Personal Accounts: On Being Possibly Sane in Possibly Insane Places

In the famous Rosenhan study (1), eight sane people, including David Rosenhan (a psychology and law professor at Stanford University) gained admittance into 12 American psychiatric institutions by pretending to hear voices. Most “pseudopatients” were diagnosed as having schizophrenia and were institutionalized for 19 days (stays ranged from seven to 52 days) before being discharged with the diagnosis of “schizophrenia in remission.”

In September 2010, I was agitated from several life stressors and impulsively visited a colleague in the United States without telling my family and friends where I was going. A series of unusual events followed, and I was admitted into a U.S. psychiatric institution. After three weeks, I was discharged to a Canadian psychiatric institution and returned home shortly afterward. Consequently, as an experimental psychology professor, I was (unwillingly) provided an opportunity to partially replicate the famous Rosenhan study. Have things changed, or are Rosenhan's findings relevant today?

Rosenhan's pseudopatients pretended to hear voices but stopped simulating abnormality once admitted and accurately provided most biographical information. In my case, no symptoms were feigned, all biographical information was accurate, and my academic credentials were known by some staff and patients. Many of Rosenhan's pseudopatients had also never visited a psychiatric ward, were nervous on admittance, and had no foreknowledge of their discharge. All of these conditions were applicable to my case. However, whereas Rosenhan's pseudopatients were examined by a psychiatrist, my diagnosis was made by a young intern (training to be a psychiatrist), and the two of us spent approximately 20 minutes together before a diagnosis of bipolar disorder was made. From my perspective, the judgment was simply a diagnostic error, supporting recent evidence that bipolar disorder is increasingly being misdiagnosed among those without the disorder (2).

Whereas Rosenhan's pseudopatients were cooperative, I, unfortunately, was not. For example, I refused to take my pills on several occasions, loudly demanded that I should receive hard copies of the Patient's Bill of Rights, and, during one exasperating day, yelled at my psychiatrist that I wanted to see a human rights representative immediately. The young intern who had made my diagnosis was also occasionally present on the unit, and it was clear from my end that we would likely not be exchanging Christmas cards later in the season.

Officially, I was on a three-day voluntary confinement, which meant that I could apply in writing to leave after three days and meet with a lawyer in case the institution challenged my application in court (which was the course of action that I followed). My lawyer was knowledgeable and noted that the institution could challenge my request and recommend a six-month involuntary confinement. Further, my lawyer explained, voluntary patients were often discharged within a few weeks, and a more prudent course of action might be to take my pills, become a “good patient,” and remember that one symptom of bipolar disorder is an irritable mood state. I followed my lawyer's advice and was discharged after 21 days (only two days longer than the average stay in Rosenhan's study).

Although the patients in the Canadian institution had chronic problems, about half of the patients in the American institution were in their 20s or 30s, displayed few obvious signs of pathology, and were discharged within a few weeks. Thus an argument can be made that the American institution had a 50% false-positive rate and that the labeling and pill-dispensing process was itself causing harm. Rosenhan made a similar point when he noted that psychiatric diagnoses carry personal, legal, and social stigmas.

My return to Canada was also relevant to Rosenhan's claim that sanity was not detectable. In my case, my plane trip was allowed only if I was accompanied by a physician, which meant that I was not yet considered fully sane. Although I expected to return home later that night, the Canadian psychiatrist informed me that I would need to spend at least 48 hours in the Canadian institution for further observation. From the emergency room, I was then escorted to the psychiatric floor and, along the way, was greeted by a “Hello, Dr. Goddard” from one of my Introductory Psychology students in the hallway. Mercifully, I was discharged 60 hours later.

Rosenhan noted that psychiatric labels are powerful and that normal behaviors were overlooked or misinterpreted by psychiatrists and hospital staff in his experiment. For example, I was not sleeping well initially, which the staff considered evidence consistent with my disorder. Later, though, I discovered that the thermostat in my room was set above 80 degrees Fahrenheit, and when it was properly adjusted, my sleep improved. Of course, a lowered temperature was confounded with delayed drug onset (the explanation favored by my psychiatrist), and at that point I decided that “good patients” do not point out the design flaws common in applied research. At the end of my second week as a “good patient,” many staff commented that my behavior had improved. A blood sample was needed to confirm that my drug was at a “therapeutic” dosage. Unexpectedly, though, my dosage was “subtherapeutic.” Given this news, my psychiatrist concluded that because the drug was responsible for improvement, the dosage needed to be increased for additional improvement. As a “good patient,” I again resisted the urge to point out the obvious alternative interpretation or possible ceiling effects.

Rosenhan noted that psychiatric labels were influential on family and friends, which was also true in my situation; agitated behavior took on new meaning once a psychiatric label was assigned. Thankfully, though, my family and friends warmly welcomed my return home, and things are back to normal. Even a university secretary who was advised by another faculty member to carefully monitor my behavior for psychopathology eventually tired of the task.

Rosenhan reported that staff spent very little time with patients, and patient requests were given cursory responses or were ignored. This was definitely not true in my experience. The staff spent a great deal of time with patients, and patient requests were seriously considered. Patient requests could also be demanding and even comical. For example, patients might be indignant that staff would not run to the cafeteria to bring them additional sugar for their coffee or recharge their iPod at a moment's notice. Finally, Rosenhan reported an array of verbal and physical abuse toward patients, but I did not witness a single instance of such treatment.

Rosenhan's pseudopatients did, however, experience depersonalization when they were administered nearly 2,100 pills. My refusal to take pills was also unusual in that I did not witness a single instance of another patient refusing pills. Rather, patients routinely took their pills, and improvement was often attributed to the pills rather than to spontaneous remission or simple adjustment to the psychiatric setting. My own efforts to convince my psychiatrist that my improvement probably resulted from the reduction in several life stressors (rather than the pills) were greeted with the bemusement appropriate to a recovering patient.

Rosenhan noted that it was frightening how many sane individuals were not recognized and were deprived of certain rights, like the right to handle their accounts. During my stay, I realized a credit card bill needed to be paid and pleaded with my psychiatrist that with online banking the transaction could be completed rapidly under staff supervision. Unfortunately, though, my request was denied. Rosenhan also wondered “how many patients might be ‘sane’ outside the psychiatric hospital but seem insane in it—not because craziness resides in them, as it were, but because they are responding to a bizarre setting” (1). These comments are relevant today. For example, imagine yourself as a new patient. You have been given a psychiatric label and administered pills that make you drowsy. In your drowsy state, you observe a few patients talking to themselves or walking ritualistically around the halls. You have been assigned a same-sex roommate (who has also been given a psychiatric label and administered pills), and your roommate displays various idiosyncratic behaviors, like snoring. You have no foreknowledge of when you will be discharged, your bed is uncomfortable, and people from the night staff enter your room at regular intervals to check on your status. How would you respond?

Rosenhan noted that powerlessness and depersonalization experienced by pseudopatients were counter-therapeutic and that both factors (and others, such as segregation and self-labeling) were likely greater for true patients. As an example of the greater powerlessness experienced by a true patient, note that Rosenhan's pseudopatients did not need to worry about compromised employment, because their sanity was never in doubt. In my case, however, my “unauthorized absence” (to use the sympathetic wording of a university administrator) required medical documentation, and my return to work required psychiatric approval. Realizing that one's job depends on the judgments of the same individuals responsible for much of one's problems is sobering.

Note also that family and friends likely showed little change in their behavior toward Rosenhan's pseudopatients. However, in my experience, the behavior of my family and friends showed at least initial changes once a psychiatric label was assigned. A well-intentioned comment like “don't stop taking your pills” assumes that the individual has a psychiatric disorder, that pills are needed to cure this disorder, and that refusing pills provides evidence for psychopathology. What made this experience particularly surreal in my case was that I was well aware of the side effects associated with my pills and the heated disputes taking place in psychiatry.

Finally, one solution proposed by Rosenhan was to outline the advantages of behavioral therapies (emphasizing environmental stressors) over drug therapies (emphasizing internal psychopathology). Rosenhan noted that behavioral therapies “tend to avoid psychiatric labels, to focus on specific problems and behaviors, and to retain the individual in a relatively nonpejorative context” (1). As a behaviorist, I fully agree.