““On Being Sane in Insane Places” … it is a work half done.”

“ON BEING SANE IN INSANE PLACES” TURNS FIFTY

Rosenhan through a “scientific experiment aimed at exposing the system’s travesties”.^[1] His article^[2] naturally had an ominous title. Quite a stir was created on its publication, as multiple normal people or pseudopatients could get admitted to various psychiatric hospitals under the diagnostic labels of serious illnesses. In this brief communication, I will try to explore the origins of the article, the reception that the article had during the early years after its publication and subsequently during the twenty-first century, Rosenhan’s response to his critics, and the article’s contemporary relevance.

The students, of Rosenhan’s 1969 abnormal psychology class, complained that his course was too conceptual and abstract. Rosenhan responded by asking them to check into a local psychiatric hospital to personally know the mentally ill. But as he cautiously checked things out for himself first and emerged humbled from nine traumatizing days in a locked ward, he had to abandon the idea of putting students through that experience. But an experiment was born.^[1]

Early years after the article

One of the major concerns of the deeply embarrassing 1973 article was the unreliability of the psychiatric diagnoses. The same year saw homosexuality most humiliatingly struck as an abnormality from the DSM. The 1960s and early 1970s were bad for American psychiatry, which was being hit by multiple crises, including the anti-psychiatry movement.^[3]

Robert Spitzer in 1974 became a natural choice for chairing the task force of DSM-III, because of his involvement in developing Research Diagnostic Criteria … and resolving the gay controversy. “Gay Psychiatric Association [a secret group] invited Spitzer to sit in on a meeting … If such successful people—without any obvious distress or impairment—could be gay, then how could they call it a disorder?”^[4]

Soon influential voices in American psychiatry were seen mounting a collective defense of the profession.^[3] So, after Spitzer became the chair, he naturally spearheaded an attack on Rosenhan^[5–9]… while expressly admitting^[7] the weaknesses of psychiatric diagnoses. “So be it.” Spitzer wrote, “But where did Rosenhan get the idea that psychiatry is the only medical specialty that is plagued by inaccurate diagnosis?” Then he attacked Rosenhan by devoting a long paragraph and quoting studies to prove that internal medicine too was plagued by the inaccuracies of diagnoses. Spitzer was personally targeting Rosenhan is clear from the title, abstract, and the entire text,^[7] which begins: “Some foods taste delicious but leave a bad aftertaste. So it is with Rosenhan’s study, “On Being Sane in Insane Places”“.

In his defense, Rosenhan argued^[10]: “The issue is not that the pseudopatients lied or that the psychiatrists believed them … [or] whether the pseudopatients should have been admitted … The issue is the diagnostic leap that was made between a single presenting symptom, hallucination, and the diagnosis, schizophrenia (or, in one case, manic-depressive psychosis). That is the heart of the matter.”

Coming back to Wilson,^[3] who wrote quoting Robert Spitzer (personal interview, May 24, 1989): “at APA annual meetings in the 1960s, the academic psychiatrists interested in presenting their work on descriptive diagnosis would be scheduled for the final day in the late afternoon. No one would attend. Psychiatrists simply were not interested in the issue of diagnosis.”

Spitzer^[7] did not even try to defend the condition of the inpatients: “I shall not dwell on the latter part of Rosenhan’s study, which deals with the experience of psychiatric hospitalization. … I find it hard to believe that conditions were quite as bad as depicted, but they may well be.”

Rosenhan revisited during the twenty-first century

Slater covered Rosenhan’s Experiment in her 2004 popular nonfiction.^[11] Even that nonacademic writing evoked a well-planned and sharp academic response from Spitzer, including a formal study to contradict “Slater’s findings”… and it was another opportunity to attack Rosenhan. “The [Rosenhan’s 1973] study was like a sword plunged into the heart of psychiatry. … The study was widely acclaimed in the popular news media, and two editorials in The Journal of the American Medical Association endorsed its findings … Many introductory psychology textbooks cited the study … Rosenhan’s study had a significant impact on the psychiatric and psychological literature: a Web of Science search conducted by the authors revealed that Rosenhan’s study has been cited over 750 times since its publication. In contrast, the critiques of Rosenhan’s study have received far less attention”.^[12]

In November 2022, Google Scholar returned 4502 citations for Rosenhan,^[2] while its critique^[7] returned only 211. More importantly “flaws in Rosenhan’s study … [was not a proof that psychiatry] had an adequately reliable diagnostic system”.^[13] While writing the 2007 Foreword Spitzer admitted that the book The Loss of Sadness^[13] “caused me to rethink my own position [about DSM approach]” and he hoped that the issue would become “one of the major topics that should be considered in the upcoming revisions that will yield the DSM-V” (pp. vii-x).

While working on DSM-III drafts, Spitzer “often returned to Rosenhan’s study and asked himself: Would David Rosenhan and his pseudopatients get past this one?… Without Rosenhan’s study, Frances told me, “Spitzer could never have done what he did with the DSM-III”“.^[4] Unlike his wife and Frances … Spitzer never publicly admitted that Rosenhan influenced his creation.

In an obituary, Ross, and Kavanagh^[14] noted: “Some critics saw this [Rosenhan] study as a personal attack on psychiatry and clinical psychology, even though the article’s emphasis was on diagnostic practices and contextual influences.” They quoted portions of the article’s concluding paragraph, which emphasized Rosenhan’s empathy and humanity towards the hospital staff. The whole paragraph is: “Quite the contrary, our overwhelming impression of them was of people who really cared, who were committed and who were uncommonly intelligent. Where they failed, as they sometimes did painfully, it would be more accurate to attribute those failures to the environment in which they, too, found themselves than to personal callousness. Their perceptions and behavior were controlled by the situation, rather than being motivated by a malicious disposition”.^[10]

Lee Shulman eulogized that Rosenhan’s work constituted “more than the report of an immensely inventive piece of research … it is a proclamation, a moral outcry, a scream of pain and a demand that the world bear witness to the consequences of wrongful diagnosis, of ungrounded labeling, of institutions whose very design shapes errors of diagnosis”.^[14]

Cahalan^[4] wrote: “Rosenhan’s flawed work had an effect on Robert Spitzer and the creation of the DSM … [and] that the study had a wide influence, contributing to the shuttering of psychiatric hospitals. … Rosenhan’s paper, as exaggerated, and even dishonest, as it was, touched on truth as it danced around it … The messages were worthy; unfortunately, the messenger was not.” While commenting on the book, Pols in Science wrote: “with The Great Pretender, yet another well-known and rhetorically powerful experiment in psychology bites the dust”.^[15] But Abbott was less forthright in condemning Rosenhan, because “she [Cahalan] cannot be completely certain that Rosenhan cheated. But she is confident enough to call her engrossing, dismaying book The Great Pretender”.^[1]

“In my first reading of “On Being Sane in Insane Places”… the first of hundreds of readings to come, I saw immediately why so much of the general public had hailed it—and why psychiatry writ large despised it. … I pinpointed so much of my own disappointment and frustration as a former patient myself. And I could feel, viscerally, the undercurrent of rage that travels through his paper that I feel, too, when I picture the face of my mirror image, that anonymous young woman, trapped in a psychiatric diagnosis, who would never be the same”.^[4] And Dr. Deborah Levy called Cahalan “a modern-day pseudopatient”. So Cahalan never disagreed with Rosenhan’s observations. She did not seem to be promoting any vested interests, and she was never absolutely sure that Rosenhan faked.

The contemporary relevance: Psychiatry will remain a work half done till we discover a better paradigm

““On Being Sane in Insane Places” is a negative work,” Rosenhan responded to his adversaries. “It tells what is wrong with treatment and diagnosis, without telling how it might be improved. … It tells those who have labored to improve psychiatric care that their efforts are grossly insufficient, without offering alternatives of demonstrated value. … It leaves scientists and practitioners in the lurch, urging them to abandon the little they have by way of hospital treatment and diagnosis, without providing them alternative tools. It would destroy a paradigm without providing an alternative. In short, it is work half done [emphasis added]”.^[10]

Even today, we continue to destroy the paradigm without realizing that we are acting like Rosenhan. The Lancet in the years 2007 and 2011 published two series about mental health. These twelve articles, whose references are here,^[16] paint a grim narrative of the mental health scenario, especially in low and middle-income countries of Asia, Africa, and Latin America. The ground reality is even grimmer in India.^[17]

We must recall Erwadi where a dargah claims healing powers for the mentally ill … unfortunate conditions prevailed in the asylums.^[18]… and in 2001 roasted alive were twenty-eight mentally challenged. The official response of the Indian psychiatrists to the tragedy was brisk and predictable.^[19,20] Siddiqui^[21] is probably showing her wild desperation (and nothing else) when hailing dargahs and other forms of faith healing as forms of critical alternatives to (a less than adequate) psychiatry.

These critiques should reinforce Rosenhan, reminding us of the work that fifty years ago Rosenhan tried to push forward, and that continues to remain half done. It will remain half-done till we find a new and better paradigm. So, it should jolt us to search for a new paradigm. His article^[2] should be seen as an attempt to reform psychiatry in its entirety and not its diagnostic processes alone.

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Conflicts of interest

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