On Being Sane in Insane Places

David L. Rosenhan’s “On Being Sane in Insane Places,” published in the influential journal Science in 1973, stands as a pivotal critique of psychiatric practices. Rosenhan, a psychologist and professor, orchestrated an experiment that would profoundly challenge the legitimacy of established psychiatric diagnoses. Beyond being an academic dissection, Rosenhan’s essay is a journey through the notions of “sanity” and “insanity,” the stigma of mental illness, and the essence of institutions entrusted with mental health care. It delves into themes such as The Unreliability of Psychiatric Diagnoses, The Subjectivity of Mental Health Terminology, and Stigmatization and Dehumanization in Mental Health Care.

This study guide refers to the original version published in Science.

Content Warning: Both the guide and the source text discuss the institutionalized treatment of psychiatric patients and societal discrimination toward mental health conditions. Although “sanity” and “insanity” are principally legal rather than clinical concepts, the guide will generally retain Rosenhan’s language, as challenging these categories is central to his project.

Rosenhan’s essay begins with a question central to his study that strikes at the core of psychiatric practice: whether it is possible to reliably distinguish “sanity” from “insanity.” He contends that despite widespread belief to the contrary, there is no substantial evidence that distinctly differentiates between what is considered “normal” and “abnormal.” Even though psychological suffering and behaviors that deviate from social norms are real, it is unclear whether diagnostic traits are inherent in individuals or influenced by the observers’ environment and context.

Rosenhan explains the experiment designed to investigate this question. The study involved eight “pseudopatients” who simulated mental illness to gain entry into 12 psychiatric hospitals across the United States. The objective was to see if the psychiatric establishment could distinguish mental illness from fabricated conditions; however, Rosenhan also explains that a significant portion of his article will detail the pseudopatients’ experiences, as conditions within mental hospitals were not widely known or discussed at the time of his writing.

Rosenhan briefly profiles the pseudopatients. He himself was one; the other seven came from various walks of life, though several were either psychologists or psychiatrists. Although the pseudopatients provided false names and careers, they otherwise presented accurate accounts of their histories and relationships. To gain entry to the hospitals, which ranged in size, location, and quality, the pseudopatients reported experiencing auditory hallucinations.

Upon admission, these pseudopatients stopped exhibiting any “symptoms,” though some experienced mild anxiety that their charade would be discovered. They acted as they would under normal circumstances, engaging with patients and staff and participating in hospital activities. They also took notes on their experience—initially covertly, but ultimately in the open. Rosenhan notes that, like “real” psychiatric patients, the pseudopatients did not know when they would be discharged, though they generally hoped to leave as quickly as possible and acted accordingly: “The psychological stresses associated with hospitalization were considerable […]. They were, therefore, motivated not only to behave sanely, but to be paragons of cooperation” (252).

Nevertheless, each pseudopatient received a psychiatric label, mainly schizophrenia. Rosenhan considers but dismisses various factors that might have influenced the inaccuracy of these particular diagnoses—hospital quality, length of stay, or the behavior of the pseudopatients themselves (several of whom other patients flagged as “sane”). Rosenhan acknowledges that medicine in general errs on the side of overdiagnosis so as to minimize patient risk, but he suggests that the particularly stigmatizing nature of psychiatric diagnoses warrants special caution. He also describes a follow-up study at a teaching hospital, where staff were falsely informed that some pseudopatients would be admitted. The staff subsequently identified several “real” patients as imposters.

Reiterating that psychiatric labels tend to “stick” once they have been applied, Rosenhan considers how such labels influence people’s perceptions of those who purportedly have a mental illness. Rosenhan demonstrates how, following a diagnosis, the hospital staff’s preconceived notions and biases often led to the reinforcement of their initial misdiagnoses. For example, clinical notes referred to one pseudopatient’s fairly typical account of waxing and waning relationships as evidence of “affective instability” and interpersonal “ambivalence”—traits associated with schizophrenia. Likewise, Rosenhan remarks that staff dismissed the pseudopatients’ record-keeping as a psychiatric symptom. More broadly, Rosenhan suggests that psychiatric hospitals fail to identify potential environmental sources of patients’ behavior—e.g., boredom, negative interactions with staff, etc. Whereas society generally accepts that a “sane” person can at times behave in ways that are out of character, no such understanding is extended to those deemed mentally ill. Rosenhan suggests that this is not only unfair but unproductive, arguing that it would be more useful to conceive of mental illness not as a stable trait but rather as responses to particular (if sometimes unknown) “stimuli.”

Returning to the stigmatizing nature of psychiatric diagnoses, Rosenhan considers the experience of hospitalization for psychiatric illness. Though such institutions—like the very concept of “mental illness”—have well-intentioned origins, according to the author, they are in practice anything but humane. Rosenhan notes that psychiatric hospitals are structured in a way that limits interaction between patients and staff; one study found that on average, staff spent only 11.3% of their day outside their own quarters. The hierarchical structure within psychiatric hospitals exacerbates this, as lower-ranking staff take their cues from doctors, who spend considerably less time with patients. In his own study, Rosenhan uncovered systemic sidelining of patient interaction. When pseudopatients approached staff with polite, reasonable inquiries (e.g., about the length of their stay), they were frequently ignored or met with nonsensical responses that showed the staff were not listening.

Amid these conditions, the pseudopatients recorded feelings of depersonalization and powerlessness. The hospitals showed little concern for their privacy—e.g., subjecting them to physical examinations in front of multiple staff members. Abuse was also common; Rosenhan himself saw a patient beaten for speaking to a staff member out of turn. The pseudopatients’ sense of invisibility was not simply a matter of perception, as staff members consistently failed to notice that they (and many “real” patients) were not taking their medication. On the subject of medication, Rosenhan suggests that the use of psychotropic drugs combines with stigma against mental illness and the hospitals’ hierarchical structure to produce dehumanization: Such medication “convince[es] staff that treatment is indeed being conducted and that further patient contact may not be necessary” (257).

Rosenhan questions the accuracy and reliability of psychiatric diagnoses and the potential harm caused by misdiagnoses. He speculates that many people without mental illness have likely been saddled with lifelong labels, while others’ purported mental illnesses may simply be a response to hospitalization. At the very least, Rosenhan argues, mental health treatment in its current form is unlikely to help patients reintegrate into society. Rosenhan advocates for a more humane and individualized approach to mental health care, praising the rise of alternatives to hospitalization (e.g., community mental health facilities, behavior therapies, etc.) and emphasizing the need for mental health care workers to understand the complex interplay among individual symptoms, societal biases, and mental health care environments.