cause in high-income nations, including the United States. In approximately 75% of suicides, the individuals had seen a physician within the prior year before their death, 45–66% within the prior month. About a third of those who died by suicide had contact with mental health services in the prior year, a fifth within the preceding month.
Psychiatry is, and has historically been, viewed as controversial by those under its care, as well as sociologists and psychiatrists themselves. There are a variety of reasons cited for this controversy, including the subjectivity of diagnosis, the use of diagnosis and treatment for social and political control including detaining citizens and treating them without consent, the side effects of treatments such as electroconvulsive therapy, antipsychotics and historical procedures like the lobotomy and other forms of psychosurgery or insulin shock therapy, and the history of racism within the profession in the United States.
Susannah Cahalan is an American writer and author, known for writing the memoir Brain on Fire: My Month of Madness, about her hospitalization with a rare autoimmune disease, anti-NMDA receptor encephalitis. She published a second book, The Great Pretender: The Undercover Mission That Changed Our Understanding of Madness, in 2019. She also works as a writer for the New York Post. Cahalan's work has raised awareness for her brain disease, making it more well-known and decreasing the likelihood of misdiagnoses.
"But some people in the department called him a bullshitter," Kenneth Gergen says. And through her deeply researched study, Cahalan seems inclined to agree with them.
Rosenhan DL. The contextual nature of psychiatric diagnosis. J Abnorm Psychol. 1975;84:462–74