experiment de rosenhan

Rosenhan (1973) Experiment – ‘On being sane in insane places’

Angel E. Navidad

Philosophy Expert

B.A. Philosophy, Harvard University

Angel Navidad is an undergraduate at Harvard University, concentrating in Philosophy. He will graduate in May of 2025, and thereon pursue graduate study in history, or enter the civil service.

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Saul McLeod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul McLeod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

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Key Takeaways

• Between 1969 and 1972, Prof. David Rosenhan, a psychiatrist at Stanford University, sent eight pseudo-patients to 12 psychiatric hospitals without revealing this to the staff. None of the pseudo-patients had any symptoms or history of mental disorders.
• In all 12 instances, pseudo-patients were diagnosed with a mental disorder and hospitalized. In no instance was the misdiagnosis discovered during hospitalization.
• In some of the 12 hospital stays, pseudo-patients observed significant deficits in patient-staff contact.
• In a follow-up study at one hospital, Prof. Rosenhan asked staff to rate patients seeking admission on a 10-point scale, from “highly likely to be a (healthy) pseudo-patient” (1 or 2) to “least likely to be a pseudo-patient.” Staff were aware of the previous study and told one or more pseudo-patients would be sent their way unannounced. Forty-one (21.24%) of 193 patients received a 1 or 2 score. No pseudo-patients were, in fact, sent.
• These findings provided convincing evidence against the accuracy and validity of psychiatric diagnoses.
• The current state of psychiatric diagnoses is still broadly at odds with recent neurological findings, leading to uncertainty regarding their accuracy. Several interventions are proposed or underway to correct this. None counts with widespread support yet.

In the years leading to 1973, professor of law and psychology at Stanford University, Mr. David L. Rosenhan, sought to investigate whether psychiatrists actually managed to tease normal and abnormal psychological states apart. As Prof. Rosenhan put it:

At its heart, the question of whether the sane can be distinguished from the insane (and whether degrees of insanity can be distinguished from each other) is a simple matter: do the salient characteristics that lead to diagnoses reside in the patients themselves or in the environments and contexts in which observers find them? Rosenhan 1973, p. 251.

The recent publication of the APA’s DSM II in 1968 underscored the popular belief among practitioners that psychiatric conditions could be distinguished from each other and from normal psychiatric good health, much like physiological diseases can be distinguished from each other and from good health itself.

In the 1960s, an increasing number of critiques of this belief emerged, arguing that psychiatric diagnoses were not as objective, valid, or substantive as their physiological counterparts, but were rather more like opinions and, therefore, subject to implicit biases even when propounded by competent psychiatrists or psychologists.

Prof. Rosenhan set out to settle the matter empirically. He resolved to have people with no current or past symptoms of serious psychiatric disorders admitted to psychiatric hospitals.

If their lack of abnormal psychiatric traits were always detected, he reasoned, we would have good evidence that psychiatrists were able to tell normal from abnormal psychiatric states. Psychiatric normality, it was presumed, was distinct enough from abnormality to be readily recognized by competent practitioners.

Nine participants, including Prof. Rosenhan, were recruited. All were deemed to have no present or past symptoms of serious psychiatric disorders. Each gained admission to one of nine distinct hospitals.

In eight cases, admittance was gained without the hospital’s staff’s foreknowledge.

In Prof. Rosenhan’s case, the hospital administrator and chief psychologist knew of their hospital’s inclusion in the study. Data from Prof. Rosehan’s stay or stays were not excluded.

Data from one participant were excluded due to a protocol breach (falsification of personal history beyond that of name, occupation, and employment). Between one and four of the remaining eight participants thereafter gained further admission to four other hospitals.

Data from 12 hospital stays, at 12 different hospitals, by eight participants were included in the study. Five of the included participants were male adults; three were female adults. Five worked or were engaged in psychology or psychiatry.

One of the 12 hospitals was privately funded; the rest received public funding. An undisclosed number of hospitals were “old and shabby” or “quite understaffed.”

The 12 hospitals were located in five states in the East and West coasts of the US.

The admittance, stay, and discharge process was as follows —

• Participants set up an appointment at one of the hospitals under a false name, occupation, and employment.
• At the appointment, participants complained they had been hearing unfamiliar, often unclear voices which seemed to come from someone of their own sex and which seemed to say “empty,” “hollow,” and “thud;” participants provided truthful information on all matters other than name, occupation, and employment, with names, occupations and employment information of friends and family changed to fit with the participant’s assumed name, occupation, and employment.
• On admittance, participants stopped simulating any psychiatric symptoms, though there were a few cases of “brief[,] … mild nervousness and anxiety” which “abated rapidly.”
• In psychiatric wards, participants engaged with patients and staff as they would normally with colleagues in everyday life. When asked by staff how they were feeling, participants indicated that they were fine and that they no longer experienced symptoms. They received but did not ingest their prescribed medication, except in one or two instances. They recorded their observations regarding the ward, staff, and patients.
• Participants were discharged when the hospital’s staff responsible for their stay saw fit. A writ of habeas corpus was kept on file for each participant an undisclosed number of days after the study began.
• Between one and four participants repeated this process at four other hospitals.

Two further protocol breaches, which did not result in exclusion, were reported. One participant revealed their occupation in psychology to staff members. Another “attempted a romance with a nurse,” revealed their occupation in psychology to staff members, and provided psychotherapy to fellow patients.

Nursing reports for an undisclosed (“most”) number of the 12 stays were obtained from the hospitals. Coding protocols and training were not reported.

Depersonalization Observations

At four of the 12 hospitals, staff responses to patient-initiated contact were also investigated.

During their stay, four participants approached staff members with a request of the form, “Pardon me, Mr. [or Dr. or Mrs.] X, could you tell me when I will be eligible for grounds privileges?” or “… when I will be presented at the staff meeting?” or “… when I am likely to be discharged?”

No staff member was approached more than once a day. Staff responses were recorded.

Criteria for response classification, recording protocols, and pre-study training were not disclosed.

At six of the 12 hospitals, patients’ daily contact with staff (in minutes), from the initial admission interview to the final discharge meeting, inclusive of both, was measured.

Measurement protocol and pre-study training were not disclosed.

Non-existent Imposter Study

A second study was arranged at a research and teaching hospital in an undisclosed location. Its staff were aware of the first study’s results.

They were informed that one or more persons, previously instructed to simulate at least one symptom of a psychiatric disorder, i.e., a pseudo-patient, would attempt to gain admission within the following three months.

Staff were asked to rate each patient seeking admission on a ten-point scale, from most likely to be a pseudo-patient (1 or 2 on the scale) to least likely. No participants were, in fact, sent to the hospital. Scores were obtained for 193 patients.

No patients were independently evaluated by Prof. Rosenhan or affiliated researchers. No scoring protocol nor pre-study training was reported.

In eleven instances, participants were admitted on a diagnosis of schizophrenia and discharged with a diagnosis of schizophrenia in remission.

In one instance, a participant was admitted on a diagnosis of manic-depressive psychosis; their discharge diagnosis was not reported. Stays ranged from 7 to 52 days, with a mean of 19 days. Standard deviation was not disclosed.

Nursing reports “uniformly indicate[d] that the [participants] were “friendly,” “cooperative,” and “exhibited no abnormal indications.” Coding results and statistical significance were not reported.

Participants’ visitors “could detect no serious behavioral consequences [of hospitalization in participants].” No information on data collection from said visitors, nor statistical analyses on these data, were reported.

The errant diagnosis on admission, Prof. Rosenhan noted, could simply be attributed to physicians’ strong bias towards type II errors. As he put it:

The reasons [for this strong bias] are not hard to find: it is clearly [less] dangerous to misdiagnose illness than health. Better to err on the side of caution, to suspect illness even among the healthy. Rosenhan 1973, p. 252

Errant diagnoses after admission, once participants had dropped all pretense of psychiatric disturbance, were more surprising and troubling to Prof. Rosenhan.

It seemed that once diagnosed with an aberrant psychiatric trait, participants were unable to escape the diagnosis, despite their having dropped the farce immediately upon admission.

It was presumed that a competent practitioner, upon being well-acquainted with participants, would eventually identify the initial diagnosis as a type II error  and subsequently correct it. No such correction took place in any of the 12 hospital stays.

The admission diagnoses seemed, in Prof. Rosenhan’s words, “so powerful that many of the [participants’] normal behaviors were overlooked entirely or profoundly misinterpreted.”

Prof. Rosenhan offered the following explanation for this surprising result. Persons not diagnosed with a mental illness, nonetheless, at times, exhibit “aberrant” behavior, like pacing around or frequently writing. Without a psychopathic diagnosis, these behaviors are attributed to something other than psychopathy, like being bored or being a writer.

But in the presence of such a diagnosis, these behaviors are more often attributed to psychopathy, as they were in two instances in the study than not. This attribution, in turn, only reinforces the diagnosis, thereby fixing any type II errors in place.

The fact that such behaviors are often attributed to psychopathies in diagnosed patients, Prof. Rosenhan argued, points more to the “enormous overlap in behaviors of the sane and the insane” than to the competence of psychiatrists, psychologists, or nurses.

On initiating contact with staff members, participants were overwhelmingly not paid any attention by psychiatrists, nurses, or attendants at four of the hospitals. Inter-hospital differences were not deemed significant and were not reported. Statistical differences and significance were not reported.

Six participants, totaling 129 days of hospitalization, measured their daily contact with staff. Daily contact with psychiatrists, psychologists, residents, and physicians ranged from 3.9 to 25.1 minutes, with a mean of 6.8 minutes. Disaggregated data, contact time with other staff, statistical differences, statistical significance, and standard deviation were not reported.

Contact, Prof. Rosenhan notes, indicates “concern and individuation,” its lack, “avoidance and depersonalization.” Staff’s overwhelming avoidance of patients, Prof.

Table 1. Self-initiated contact by participants with psychiatrists, nurses, and attendants. Adapted from Table 1 of the 1973 Rosenhan study, p. 255. Copyright (c) 1973 AAAS.

Rosenhan notes resulted in an “overwhelming sense of powerlessness which invades the individual as he is continually exposed to the depersonalization of the psychiatric hospital.”

The import of this practice, and the powerlessness it elicited, Prof. Rosenhan argued, could be readily inferred.

[H]ow 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 … ? — Rosenhan 1973, p. 257

Of the 193 scores obtained, 41 patients were judged highly likely to have been a pseudo-patient by at least one staff member, 23 by at least one psychiatrist, and 19 by one psychiatrist and at least one other staff member. No pseudo-patients were sent by Prof. Rosenhan or affiliated researchers.

Of the 41 patients judged highly likely to have been pseudo-patients —

• Either they did not, in fact, have any abnormal psychiatric symptoms and were correctly judged pseudo-patients by the staff;
• Or they did, in fact, have abnormal psychiatric symptoms (as presumed by the fact that they wished to be admitted), in which case the staff misdiagnosed them as pseudo-patients and thereby made a type I error in seeking to avoid type II errors.

In either case, Prof. Rosenhan pointed out the results indicated “that the tendency to designate sane people as insane can be reversed when the stakes (in this case, prestige and diagnostic acumen) are high.”

But it is notable that, in the second case, the price for avoiding type II errors might just be a higher type I error rate.

It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals. The hospital itself imposes a special environment in which the meanings of behaviour can easily be misunderstood. Rosenhan 1973, p. 257

Both practitioners and patients, the study reveals, seem caught in Catch-22s. Out of an excess of caution, psychiatrists and psychologists strongly tend towards type II errors on admission. But once said error is made, there’s a slim chance it will be caught during in-patient treatment.

On the other hand, should practitioners try to avoid type II errors from sticking to patients, they run the risk of equally damaging type I errors. On the other hand, patients, once admitted, are likely to develop psychopathies, whether they truly had any on admission or not, given the bizarre setting they are thrust into on admittance.

But should they seek to avoid the setting — the psychiatric hospital — they run the risk of an untreated mental illness getting worse, in the case they truly suffered one, to begin with.

A way out for practitioners and patients is not immediately clear to Prof. Rosenhan. Two promising directions he noted were —

• The avoidance of psychiatric diagnoses of the form encouraged by the DSM II in favor of diagnosing patients with “specific problems and behaviors” so as to provide treatment outside of psychiatric hospitals and to keep any diagnostic label from “sticking” to a patient;
• Increasing “the sensitivity of mental health workers and researchers to the Catch-22 position of psychiatric patients,” for e.g., by having them read pertinent literature.

Other Conclusions

A good number of the study’s shortcomings should give us pause when drawing conclusions. Sampling, randomization, control, blinding, and statistical analysis methods were largely unreported and so likely not to have been up to present-day standards.

Participant training was not reported and so likely not undertaken before the study. No data on participants’ visitors and their evaluations were reported.

Study flaws aside, the observed effects were large enough to likely be clinically, and easily statistically, significant —

• All 12 hospitalizations resulted in type II errors both on admission and discharge;
• 2.94% of the 1,468 recorded participant-initiated interactions with psychiatric staff resulted in verbal engagement with the participant;
• 9.84% of the 193 patients scored at a research and teaching hospital were deemed very likely to have had no psychopathic traits on admission by both a psychiatrist and at least one other staff member.

The findings pointed to an unacceptable preponderance and persistence of type II errors by competent psychiatric staff and to the danger of psychiatric harm to patients posed by then-current psychiatric practices.

Critical Evaluation

Was the sample representative.

Field experiments have the major advantage of being conducted in a real environment and this gives the research high ecological validity. However, it is not possible to have as many controls in place as would be possible in a laboratory experiment.

Participant observation allows the collection of highly detailed data without the problem of demand characteristics. As the hospitals did not know of the existence of the pseudopatients, there is no possibility that the staff could have changed their behavior because they knew they were being observed.

However, this does raise serious ethical issues (see below) and there is also the possibility that the presence of the pseudopatient would change the environment in which they are observing.

Strictly speaking, the sample is the twelve hospitals that were studied. Rosenhan ensured that this included a range of old and new institutions as well as those with different sources of funding.

The results revealed little differences between the hospitals. This suggests that it is probably reasonable to generalize from this sample and suggest that the same results would be found in other hospitals.

Prof. Rosenhan’s 1973 paper does not detail —

• How his sample size was determined, nor how his sample was selected;
• The study’s inclusion/exclusion criteria;
• How past or present serious psychiatric symptoms were diagnosed, nor by whom;
• Whether past or present mild to moderate psychiatric symptoms were diagnosed, nor by whom;
• How hospitals were selected;
• How participants were matched with false names, occupations, and employment information;
• How participants were matched with hospitals.

What type of data was collected in this study?

There is a huge variety of data reported in this study, ranging from quantitative data detailing how many days each pseudopatient spent in the hospital and how many times pseudopatients were ignored by staff to qualitative descriptions of the experiences of the pseudopatients.

One of the strengths of this study could be seen as the wealth of data that is reported and there is no doubt that the conclusions reached by Rosenhan are well illustrated by the qualitative data that he has included.

Was the study ethical?

Strictly speaking, no. The staff were deceived as they did not know that they were being observed and you need to consider how they might have felt when they discovered the research had taken place.

Was the study justified? This is more difficult as there is certainly no other way that the study could have been conducted and you need to consider whether the results justified the deception. This is discussed later under the heading of usefulness.

What does the study tell us about individual/situational explanations of behavior?

The study suggests that once the patients were labeled, the label stuck. Everything they did or said was interpreted as typical of a schizophrenic (or manic-depressive) patient. This means that the situation that the pseudopatients were in had a powerful impact on the way that they were judged.

The hospital staff was not able to perceive the pseudopatients in isolation from their label and the fact that they were in a psychiatric hospital, and this raises serious doubts about the reliability and validity of the psychiatric diagnosis.

What does the study tell us about reinforcement and social control?

The implications of the study are that patients in psychiatric hospitals are ‘conditioned’ to behave in certain ways by the environments that they find themselves in.

Their behavior is shaped by the environment (nurses assume that signs of boredom are signs of anxiety, for example) and if the environment does not allow them to display ‘normal’ behavior, it will be difficult for them to be seen as normal.

Labeling is a powerful form of social control. Once a label has been applied to an individual, everything they do or say will be interpreted in the light of this label.

Rosenhan describes pseudopatients going to flush their medication down the toilet and finding pills already there. This would suggest that so long as the patients were not causing anyone any trouble, very few checks were made.

Was the study useful?

The study was certainly useful in highlighting the ways in which hospital staff interact with patients. There are many suggestions for improved hospital care/staff training that could be made after reading this study.

However, it is possible to question some of Rosenhan’s conclusions. If you went to the doctor falsely complaining of severe pains in the region of your appendix and the doctor admitted you to the hospital, you could hardly blame the doctor for making a faulty diagnosis.

Isn’t it better for psychiatrists to err on the side of caution and admit someone who is not really mentally ill than to send away someone who might be genuinely suffering?

This does not entirely excuse the length of time that some pseudopatients spent in the hospital acting perfectly normally, but it does go some way to supporting the actions of those making the initial diagnosis.

Outlook of Diagnostic Accuracy

Psychiatric diagnoses continue to be made as they were at the time of Prof. Rosenhan’s study — largely on the basis of inferences drawn from patient self-reports and practitioners’ observations of patient behavior and largely on the basis of criteria set by the APA’s DSM. This suggests two sources of diagnostic problems in psychiatry —

• the evidence used to reach a diagnosis, and
• the criteria by which said evidence is evaluated in reaching a diagnosis.

The evidence available to psychiatrists and psychologists in diagnosing mental disorders has long been much sparser than that available to other physicians.

There have been advances in the etiology of mental disorders — the relevant MeSH term now counts over 370,000 articles in PubMed, 4.00% of which are RCTs, meta-analyses, or systematic reviews.  This growing corpus has yet to yield diagnostic tests, though.

In 2012, a group of three psychiatrists, led by Prof. Shitij Kapur of King’s College London, argued that a number of reasons were responsible for this lag, including widespread methodological shortcomings and the DSM’s classification itself.

On that note, the DSM has left much to desire. As Mr. Thomas Insel, former director of the NIMH, put it —

Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. Insel 2013, second para.

Since its first publication in 1958, the DSM has reached a classification of mental disorders without data on their biological underpinnings.

Its nosology is increasingly at odds with aetiological research, which increasingly suggests that mental disorders are rather gradual deviations from typical brain functions.

This, in turn, suggests that mental disorders should be classified as points or areas on spectra rather than the neat categories propounded by the DSM. One effort at building such a nosology was begun by the NIMH in 2010.

The project dubbed the RDoC, is still confined to research, and is not ready for clinical application.

The myriad problems in psychiatric research and practice preclude any consensus on the accuracy of psychiatric diagnoses and are likely to do so until they are resolved.

The field has not converged on a corrective program, though there exist a number of such programs competing for widespread support.

What did the Rosenhan study suggest in 1973?

The Rosenhan study in 1973 suggested that psychiatric diagnoses are often subjective and unreliable. Rosenhan and his associates feigned hallucinations to get admitted to mental hospitals but acted normally afterward.

Despite this, they were held for significant periods and treated as if they were genuinely mentally ill. The study highlighted issues with the validity of psychiatric diagnosis and the stigma attached to mental illness.

What did the classic study by Rosenhan reveal about the power of labels that are applied to individuals?

The classic study by Rosenhan showed the influential effect of labels on individuals, specifically psychiatric labels. By pretending to have hallucinations, mentally healthy participants gained admission to psychiatric hospitals.

The study demonstrated that once labeled as mentally ill, their behaviors were consistently interpreted in that context, even when they stopped simulating symptoms.

Adam, D. (2013). On the spectrum. Nature, 496(7446), 416.

Insel, T. .R. (2013, 29th April). Transforming Diagnosis. [Weblog]. Retrieved 4 November 2020, from https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2013/transforming-diagnosis.shtml

Kapur, S., Phillips, A. G., & Insel, T. R. (2012). Why has it taken so long for biological psychiatry to develop clinical tests and what to do about it?. Molecular psychiatry, 17 (12), 1174-1179.

Rosenhan, D. L. (1973). On being sane in insane places. Science, 179( 4070), 250-258.

Sharp, C., Fowler, J. C., Salas, R., Nielsen, D., Allen, J., Oldham, J., Kosten, T., Mathew, S., Madan, A., Frueh, B. C., & Fonagy, P. (2016). Operationalizing NIMH Research Domain Criteria (RDoC) in naturalistic clinical settings. Bulletin of the Menninger Clinic, 80 (3), 187–212.

Further Information

• Rosenhan, D. L. (1973). On being sane in insane places. Science, 179(4070), 250-258.
• Spitzer, R. L. (1975). On pseudoscience in science, logic in remission, and psychiatric diagnosis: A critique of Rosenhan”s” On being sane in insane places.”
• David Rosenhan’s Pseudo-Patient Study

The Rosenhan Experiment: When Fake Mental Patients Fooled Psychiatrists

How the rosenhan experiment showed that "it is clear that we cannot distinguish the sane from the insane in psychiatric hospitals.".

Duane Howell/The Denver Post via Getty Images Dr. David Rosenhan. 1973.

What does it mean to be sane? How reliably can even medical professionals distinguish the sane from the insane?

Psychologist Dr. David Rosenhan of Stanford University had long been interested in these age-old questions and, in 1969, devised a unique experiment to put them to the test.

Rosenhan and seven other perfectly sane subjects went undercover inside various psychiatric hospitals from 1969-1972 and acted insane in order to see if the doctors there could tell that they were faking. The doctors could not.

How The Rosenhan Experiment Was Carried Out

Wikimedia Commons St. Elizabeths Hospital in Washington, D.C., one of the locations used in the Rosenhan experiment.

The Rosenhan experiment’s eight sane subjects went inside 12 different psychiatric hospitals, all but one state- or federally-run, spread across five U.S. states. These pseudopatients consisted of three women and five men, including Rosenhan himself, whose occupations ranged from actual psychologist to painter.

The participants assumed false names and professions and were instructed to set up appointments at the hospitals and claim that they had been hearing strange voices muttering words like “empty” and “hollow” (these words were meant to evoke an existential crisis, as in, “my life is empty and hollow”). On the basis of these appointments, every single pseudopatient was admitted to the hospital that they contacted.

According to the landmark 1973 report that Rosenhan published about his experiment, On Being Sane in Insane Places , “none of the pseudopatients really believed that they would be admitted so easily.”

Not only was every pseudopatient admitted, but all except one received a diagnosis of schizophrenia (the other diagnosis was “manic-depressive psychosis”). All they had done was feign auditory hallucinations. They exhibited no other symptoms and invented no false details about their lives aside from their names and professions. Yet they were diagnosed with serious psychological disorders.

Once checked into the hospitals and diagnosed, the pseudopatients were on their own. None knew when the doctors would deem them fit for release — or find out that they were faking first.

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The disturbing results.

U.S. National Library of Medicine A patient (not involved with the Rosenhan experiment) at St. Elizabeths Hospital. Circa 1950s.

At the start of the experiment, the patients’ biggest concern was that they would “be immediately exposed as frauds and greatly embarrassed,” according to Rosenhan. But as it turned out, there was no need to worry on this account.

There was a “uniform failure to recognize sanity” in any of the pseudopatients, Rosenhan wrote, and not one of them was ever found out by the hospital staff. The pseudopatients showed no new symptoms and even reported that the strange voices had gone away, yet the doctors and staff continued to believe that their diagnoses were correct.

In fact, hospital staff would observe totally normal behavior on the part of the pseudopatients and characterize it as abnormal. For instance, Rosenhan instructed the pseudopatients to take notes on their experiences. And one nurse who observed this note-taking wrote in a daily report that the “patient engages in writing behavior.”

As Rosenhan saw it, doctors and staff would assume that their diagnosis was correct and work backward from there, reframing everything they observed so that it would be in harmony with that diagnosis:

“Given that the patient is in the hospital, he must be psychologically disturbed. And given that he is a disturbed, continuous writing must be a behavioral manifestation of that disturbance, perhaps a subset of the compulsive behaviors that are sometimes correlated with schizophrenia.”

Likewise, one of the pseudopatients was a man who described his home life by truthfully reporting that he had a warm relationship with his wife, with whom he fought occasionally, and children, who he spanked minimally for misbehavior. But because he was admitted to a psychiatric hospital and diagnosed with schizophrenia, his discharge report stated that “His attempts to control emotionality with his wife and children are punctuated by angry outbursts and, in the case of the children, spankings.”

Had the man not been a patient in a psychiatric hospital, his common, mundane home life surely wouldn’t have been described in such dark tones.

“Diagnoses were in no way affected by the relative health of the circumstances of a pseudopatient’s life,” Rosenhan wrote. “Rather, the reverse occurred: The perception of his circumstances was shaped entirely by the diagnosis.”

Library of Congress/Wikimedia Commons A patient sits inside St. Elizabeths Hospital. 1917.

And in addition to stubbornly sticking to their diagnoses, hospital staff would treat the pseudopatients coldly. Interactions with the staff ranged from disinterested at best to abusive at worst. Even when the pseudopatients attempted to engage with staff in a friendly, conversational manner, responses were perfunctory (when given at all).

But while hospital staff treated the pseudopatients poorly and never realized they were faking, the actual patients often had no trouble detecting them. When the researchers were able to keep track, 35 out of 118 actual patients blatantly accused the pseudopatients of faking, with some outright stating, “You’re not crazy. You’re a journalist or a professor.”

Nevertheless, the doctors never got wise. The pseudopatients were eventually released — stays ranged from 7 to 52 days, with an average of 19 — but all with the same diagnosis under which they’d been admitted. They were released, however, because doctors decided that their condition was “in remission.”

As Rosenhan wrote:

“At no time during any hospitalization had any question been raised about any pseudopatient’s simulation. Nor are there any indications in the hospital records that the pseudopatient’s status was suspect. Rather the evidence is strong that, once labeled schizophrenic, the pseudopatient was stuck with that label. If the pseudopatient was to be discharged, he must naturally be ‘in remission’; but he was not sane, nor, in the institution’s view, had he ever been sane.”

The Legacy Of The Rosenhan Experiment

“It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals,” Rosenhan wrote at the outset of his report’s conclusion.

Rosenhan theorized that the willingness of the hospitals to admit sane people resulted from what’s known as a “Type 2” or “false positive” error, which results in a greater willingness to diagnose a healthy person as sick than a sick person as healthy. This kind of thinking is understandable to a point: failing to diagnose a sick person usually has more severe consequences than misdiagnosing a healthy one. However, the consequences of the latter can be dire.

Either way, the results of the Rosenhan experiment caused a sensation. People were astonished about the unreliability of psychiatric diagnoses and the ease with which hospital staff had been duped.

However, some researchers criticized the Rosenhan experiment, stating that the pseudopatients’ dishonest reporting of their symptoms made the experiment invalid because patients’ self-reports are one of the cornerstones on which psychiatric diagnoses are built.

But other researchers have affirmed Rosenhan’s methods and results, with some even partially replicating his experiment and coming up with similar conclusions .

Of course, even Rosenhan was not the first American to bring the darker side of the mental health system to light in this way.

Wikimedia Commons Nellie Bly

In 1887, journalist Nellie Bly went undercover in an insane asylum and published her findings as Ten Days in a Mad-House .

Bly too concluded that many of the other patients were just as “sane” as she and had been sent to the asylum unfairly. Bly’s work resulted in a grand jury investigation that attempted to make psychiatric examinations more thorough in an attempt to make sure that less “sane” people were institutionalized.

Almost a century later, Rosenhan showed that the mental health profession still had a long way to go in being able to reliably and consistently distinguish the sane from the insane.

After the results of the Rosenhan experiment were published, the American Psychiatric Association changed the Diagnostic and Statistical Manual of Mental Disorders . The new version of the manual, published in 1980, presented a more thorough list of symptoms for every mental illness and stated that, in order to diagnose a patient with a certain disorder, multiple symptoms had to be present as opposed to just one.

These changes in the manual survive to this day, although it has yet to be conclusively determined whether it has been successful in preventing false diagnoses. Perhaps the Rosenhan experiment could be duplicated today.

New Research Casts Doubt

Because the pseudopatients of the Rosenhan experiment would never be able to talk about their participation and because relatively little had been written authoritatively about the course of the study itself, it became a difficult experiment to discuss and critique — there simply wasn’t much to argue with. However, subsequent research that utilized uncovered documentation from the original experiment eventually found fault with Rosenhan’s study.

In her 2019 book on the Rosenhan experiment, The Great Pretender , journalist Susannah Cahalan cited unearthed primary sources like correspondence, diary entries, and excerpts from Rosenhan’s unfinished book. And such documentation, Cahalan found, actually contradicted the results that Rosenhan published on certain points.

For one, Cahalan claimed that Rosenhan himself, when undercover in an institution as part of his own experiment, told doctors there that his symptoms were quite severe, which would explain why he was so quickly diagnosed. This is significant because it runs counter to Rosenhan’s report, which claimed that he told doctors of some relatively light symptoms, which is precisely what made those doctors’ diagnoses seem like such an overreaction.

Furthermore, when Cahalan was finally able to track down one of the pseudopatients, he summed up his experience inside an institution with one word — “positive” — a stark rebuttal of the horror shows that Rosenhan’s participants had supposedly endured. But Rosenhan allegedly ignored this data when drafting his report.

“Rosenhan was interested in diagnosis, and that’s fine, but you’ve got to respect and accept the data, even if the data are not supportive of your preconceptions,” said the participant in question, Harry Lando.

If such claims are accurate and the Rosenhan experiment didn’t quite prove what it purported to, who knows how the course of psychiatric care in the U.S. may have unfolded in the decades since.

After this look at the Rosenhan experiment, read up on the infamous Milgram experiment and Stanford prison experiment . Then, take a disturbing look inside mental asylums of decades past .

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Why the Rosenhan Experiment still matters

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• In 1973, eight experimenters faked insanity to see how easy it was to get into a mental hospital. The hard part was getting out.
• Their findings sparked a great debate over how psychiatry treated patients and how accurate diagnostic procedures were.
• In an age marked by a lack of proper mental health care, the finding that it was too easy to get a doctor’s attention seems shocking.

In the United States, mental health care can be difficult to come by. One-third of Americans live in a “ mental health professional shortage area ” and lack access to mental health facilities; this probably explains why less than half of the people who need treatment get it . It can almost seem like you have to be at the end of your rope to get help sometimes.

It didn’t use to be this way though; there was that one time that a psychologist found it was easier to fake your way into a mental hospital than it was to get out.

The Rosenhan experiment

In 1973, after hearing a lecture from the anti-psychiatry figure R.D. Laing the psychologist David Rosenhan decided to test how rigorous psychiatric diagnoses were at modern hospitals by first trying to get into them with fake symptoms and then trying to get out by acting normally.

Eight experimenters participated, including Dr. Rosenhan. All but two of them were somehow involved in medicine, so fake names and occupations were created to both avoid the enhanced scrutiny they expected members of their field to be given when claiming insanity and to prevent the test subjects from facing the stigmas of mental illness after the experiment ended.

The pseudopatients all reported the same symptoms, an auditory hallucination saying the words “empty,” “hollow,” and “thud.” These words were chosen to invoke the idea of an existential crisis. They were also chosen because, at the time, there was no literature on an “existential psychosis.”

Much to the pseudopatients’ surprise, they were all admitted to all 12 hospitals they went to with little difficulty. In all but one case, they were given a diagnosis of schizophrenia . In the outlier, a private hospital gave them a slightly more optimistic diagnosis of “ manic-depressive psychosis .”

Once admitted to the hospital, the patients were instructed to act normally and do what they could to be released. This led them all to be “paragons of cooperation” and to fully participate in ward life. They attended therapy, socialized with others, and even accepted their medications which they then disposed of. If asked, they were to say their symptoms had disappeared entirely.

Shockingly, the staff had no idea any of them were faking. Their normal behavior was medicalized into symptoms of their schizophrenia. For example, since all of the pseudopatients were taking notes on the hospital, naturally one of them had the note “patient engages in writing behavior” added to their file. Also, simply lining up early to get food was cited as an example of “oral-acquisitive” psychotic behavior.

The life details of the subjects, all fairly typical for the time, were suddenly signs of pathological behavior. One pseudopatient reported that he had a happy marriage though he occasionally fought with his wife and that he did spank his children on rare occasions. While this might seem like a standard 1960s life, his file read:

“His attempts to control emotionality with his wife and children are punctuated by angry outbursts and, in the case of the children, spankings.”

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Schizophrenia’s Identity Crisis

Amusingly, while the staff at the hospitals had no idea they had fakers in the ward, the real patients often caught on very quickly. The participants reported dozens of cases of their wardmates coming up to them and accusing them of being either a journalist or professor playing sick in order to take notes about the hospital.

Disturbingly, the fakers also reported that the staff was dehumanizing and often brutal. Conversations with staff were limited by their frequent absence. When the staff did have time to talk, they were often curt and dismissive. Orderlies would often be both physically and verbally abusive when other workers were absent. The pseudopatients reported they often felt invisible, as the staff would act like they weren’t even there. These details were made worse by the powerlessness felt by the pseudopatients , which was reinforced both by hospital hierarchy and then current law.

Despite all the evidence that the experimenters were faking it, the shortest stay lasted a week, and the longest was 52 days. The typical stint lasted almost three weeks. All of the patients diagnosed with schizophrenia were deemed “in remission” upon being discharged, leading Dr. Rosenhan to write:

“At no time during any hospitalization had any question been raised about any pseudopatient’s simulation. Nor are there any indications in the hospital records that the pseudopatient’s status was suspect. Rather the evidence is strong that, once labeled schizophrenic, the pseudopatient was stuck with that label. If the pseudopatient was to be discharged, he must naturally be ‘in remission’; but he was not sane, nor, in the institution’s view, had he ever been sane.”

Dr. Rosenhan concluded that, “It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals.” He was forgiving, however, and noted that at least some of the problem could be attributed to a desire to err on the side of caution and admit a potential faker with only one reported symptom before letting somebody in serious need of treatment go without.

He went on to explain how another hospital challenged him to send an actor which they would then identify. After presenting him with their lengthy list of suspected actors they had admitted, Dr. Rosenhan revealed that he hadn’t sent anybody at all. He saw this as further evidence of his conclusion.

How did people take this report?

The report, published in Science , was a minor bombshell that landed on a profession that was already reevaluating its methods in the wake of a society suddenly coming to grips with the conditions of mental asylums, an increasing number of findings that suggested institutionalization wasn’t the only way to treat mental illness, and the discovery by a group of British shrinks that American doctors were handing out diagnoses of schizophrenia left and right when other conditions were really at work .

When the Diagnostic and Statistical Manual of Mental Disorders , the big book of mental illnesses and their symptoms, was updated in 1980 for its third edition, the debate around Rosenhan’s experiment likely motivated the authors to make the symptom descriptions used to define various conditions more stringent .

What’s the catch? There has to be a catch with a study like this.

The methods of this experiment were questioned immediately, as they are atypical at best and unscientific at worst.

Physician Fred Hunter pointed out in his letter to Science that if the patients were acting “normally” during their stays, they would have revealed their lie and asked to leave shortly after arriving. He also criticized both the methods and the findings of the stunt. Psychiatrist Robert Spitzer also dismissed the whole thing as pseudoscience in a strongly worded academic article.

There is also the question of whether the conclusion is meaningful at all. Neuroscientist Seymour S. Kety pointed out that a similar stunt in an emergency room would hardly be considered a groundbreaking study, given how important honest reporting is in medicine:

“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.”

The continuing problems of dehumanization and deinstitutionalization

The findings of the study on how the mentally ill were treated, even in cases where they were paragons of cooperation, was widely accepted as a valid and needed critique. Even Dr. Hunter admitted that Rosenhan’s experiment did a good thing by exposing these horrors. Regrettably, today we still have need of Rosenhan’s reports on this subject.

In the United States, sixteen percent of people in jails have a mental illness . This is three times as many people as are seeking care for these conditions in hospitals and is creating new forms of institutionalization . The stigma around mental illness remains as strong as ever . While many people think the mentally ill are dangerous, statistics show they are much more likely to be the victims of violence themselves rather than hurt anybody else .

It seems that Dr. Rosenhan’s lament that “The mentally ill are society’s lepers” has yet to be made obsolete by progress.

Are there any other experiments like this? Could this have just been a disturbing blip?

Depressingly, this isn’t the only experiment to use these methods to conclude that how we treat mental illness needs work. In 1887, almost a century before Rosenhan’s article, Nellie Bly faked insanity to enter the Woman’s Lunatic Asylum in New York City. The book she wrote about her experience, Ten Days in a Madhouse , revealed the horrific conditions in the hospital and led to an inquiry that resulted in increased funding and more rigorous standards .

Modern attempts to recreate the study have shown some changes in the field of psychiatry. In 2001 , seven people who had schizophrenia presented themselves to intake offices in search of treatment; all of them were denied care due to lack of resources. In 2004, writer Lauren Slater claimed to have repeated Rosenhan’s experiment herself but was only given medication to go with her quick diagnosis. If she actually carried out this experiment remains a subject of debate .

Psychiatry has improved dramatically since the days of One Flew Over the Cuckoo’s Nest and David Rosenhan’s stings. Studies have shown the objectivity of psychiatric diagnoses remains comparable to that of the rest of medical science while acknowledging that some subjectivity is inevitable. Better methods of integration have made it difficult to tell who has a diagnosed mental illness and who doesn’t in normal circumstances. Deinstitutionalization has improved the lives of many people who would otherwise be locked away.

But while asylums are largely gone, there is still much work to be done. Rosenhan’s experiment will continue to remind us that being labeled as crazy can lead to a dehumanization with consequences just as isolating as any mental illness.

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The flawed experiment that destroyed the world's faith in psychiatry

Fifty years ago, psychiatrist David Rosenhan went undercover in a psychiatric hospital to expose its dark side. But his shocking findings aren't what they seem, reveals Susannah Cahalan

By Susannah Cahalan

5 February 2020

Many psychiatric hospitals closed as mental health care shifted to communities

Zodebala/Getty Images

ON 6 February 1969, David Lurie told a psychiatrist at Haverford State Hospital in Pennsylvania that he had been hearing voices. “Hollow”, “empty” and “thud”, they said.

The voices were the only symptom experienced by the otherwise healthy 39-year-old copywriter. After an in-depth interview, in which Lurie was asked about his family life and two children, he was diagnosed with schizophrenia and hospitalised.

Yet all was not as it seemed. David Lurie didn’t exist. This was, in fact, an alias for psychologist David Rosenhan of Stanford University in California, who went undercover with seven other “pretenders” to test whether psychiatric staff could distinguish sanity from insanity .

Published in 1973, his study contributed to an erosion of public faith in psychiatry, a mistrust memorably portrayed in the 1975 film One Flew Over the Cuckoo’s Nest starring Jack Nicholson. Rosenhan’s work held up for scrutiny the often harmful nature of psychiatric hospitals and galvanised a growing movement to shut the large ones and replace them with smaller, community-based mental health centres. In its wake, “psychiatrists looked like unreliable and antiquated quacks unfit to join in the research revolution”, says psychiatrist Allen Frances, formerly at Duke University School of Medicine in North Carolina.

Rosenhan’s paper was “one of the most influential pieces of social science published in the 20th century”, says sociologist and historian Andrew Scull at the University of California, San Diego.

But it wasn’t all it seemed. After spending six years investigating Rosenhan and his famous work, I believe he may have carried out a second deception, the effects of which are still…

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On the troubling trail of psychiatry’s pseudopatients stunt

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The Great Pretender: The Undercover Mission that Changed our Understanding of Madness Susannah Cahalan Grand Central Publishing (2019)

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On Being Sane in an Insane Place – The Rosenhan Experiment in the Laboratory of Plautus’ Epidamnus

• Published: 01 October 2013
• Volume 32 , pages 348–365, ( 2013 )

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Plautus’ Roman comedy Menaechmi ( The Two Menaechmuses ) of c. 200 BC anticipates in fictional form the famous Rosenhan experiment of 1973, a landmark critique of psychiatric diagnosis. An analysis of the scenes of feigned madness and psychiatric examination suggests that the play (and the earlier Greek play from which it was adapted) offers two related ethical reflections, one on the validity of psychiatric diagnoses, the other on the validity of the entire medical model of insanity—that is, of the popular notion and political truth that mental illness is a (bodily) disease “like any other.” This essay is offered as a contribution to the interpretation of the play as well as to the history of psychiatry.

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Burzacchini ( 2007 ) reviews suggestions for Menaechmi ’s model. Posidippus of Cassandreia (316 – c. 250 BC) is often thought to be its author. I return to the question in §7 below.

Readers can watch Rosenhan summarizing it himself at http://www.youtube.com/watch?v=j6bmZ8cVB4o (accessed September 11, 2013).

An earlier charge (198) is colloquial rather than clinical.

At v. 902 Menaechmus in frustration refers to his errand boy as meus Ulixes, suo qui regi tantum concivit mali (“That Ulysses of mine, who caused so much trouble for his king”). The “king” is of course Menaechmus himself (a parasite’s patron is commonly called rex ). What legend is he alluding to? Perhaps to Odysseus’ legendary malingering. On the eve of the Trojan War Odysseus feigned insanity to avoid conscription, but was subsequently detected at the behest of Agamemnon. In the sequel Odysseus murdered Palamedes, whose father in turn convinced Clytemnestra, Agamemnon’s wife, to take Aegisthus as her lover—who, in turn, murdered Agamemnon (Apollodorus Epitome 6.7–9).

According to Stok ( 1996 ), bare arms were medically associated with insomnia in antiquity (p. 2294).

Some editors reassign the lines and understand:

Psychiatrist ( pinching Menaechmus’ arm ) Do you feel anything? Menaechmus Of course I do!

With this much-misunderstood question the doctor is probing two points derived from Hippocratic medical inquiry of the times:

Explicitly he is inquiring about a sudden change in drinking habits . As Rankin ( 1972 ) has noticed, Hippocratic teaching held that a sudden change in dietary habits could produce malign effects on the body (p. 187). At the end of chapter 10 of On Regimen in Acute Diseases Hippocrates states, “White and dark wines ( leukos te kai melas oinos ) are both strong, but if a person makes an unaccustomed ( para to ethos ) switch to one from the other, they will alter many things in his body.” The repetition in Menaechmus’ reply of soleam (= Greek to ethos ), “normally,” indicates that the doctor is inquiring whether Menaechmus customarily drinks “white” (Greek leukos ~ album ) or “dark” wine (Greek melas ~ atrum ) ( HVA part 3 Kühn 15.626–30 = CMG 5.91 Helmreich). Had he gotten a chance to ask it, the doctor’s next question would have been, “Have you been drinking the other kind today?”

Implicitly the doctor is afraid Menaechmus has been drinking dark wine, since according to Ps.-Aristotle ( Problemata 30.1, 954a [cf. 953b]) it produces the same symptoms as does black bile in melancholic individuals.

These observations decisively refute an older suggestion that the doctor’s questions relate to the regularity of Menaechmus’ bowel movements (as cited in Gratwick 1993 , ad loc.).

Incidentally, color is not really the sole issue. In his commentary on Hippocrates’ passage Galen (AD 129- c.200/c.216) points out that color implies taste, clarity or consistency ( systasis ), odor, and strength. For him, “dark” ( melas ) wine is usually muddy ( pachys ). Indeed we might well translate the two adjectives as “clear” and “muddy” respectively. This ambiguity explains why Menaechmus finds the question so bizarre. Latin album and atrum do mean “clear” and “muddy,” but very rarely—only one attestation apiece, and both very late (Apicius 1.6 and Palladius 11.14.9 respectively). Moreover, “dark” wine in Latin is usually nigrum , not atrum (Fantham 2007 , 2011 ). Baffled, Menaechmus naturally takes the two words to mean literally “white” and “black”—like Crayola colors as it were. (Since the wordplay on melas works better in Greek than in Latin, I assume it derives thence and not, as so often elsewhere, from the wellspring of Plautus’ imagination.)

Zanini ( 1984 ) nearly got this idea in identifying the two central themes of Plautus’ play as “ simillimi” (identicals) and “ insania ,” but missed the epistemological point that unites them.

Sextus Empiricus Adv. Math . 7.408–410, Cicero Acad . 2.54–8 and 2.84–7. I am grateful to my colleague Charles Brittain for help on this point.

Burzacchini, G. (2007). Sull’ignoto modello greco dei Menaechmi . In R. Raffaelli & A. Tontini (Eds.), Lecturae plautinae sarsinates X: Menaechmi (pp. 11–19). Urbino: QuattroVenti.

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Dedicated to the memories of David L. Rosenhan (1929–2012) and Thomas S. Szasz (1920–2012).

Note on text and translation Translations of Menaechmi in this paper are adapted at whim from those of Erich Segal ( 1996 ) and Paul Nixon ( 1917 ). The corresponding Latin text (which I have independently checked) is basically that of Friedrich Leo ( 1895 ).

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Fontaine, M. On Being Sane in an Insane Place – The Rosenhan Experiment in the Laboratory of Plautus’ Epidamnus. Curr Psychol 32 , 348–365 (2013). https://doi.org/10.1007/s12144-013-9188-z

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The Rosenhan Experiment That Shattered the Boundaries of Sanity

• Post author: Becky Storey
• Post published: December 4, 2019
• Reading time: 7 mins read
• Post category: Human Brain / Psychology & Mental Health / Uncommon Science

In 1973, David Rosenhan published a psychological paper titled “On Being Sane in Insane Places” . This study became known famously as the Rosenhan Experiment . He wanted to discover whether medical professionals could really tell the difference between the sane and the insane.

His research sent shockwaves through the psychiatry community and ultimately changed how diagnoses are given. Despite the praise though, there have been several conflicting ideas and criticisms of his work too.

The Rosenhan Experiment

The Rosenhan Experiment used eight willing participants, including Rosenhan himself. Some were psychologists too, while others hadn’t had anything to do with the profession at all. They were all mentally healthy. He called these participants “pseudopatients” .

They gave fake names and occupations, but kept all other details about themselves truthful, such as their family situations and childhoods. Their goal was to be admitted into a psychiatric unit based on the fictional symptoms they reported.

They each contacted hospitals across five US states and reported the same symptoms. They said they were hearing voices that said things like “hollow”, “empty” and “thud” . Rosenhan chose these words because they suggest an existential crisis , in the form of psychosis.

At the time, there was no literature on existential psychosis. As per the goal for the Rosenhan Experiment, the intention was to learn whether doctors would diagnose something based on symptoms that weren’t recognized as part of any psychiatric disorder .

All eight pseudopatients were successful in getting admitted. They were all diagnosed with Schizophrenia , based on the one symptom they reported, except for one who was given the diagnosis of Bipolar Disorder . Once they were let into the hospitals, they all stopped exhibiting their fake symptoms and returned to being entirely themselves. The experiment into how firmly the doctors would stick to their diagnosis had finally begun.

After Admittance

Once a pseudopatient entered the hospital, they began testing the doctors and nurses and recording their results for Rosenhan’s Experiment. They engaged in typical day to day activities on the ward, such as socializing, playing games and speaking to staff and other patients as they would in the outside world.

When asked how they felt, Rosenhan instructed them to say that they are well and to make it clear that they no longer experience any abnormal symptoms. Despite, their normal behavior, no doctor ever considered that their diagnosis was incorrect.

In 4 of the 12 hospitals tested in the Rosenhan Experiment, the pseudopatients also observed the staff’s interactions with the patients. They reported that very few ever paid much attention to those who needed it. Most of them wouldn’t respond to questions such as “when am I likely to be discharged?”, despite the calm and sane nature of the question.

This ultimately became a common criticism of the Rosenhan Experiment. Maybe it wasn’t a misunderstanding of sanity, but simply not giving enough time to finding out.

All of the pseudopatients hated their time on the wards. They described becoming depersonalized and feeling powerless . They all wanted to leave immediately. Their stays ranged between 7 and 52 days before discharge, and they were all discharged under the notion that their psychosis was “in remission”. At no point was it considered by the staff that they might not have a psychiatric disorder at all.

The staff were often absent and rarely spent time with the patients. They kept their interactions to a minimum. Some pseudopatients even reported the doctors and nurses being abusive and rude.

Rosenhan’s Results

Ultimately, the Rosenhan Experiment resulted in the anticipated way. David Rosenhan concluded that hospitals truly could not distinguish between the sane and the insane .

Some of the records and observations made by the pseudopatients were shocking and further confirmed the point that the Rosenhan Experiment had been set up to prove. Other genuine patients in the hospitals easily picked the pseudopatients out as fakes.

35 of the 118 real patients they interacted with noticed that they didn’t belong there. One real patient even accused a pseudopatient of being a journalist. This leads us to wonder if the pseudopatients were clearly fakes , the doctors were just not attentive enough to notice.

Some of the doctors and nurses even went as far as to label normal or healthy behaviors as pathological . In three nurses’ reports relating to the pseudopatients, they refer to their writing in notebooks as a psychotic behavior. This writing was done for the purposes of the Rosenhan Experiment and is a “sane” thing to do for any person who struggles with their mental health.

Similarly, it was reported that a group of staff had accused patients who gathered early for dinner of having Oral-Acquisitive Syndrome. In reality, as the pseudopatients reported, they were simply bored.

Rosenhan even conducted a second experiment where the doctors and nurses were aware that there was a pseudopatient on the ward. 83 out of a possible 193 patients were identified as suspicious by at least one member of staff. Rosenhan then revealed that there was no pseudopatient at all. Clearly, there was no uniform idea of what they were looking for in a “sane” person.

Criticisms of the Rosenhan Experiment

Unfortunately, despite its general success, some psychologists have presented issues with the Rosenhan Experiment . Some raise issues with the confidentiality of the experiment. While Rosenhan may have had good intentions, he kept the names of the hospitals and the pseudopatients confidential. This meant verifying his findings was impossible.

Rosenhan’s experiment also reports conflicting views on the doctors and nurses who tended to the pseudopatients. While in some reports they’re considered ignorant and abusive, in others they’re praised for being intelligent and committed.

Critics also wonder if the pseudopatients behaved “normally” at all. By writing and observing and the fear of being caught, there’s a chance the Rosenhan Experiment was flawed from conception .

Ultimately, both Rosenhan and his critics came to the same conclusion. It is difficult to distinguish the sane from the insane, even for medical professionals. As part of the human experience, we swing through all sorts of emotions all the time. Sadness, anxiousness, and anger are all normal feelings.

Sane and insane are extreme labels and we all sit on a spectrum rather than within definite labels. Fortunately, this is how modern-day psychiatrists view mental health now – in part due to the success of the Rosenhan Experiment.

References :

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A few similar studies should be done with GPs. I have had several incidences with doctors. Some would give me any script I wanted. Some pushed scripts on me. Some refused to believe that I had a health issue that scripts cant resolve. When i seen another doctor, I found out it was worse because I waited (due to the other doctor) I was given a proper remedy. And lastly but most important, how many times I have asked a doctor “why” is this happening? One of two responses “it could be many things” or a bewildered look on their face as they try to compose themself to answer.

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El Experimento Rosenhan y sus implicaciones

Se conoce con el nombre de experimento Rosenhan a la investigación que llevó a cabo David Rosenhan entre 1968 y 1972, donde pretendía demostrar que el análisis psiquiátrico llevado a cabo entonces en las instituciones mentales de EE.UU. tenía fallos importantes que empeoraban la salud mental de los pacientes.

¿Qué fue el experimento Rosenhan?

El experimento Rosenhan se diseñó para comprobar la ineficiencia de la práctica del análisis psiquiátrico en EE.UU. a finales de los años 70. Para el psicólogo David L. Rosenhan, las instituciones no eran capaces de distinguir a los “cuerdos” de los “locos”, y se propuso demostrarlo.

Además, mantenía la tesis de que muchos de los pacientes internos en instituciones psiquiátricas mejorarían significativamente en su vida y en su condición si eran sacados de un entorno hostil y aséptico -como el de las instituciones- y recibían una terapia adecuada.

De hecho, en el estudio afirmaba que los profesionales de estas instituciones no estaban preparados para atender con la debida humanidad y empatía a los enfermos, lo que resultaba antiterapéutico.

Para probar sus ideas, Rosenhan se sirvió de un puñado de voluntarios de ambos sexos y ocupaciones profesionales variadas a los que instruyó para que se hicieran pasar por pacientes con alucinaciones acústicas y lograran ser internados en distintos hospitales psiquiátricos .

Todos ellos lo consiguieron, sin excepción, aunque vivieron experiencias distintas. A pesar de ser pseudopacientes, fueron diagnosticados con enfermedades psiquiátricas, y pasaron como internos periodos variables.

De hecho, incluso a pesar de que los voluntarios referían los mismos síntomas , los diagnósticos entre ellos no fueron los mismos, y sus internamientos en las instituciones tuvieron duraciones distintas.

Todos volvieron a la calle tras aceptar el diagnóstico del psiquiatra y prometer que tomarían su medicación que, obviamente, no tomaban. Los profesionales a cargo de los pseudopacientes ni siquiera fueron capaces de darse cuenta de este hecho.

¿Qué nos enseñó este experimento?

Aunque no todos sufrieron el mismo tipo de trato, para Rosenhan sus experiencias representaron indicios suficientemente claros de que era necesario humanizar la terapia de los enfermos psiquiátricos.

La privacidad, la autonomía y el respeto a las personas realmente enfermas eran una anécdota en el día a día de un hospital psiquiátrico. La atención se reducía a unos minutos al día y, aun así, algunos pseudopacientes sufrieron abusos verbales por parte de algunos miembros del personal.

Las intuiciones de Rosenhan cuando llevó a cabo el experimento y las notas que tomaron los pseudopacientes durante su experiencia pusieron de manifiesto la necesidad de denunciar la segregación y la mortificación a la que estaban sometidos los verdaderos pacientes.

Despersonalizados e impotentes , los pacientes eran etiquetados y referidos en función de sus diagnósticos, pasando por una experiencia profundamente dolorosa que generaba sentimientos de abandono.

Esto, entendía Rosenhan, era evidentemente todo lo contrario a lo que se pretendía con la asistencia, ya fuera pública o privada, en salud mental.

Es importante destacar que Rosenhan no pretendía sustituir la voz de los pacientes que eran enfermos reales , sino poner de manifiesto que, incluso cuando tenían buenas intenciones, los profesionales de las instituciones psiquiátricas no trataban a los pacientes de una forma coherente con la idea de que podían mejorar .

Además, su crítica daba un paso más allá: incluso aunque los pseudopacientes hubieran mentido con sus alucinaciones, ¿por qué habían continuado como pacientes ingresados tanto tiempo después de haber afirmado que ya no las tenían?

La reacción de los psiquiatras

Con la publicación del estudio definitivo en 1973, algunos gestores de hospitales psiquiátricos estadounidenses se sintieron estafados e insultados, y otros directamente no tomaron en serio el experimento de Rosenhan.

Para poder demostrar que la idea de que “no somos capaces de distinguir a los cuerdos de los locos” seguía siendo una idea válida, Rosenhan retó a una de las instituciones, informando a su personal de que en el corto plazo varios pseudopacientes intentarían ser admitidos en la institución.

Durante los meses siguientes, el personal del hospital psiquiátrico llevó a cabo numerosas evaluaciones psiquiátricas , y además se permitió que cada persona de la plantilla pudiese, a título individual, señalar a algún pseudopaciente.

Los resultados fueron evidentes: de 193 admitidos a la institución, 41 pacientes fueron señalados como “falsos” por al menos un miembro del equipo del hospital, 23 fueron etiquetados como pacientes dudosos por al menos un psiquiatra y 19 lo fueron por un psiquiatra y además otro miembro del equipo.

¿La realidad? Rosenhan no había enviado a ningún paciente falso . Los profesionales de la plantilla estaban simplemente confirmando sus propios sesgos .

El experimento de Rosenhan sirvió para poner el dedo en la llaga sobre dos cuestiones cruciales: el tratamiento general de los pacientes en hospitales psiquiátricos y la extensión de los diagnósticos cuando no existen razones poderosas para hacerlo.

De hecho, se considera que la publicación del estudio Rosenhan supone un antes y un después en la reforma del diagnóstico psiquiátrico y el tratamiento de pacientes en instituciones de este tipo.

Marta Guerri

Marta Guerri es Licenciada en Psicología por la UOC y Diplomada en Enfermería por la UB . Es Psicóloga General Sanitaria , con un Máster en Terapia de la Conducta y la Salud, Postgrado en Terapia Familiar Socioeducativa, y un Postgrado en Salud Mental y Psiquiatría por la Universitat de Barcelona (UB). Ha trabajado en terapia con familias con vulnerabilidad social en el Servicio de Orientación y Acompañamiento a Familias (SOAF) y actualmente ejerce de Psicóloga en la Clínica Fertty, donde se dedica a la atención de pacientes y donantes en tratamientos de fertilidad. Además, es miembro de la Sociedad Española de Fertilidad (SEF), donde dirige uno de los grupos de estudio dedicado a la atención de donantes y ha realizado distintas ponencias sobre este tema. Es CEO y gestora de contenidos de Psicoactiva.com, un portal líder en psicología, que ha crecido hasta convertirse en una comunidad de referencia en el ámbito de la psicología y las neurociencias. Marta ha publicado varios libros sobre psicología y salud emocional, incluyendo "Inteligencia Emocional, una guía útil para mejorar tu vida" y "Entrenamiento mental para mejorar tu inteligencia" de la editorial Mestas Ediciones. Además, a través de su trabajo voluntario con la asociación Cracbaix, se dedica a asesorar a las familias con hijos de Altas Capacidades Intelectuales.

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

Atul agarwal.

Retired Professor and Consultant

“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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On being sane in insane places: david rosenhan and his thud experiment.

The “ Rosenhan Experiment”  or Thud experiment was a study conducted to determine the validity of the psychiatric diagnosis. The participants feigned hallucinations to enter psychiatric hospitals but acted usually afterward. They diagnosed them with psychiatric disorders and gave them antipsychotic medication. David Rosenhan, a Stanford University professor, conducted this study, and published it in the journal Science in 1973 under the title “On Being Sane in Insane Places”.

Some consider it an essential criticism of psychiatric diagnosis and broach wrongful involuntary commitment. Rosenhan did the study in eight parts. The first part involved using healthy associates or “pseudopatients” (three women and five men, including Rosenhan himself) who briefly feigned auditory hallucinations to gain admission to twelve psychiatric hospitals in five states in the United States. They admitted all and were diagnosed with psychiatric disorders. After admission, the pseudopatients acted usually and told staff that they no longer experienced any other hallucinations. As a condition of their release, they forced all the patients to admit to having a mental illness and had to agree to take antipsychotic medication. The average time that the patients spent in the hospital were 19 days. They diagnosed all but one with schizophrenia “in remission” before their release. The second part of his study involved a hospital administration challenging Rosenhan to send pseudopatients to its facility, whose staff asserted that they could detect them.

Rosenhan agreed, and they found in the following weeks forty-one out of 193 new patients as potential pseudopatients, with 19 of these receiving suspicion from at least one psychiatrist and one other staff member. Rosenhan sent no pseudopatients to the hospital. While listening to a lecture by R. D. Laing, associated with the anti-psychiatry movement, Rosenhan conceived the experiment to test the reliability of psychiatric diagnoses. The study concluded that “we cannot distinguish the sane from the insane in psychiatric hospitals” and illustrated the dangers of dehumanization and labelling in psychiatric institutions. It suggested that using community mental health facilities that concentrated on specific problems and behaviours rather than psychiatric labels might be a solution. It recommended education to make psychiatric workers more aware of the social psychology of their facilities.

The procedure

Results of the Study

They diagnosed all but one pseudopatient with schizophrenia (the other with the bipolar depressive disorder). They admitted all of them to the hospital and discharged each with a diagnosis of schizophrenia in remission. (i.e. Symptoms were not present at the time of release) the length of hospitalization varied from 7 to 52 days, with an average of 19 days. They never detected pseudopatients, no records or behavior by hospital staff showed that there were any doubts over the authenticity of the patients’ visitors and other patients recognized that some pseudopatients were sane. During the first three hospitalizations, 35 out of 118 patients on the admissions wards voiced their suspicions, such as you are not crazy. You are a journalist or a professor. 

Conclusions

Failure to detect sanity may be because doctors are more likely to favour a type 2 error (they are more likely to diagnose a healthy person as sick) than a type 1 error (than a sick person as healthy) less dangerous this works for medicine but is not necessarily the case for psychiatry as once we label a person as being mentally ill, it is challenging to shift the label the fact that some patients noticed the pseudopatients were sane when the staff did not raise important questions perhaps the results seem to suggest that diagnosis is reliable as they gave all but one individual a diagnosis of schizophrenia when presenting similar symptoms discharge of schizophrenia in remission when they were not actually suffering from any known disorder (affects reliability)it is interesting to note that the staff interpreted many of the pseudo-patients behaviours as being in line with the symptoms of the condition they had diagnosed them with. Rosenman believed that once given a label, we overlook all normal behaviours. For example, they saw their notetaking as an aspect of their pathological behaviour. Staff wrote in one patient’s notes: the patient engages in writing behaviour.

Second Experiment

Another hospital had heard of the findings of the first part of the study, and the staff over there did not believe the results would have occurred in their hospital. Rosenhan informed the staff that in the next three months, one or more pseudopatients would try again to gain entry to the hospital each member of staff was asked to rate every patient (either at admission or on the ward) who wanted admission on a scale from 1 to 10 in terms of whether they thought the patient was a real or fake score of 1 reflected an elevated level of confidence that the patient was fake. Over the 3 months, 193 patients tried to gain admission.

• What was the aim of Rosenhan?
• He wanted to test the reliability of a mental health diagnosis, to see if medical professionals could tell the sane from insane. 
• Was Rosenhan’s experiment or the Thud experiment an experiment?

No, it was an observational study. 

Who were the participants of the thud experiment?

The participants were staff and patients at the twelve hospitals.

Where were the hospitals of Rosenhan’s experiment?

In five states on the East and West coasts of the US. 

Who knew about the pseudopatients in the Thud experiment?

The hospital administrator and chief psychologist

How many pseudopatients were they, and who were they?

8 (3 women and five men) confederates.

Was Rosenhan a pseudo-patient?

Yes, Rosenhan also volunteered as a pseudopatient.

How would patients leave the hospital?

They had to convince the staff they were sane.

What did patients act like when they were admitted them?

They behaved like normal individuals. 

What did the staff do once in the wards?

Took notes. 

Were notes taken in the open?

Only once they were sure staff were not suspicious

What words they chose as the voices?

Thud, empty, and hollow.

What did they change about the patient’s information?

Just the name and occupation, all personal backgrounds stayed the same

How did patients contact the hospital?

Called them up.

What did patients report?

Hearing voices

What did Rosenhan measure?

How many days it took for the psychiatrists to release the patients.

Did they give the patients drugs?

Yes, but they did not swallow the medications. 

What were the patients diagnosed with?

11 schizophrenia and 1 manic depressive disorder

What did the average days of stay in the hospital?

Who many days did it vary by?

Were patients detected?

No, no evidence or records that staff doubted the authenticity

How many of the patients on the ward voiced their concerns?

What did real-life patients say?

‘You’re not crazy, you’re a journalist. 

How many were admitted to hospitals?

What is a type 2 error?

Diagnose a healthy person as sick

What is a type 1 error?

Diagnosing a sick person as healthy

What error did the doctors make?

Why did they make this type of error?

Considered less dangerous?

What is the problem with a type 2 error in mental health?

Hard to move the stigma

Why was it thought that even when behaving normally they were not let out?

Once given a label, they overlook all normal behavior.

Is reliability good?

Could be said to be as all same diagnosis but did not have it

What was the aim of his second study?

To investigate if we could reverse the tendency to diagnose sane as insane.

Why did a second experiment take place?

They said that the results in the first one would not happen in theirs.

What did Rosenhan inform the hospital in experiment two?

That he would send one or more pseudopatients in over the course of three months

What were the staff asked to do in experiment-two?

Rate patients on a scale of 1-10 of how real they were (1 being fake)

How many patients tried to gain admission during experiment two?

How many patients did Rosenhan send in for the second experiment?

How many patients did they judge as fake in the second experiment?

How many did one psychiatrist suspect in the experiment two?

Twenty-three

What is the conclusion?

The results show issues with the reliability and validity of diagnosis and strongly suggest that it is not possible to detect the sane from the insane, as staff members could not identify that none of the patients were pseudopatients

What do the results show?

Issues with reliability and validity

When did the study take place?

•   Gaughwin, Peter (2011). “On Being Insane in Medico-Legal Places: The Importance of Taking a Complete History in Forensic Mental Health Assessment”. Psychiatry, Psychology, and Law. 12(1): 298–310. doi:10.1375/pplt.12.2.298. S2CID 53771539.
• Rosenhan, David (19 January 1973). “On being sane in insane places”. Science. 179 (4070): 250–258. Bibcode:1973Sci...179..250R. doi:10.1126/science.179.4070.250. PMID 4683124. S2CID 146772269. Archived from the original on 17 November 2004.
• Slater, Lauren (2004). Opening Skinner’s Box: Great Psychological Experiments of the Twentieth Century. W. W. Norton. ISBN 0-393-05095-5.
• Kornblum, William (2011). Mitchell, Erin; Jucha, Robert; Chell, John (eds.). Sociology in a Changing World (Google Books)(9th ed.). Cengage learning. p. 195. ISBN 978-1-111-30157-6.
• Spitzer, Robert (October 1975). “On pseudoscience in science, logic in remission, and psychiatric diagnosis: a critique of Rosenhan’s “On being sane in insane places””. Journal of Abnormal Psychology. 84 (5): 442–52. doi:10.1037/h0077124. PMID 1194504. S2CID 8688334.
• Abbott, Alison (29 October 2019). “On the troubling trail of psychiatry’s pseudopatients stunt”. Nature. 574 (7780): 622–623. Bibcode:2019Natur.574..622A. doi:10.1038/d41586-019-03268-y. “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.
• Temerlin, Maurice (October 1968). “Suggestion effects in psychiatric diagnosis”. The Journal of Nervous and Mental Disease. 147 (4): 349–353.  doi:10.1097/00005053-196810000-00003 . PMID 5683680. S2CID 36672611.
• Loring, Marti; Powell, Brian (March 1988). “Gender, race, and DSM-III: a study of the objectivity of psychiatric diagnostic behavior”. Journal of Health and Social Behavior. 29 (1): 1–22. doi:10.2307/2137177. JSTOR 2137177. PMID 3367027.
• Moran, Mark (7 April 2006). “Writer Ignites Firestorm With Misdiagnosis Claims”. Psychiatric News. American Psychiatric Association. 41 (7): 10–12. doi:10.1176/pn.41.7.0010. ISSN 1559-1255.

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REPLICATING ROSENHAN’S STUDY: A METHODOLOGICAL AND ETHICAL ARGUMENT AND PROPOSAL

• Posted by Alan Eppel
• Posted in Ethics

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Experimento de rosenhan

El experimento de Rosenhan o experimento de Thud fue un experimento realizado para determinar la validez del diagnóstico psiquiátrico. Los participantes se sometieron a evaluación en diversas instituciones psiquiátricas y fingieron alucinaciones para ser aceptados, pero a partir de entonces actuaron con normalidad. A cada uno se le diagnosticó un trastorno psiquiátrico y se le administró medicación antipsicótica. El estudio fue realizado por el psicólogo David Rosenhan, profesor de la Universidad de Stanford, y publicado por la revista Science en 1973 con el título "Sobre estar cuerdo en lugares insanos".

Se considera una crítica importante e influyente al diagnóstico psiquiátrico y aborda el tema del internamiento involuntario injusto. Rosenhan junto con otras ocho personas (cinco hombres y tres mujeres) ingresaron en 12 hospitales en cinco estados de la costa oeste de Estados Unidos. Tres de los participantes fueron admitidos sólo por un corto período de tiempo y, para obtener suficientes experiencias documentadas, volvieron a postularse a instituciones adicionales. Sin embargo, en 2019, la autora Susannah Cahalan publicó un libro acusando todo el experimento de ser un engaño.

Experimento de pseudopaciente

Rosenhan describió su estudio en dos partes. La primera parte implicó el uso de asociados sanos o "pseudopacientes" (tres mujeres y seis hombres, incluido el propio Rosenhan) que fingieron brevemente alucinaciones auditivas en un intento de ser admitidos en 12 hospitales psiquiátricos en cinco estados de Estados Unidos. Todos fueron ingresados y diagnosticados con trastornos psiquiátricos. Después del ingreso, los pseudopacientes actuaron con normalidad y dijeron al personal que ya no experimentaban más alucinaciones. Como condición para su liberación, todos los pacientes fueron obligados a admitir que padecían una enfermedad mental y aceptar tomar medicamentos antipsicóticos. El tiempo medio que los pacientes pasaron en el hospital fue de 19 días. A todos menos uno se les diagnosticó esquizofrenia "en remisión" antes de su liberación.

La segunda parte de su estudio involucró a la administración de un hospital desafiando a Rosenhan a enviar pseudopacientes a sus instalaciones, cuyo personal afirmó que serían capaces de detectar a los pseudopacientes. Rosenhan estuvo de acuerdo y en las semanas siguientes, 41 de 193 nuevos pacientes fueron identificados como pseudopacientes potenciales, y 19 de ellos recibieron sospechas de al menos un psiquiatra y otro miembro del personal. Rosenhan no envió ningún pseudopaciente al hospital.

Mientras escuchaba una conferencia de R. D. Laing, asociado con el movimiento antipsiquiátrico, Rosenhan concibió el experimento como una forma de probar la confiabilidad de los diagnósticos psiquiátricos. El estudio concluyó que "está claro que no podemos distinguir a los cuerdos de los locos en los hospitales psiquiátricos". y también ilustró los peligros de la deshumanización y el etiquetado en las instituciones psiquiátricas. Sugirió que una solución podría ser el uso de centros comunitarios de salud mental que se concentraran en problemas y comportamientos específicos en lugar de etiquetas psiquiátricas, y recomendó educación para que los trabajadores psiquiátricos fueran más conscientes de la psicología social de sus centros.

El propio Rosenhan y siete asociados mentalmente sanos, llamados "pseudopacientes", intentaron ser admitidos en hospitales psiquiátricos solicitando una cita y fingiendo alucinaciones auditivas. El personal del hospital no fue informado del experimento. Los pseudopacientes incluían un estudiante de psicología de unos veinte años, tres psicólogos, un pediatra, un psiquiatra, un pintor y un ama de casa. Ninguno tenía antecedentes de enfermedad mental. Los seudopacientes utilizaban seudónimos y a quienes trabajaban en el campo de la salud mental se les asignaban trabajos falsos en un sector diferente para evitar invocar ningún tratamiento o escrutinio especial. Además de dar nombres falsos y detalles laborales, se informaron verazmente más detalles biográficos.

Durante su evaluación psiquiátrica inicial, los pseudopacientes afirmaron haber escuchado voces del mismo sexo que el paciente, que a menudo eran confusas, pero que parecían pronunciar las palabras "vacío", "hueco" 34;, o "ruido sordo", y nada más. Se eligieron estas palabras porque sugieren vagamente algún tipo de crisis existencial y por la falta de literatura publicada que se refiera a ellas como síntomas psicóticos. No se afirmaron otros síntomas psiquiátricos. Si eran admitidos, los pseudopacientes recibían instrucciones de "actuar normalmente", informando que se sentían bien y que ya no escuchaban voces. Los registros hospitalarios obtenidos después del experimento indican que el personal caracterizó a todos los pseudopacientes como amigables y cooperativos.

Todos fueron admitidos en 12 hospitales psiquiátricos en todo Estados Unidos, incluidos hospitales públicos deteriorados y con fondos insuficientes en áreas rurales, hospitales urbanos administrados por universidades con excelente reputación y un hospital privado costoso. Aunque presentaban síntomas idénticos, siete fueron diagnosticados con esquizofrenia en hospitales públicos y uno con psicosis maníaco-depresiva, un diagnóstico más optimista y con mejores resultados clínicos, en el hospital privado. Sus estancias oscilaron entre 7 y 52 días, siendo la media de 19 días. Todos menos uno fueron dados de alta con un diagnóstico de esquizofrenia "en remisión", lo que Rosenhan consideró como evidencia de que la enfermedad mental se percibe como una condición irreversible que crea un estigma de por vida en lugar de una enfermedad curable.

A pesar de tomar constante y abiertamente notas exhaustivas sobre el comportamiento del personal y de otros pacientes, ninguno de los pseudopacientes fue identificado como impostor por el personal del hospital, aunque muchos de los otros pacientes psiquiátricos parecieron poder identificarlos correctamente como impostores.. En las tres primeras hospitalizaciones, 35 del total de 118 pacientes expresaron sospechas de que los pseudopacientes estaban cuerdos, y algunos sugirieron que los pacientes eran investigadores o periodistas que investigaban el hospital. Las notas del hospital indicaron que el personal interpretó gran parte de las respuestas de los pseudopacientes. comportamiento en términos de enfermedad mental. Por ejemplo, una enfermera calificó la toma de notas de un pseudopaciente como "comportamiento de escritura"; y lo consideró patológico. Los pacientes' Las biografías normales se reformularon en los registros hospitalarios siguiendo las líneas de lo que se esperaba de los esquizofrénicos según las teorías entonces dominantes sobre su causa.

El experimento requirió que los pseudopacientes salieran del hospital por su cuenta haciendo que el hospital los diera de alta, aunque se contrató a un abogado para que estuviera de guardia en caso de emergencia cuando quedó claro que los pseudopacientes nunca serían dados de alta voluntariamente. corto plazo. Una vez ingresados y diagnosticados, los pseudopacientes no pudieron obtener su alta hasta que acordaron con los psiquiatras que padecían una enfermedad mental y comenzaron a tomar medicamentos antipsicóticos, que tiraron por el inodoro. Ningún miembro del personal informó que los pseudopacientes estuvieran tirando sus medicamentos por los inodoros.

Rosenhan y los otros pseudopacientes informaron de una abrumadora sensación de deshumanización, grave invasión de la privacidad y aburrimiento mientras estaban hospitalizados. Se registraron sus pertenencias al azar y, en ocasiones, se les observó mientras utilizaban el baño. Informaron que, aunque el personal parecía tener buenas intenciones, en general objetivaban y deshumanizaban a los pacientes, a menudo hablaban extensamente de ellos en su presencia como si no estuvieran allí y evitaban la interacción directa con los pacientes excepto cuando era estrictamente necesario para realizar tareas oficiales.. Algunos asistentes eran propensos a abusar verbal y físicamente de los pacientes cuando el resto del personal no estaba presente. Un médico dijo a sus alumnos que un grupo de pacientes que esperaban afuera de la cafetería media hora antes de la hora del almuerzo estaban experimentando una sensación de "oral-adquisitiva" síntomas psiquiátricos. El contacto con los médicos promedió 6,8 minutos por día.

Experimento impostor inexistente

Para este experimento, Rosenhan utilizó un conocido hospital universitario y de investigación, cuyo personal había oído hablar de los resultados del estudio inicial pero afirmó que no se podían cometer errores similares en su institución. Rosenhan acordó con ellos que durante un período de tres meses, uno o más pseudopacientes intentarían ser admitidos y el personal calificaría a cada paciente entrante según la probabilidad de que fuera un impostor. De 193 pacientes, 41 fueron considerados impostores y otros 42 sospechosos. En realidad, Rosenhan no había enviado ningún pseudopaciente; Todos los pacientes sospechosos de impostores por el personal del hospital eran pacientes comunes y corrientes. Esto llevó a la conclusión de que "cualquier proceso de diagnóstico que se preste demasiado fácilmente a errores masivos de este tipo no puede ser muy confiable".

Rosenhan publicó sus hallazgos en Science , en los que criticó la confiabilidad del diagnóstico psiquiátrico y la naturaleza degradante y desempoderadora de la atención al paciente experimentada por los asociados en el estudio. Además, describió su trabajo en diversas apariciones en noticias, incluida la BBC:

Le dije a mis amigos: "Puedo salir cuando pueda salir. Eso es todo. Estaré allí un par de días y saldré". Nadie sabía que estaría allí por dos. meses ... La única manera de salir era señalar que son correctos. Dijeron que estaba loco, "Yo am loco, pero me estoy poniendo mejor". Esa fue una afirmación de su opinión sobre mí.

The experiment is argued to have "accelerated the movement to reform mental institutions and to deinstitutionalize as many mental patients as possible in#34;.

Muchos de los que respondieron a la publicación defendieron la psiquiatría, argumentando que como el diagnóstico psiquiátrico depende en gran medida del informe del paciente sobre sus experiencias, fingir su presencia no demuestra más problemas con el diagnóstico psiquiátrico que mentir sobre otros síntomas médicos. En este sentido, el psiquiatra Robert Spitzer citó a Seymour S. Kety en una crítica de 1975 al estudio de Rosenhan:

Si bebiera un litro de sangre y, ocultando lo que había hecho, llegara a la sala de emergencias de cualquier hospital vomitando sangre, el comportamiento del personal sería bastante predecible. Si me etiquetan y me tratan como tener una úlcera péptica sangrante, dudo que pueda argumentar convincentemente que la ciencia médica no sabe diagnosticar esa condición.

Kety también argumentó que no necesariamente se debe esperar que los psiquiatras asuman que un paciente finge tener una enfermedad mental, por lo que el estudio carecía de realismo. Rosenhan llamó a esto el "efecto experimentador" o "sesgo de expectativa", algo indicativo de los problemas que descubrió más que un problema en su metodología.

Acusación de engaño

En The Great Pretender , un libro de 2019 sobre Rosenhan, la autora Susannah Cahalan cuestiona la veracidad y validez del experimento de Rosenhan. Al examinar los documentos que dejó Rosenhan después de su muerte, Cahalan encuentra una aparente distorsión en el artículo de Science : datos inconsistentes, descripciones engañosas y citas inexactas o inventadas de registros psiquiátricos. Además, a pesar de una búsqueda exhaustiva, sólo puede identificar a dos de los ocho pseudopacientes: el propio Rosenhan y un estudiante de posgrado cuyo testimonio supuestamente no coincide con la descripción de Rosenhan en el artículo. A la luz de la aparente voluntad de Rosenhan de tergiversar la verdad de otras maneras con respecto al experimento, Cahalan se pregunta si algunos o todos los otros seis pseudopacientes podrían haber sido simplemente inventados por Rosenhan. En febrero de 2023, Andrew Scull, de la Universidad de California en San Diego, publicó un artículo en la revista revisada por pares History of Psychiatry en apoyo de las acusaciones de Cahalan.

Experimentos relacionados

En 1887, la periodista de investigación estadounidense Nellie Bly fingió síntomas de una enfermedad mental para ser admitida en un manicomio e informar sobre las terribles condiciones que allí se encontraban. Los resultados se publicaron como Diez días en un manicomio .

En 1968, Maurice K. Temerlin dividió a 25 psiquiatras en dos grupos y les hizo escuchar a un actor que interpretaba a un personaje con una salud mental normal. A un grupo le dijeron que el actor "era un hombre muy interesante porque parecía neurótico, pero en realidad era bastante psicótico". mientras que al otro no le dijeron nada. El sesenta por ciento del primer grupo diagnosticó psicosis, con mayor frecuencia esquizofrenia, mientras que ninguno del grupo de control lo hizo.

En 1988, Loring y Powell dieron a 290 psiquiatras una transcripción de una entrevista con un paciente y les dijeron a la mitad de ellos que el paciente era negro y la otra mitad blanco; De los resultados concluyeron que "los médicos parecen atribuir violencia, desconfianza y peligrosidad a los clientes negros a pesar de que los estudios de caso son los mismos que los de los clientes blancos".

En 2004, la psicóloga Lauren Slater afirmó haber realizado un experimento muy similar al de Rosenhan para su libro Abriendo la caja de Skinner . Slater escribió que se había presentado en 9 salas de emergencia psiquiátricas con alucinaciones auditivas, por lo que le diagnosticaron "casi todas las veces" con depresión psicótica. Sin embargo, cuando se le pidió que proporcionara pruebas de que realmente había realizado su experimento, no pudo. Las serias preocupaciones metodológicas y de otro tipo con respecto al trabajo de Slater aparecieron como una serie de respuestas a un informe de una revista, en la misma revista.

En 2008, el programa científico Horizon de la BBC realizó un experimento similar en dos episodios titulado "How Mad Are You?". En el experimento participaron diez sujetos, cinco con problemas de salud mental previamente diagnosticados y cinco sin dicho diagnóstico. Fueron observados por tres expertos en diagnósticos de salud mental y su desafío fue identificar a los cinco con problemas de salud mental únicamente a partir de su comportamiento, sin hablar con los sujetos ni conocer nada de sus historias. Los expertos diagnosticaron correctamente a dos de los diez pacientes, diagnosticaron erróneamente a un paciente e identificaron incorrectamente a dos pacientes sanos con problemas de salud mental. Sin embargo, a diferencia de los otros experimentos enumerados aquí, el objetivo de este ejercicio periodístico no fue criticar el proceso de diagnóstico, sino minimizar la estigmatización de los enfermos mentales. Su objetivo era ilustrar que las personas con un diagnóstico previo de una enfermedad mental podían vivir una vida normal sin que sus problemas de salud fueran evidentes para los observadores a partir de su comportamiento.

Contenido relacionado

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Title: can llms generate novel research ideas a large-scale human study with 100+ nlp researchers.

Abstract: Recent advancements in large language models (LLMs) have sparked optimism about their potential to accelerate scientific discovery, with a growing number of works proposing research agents that autonomously generate and validate new ideas. Despite this, no evaluations have shown that LLM systems can take the very first step of producing novel, expert-level ideas, let alone perform the entire research process. We address this by establishing an experimental design that evaluates research idea generation while controlling for confounders and performs the first head-to-head comparison between expert NLP researchers and an LLM ideation agent. By recruiting over 100 NLP researchers to write novel ideas and blind reviews of both LLM and human ideas, we obtain the first statistically significant conclusion on current LLM capabilities for research ideation: we find LLM-generated ideas are judged as more novel (p < 0.05) than human expert ideas while being judged slightly weaker on feasibility. Studying our agent baselines closely, we identify open problems in building and evaluating research agents, including failures of LLM self-evaluation and their lack of diversity in generation. Finally, we acknowledge that human judgements of novelty can be difficult, even by experts, and propose an end-to-end study design which recruits researchers to execute these ideas into full projects, enabling us to study whether these novelty and feasibility judgements result in meaningful differences in research outcome.

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Trust in artificial intelligence

2023 global study on the shifting public perceptions of AI.

• Our insights

Artificial Intelligence (AI) is transforming the way work is done and how services are delivered. Organizations are leveraging the remarkable power of AI to improve data-based predictions, optimize products and services, augment innovation, enhance productivity and efficiency and lower costs. However, AI adoption also poses risks and challenges, raising concerns about whether AI use today is truly trustworthy.

Realizing the potential benefits of AI, and a return on investment, requires a clear and sustained focus on maintaining the public’s trust. To drive adoption, people need to be confident that AI is being developed and used in a responsible and trustworthy manner.

In collaboration with the University of Queensland, KPMG Australia led the world-first deep dive into trust and global attitudes towards AI across 17 countries. Trust in artificial intelligence: A global study 2023 provides broad-ranging global insights into the drivers of trust, the perceived risks and benefits of AI use, community expectations of governance of AI and who is trusted to develop, use and govern AI.

This report,  Trust in artificial intelligence: 2023 global study on the shifting public perceptions of AI,   highlights key findings from the global study and provides individual country snapshots which should be instructive to those involved in leading, creating or governing AI systems. Importantly, four critical pathways are highlighted for policymakers, standards setters, governments, businesses and NGOs to consider as they navigate the trust challenges in AI development and deployment.

Explore the global key findings on the shifting public perceptions of AI

Ai trust and acceptance.

Most people are wary about trusting AI systems and have low or moderate acceptance of AI. Trust and acceptance depend on the AI application.

• Three in five  (61 percent) are wary about trusting AI systems.
• 67 percent  report low to moderate acceptance of AI.
• AI use in human resources is the  least trusted  and accepted, while AI use in healthcare is the  most trusted  and accepted.
• People in emerging economies  are more trusting, accepting and positive about AI than people in other countries.

Potential AI benefits and risk

People recognize AI’s many benefits, but only half believe the benefits outweigh the risks. People perceive AI risks in a similar way across countries, with cybersecurity rated as the top risk globally.

• 85 percent  believe AI results in a range of benefits.
• Yet only half  of respondents believe the benefits of AI outweigh the risks.
• Top concern  is cybersecurity risk at 84 percent.

Who's trusted to develop and govern AI

People are most confident in universities and defense organizations to develop, use and govern AI and they are least confident in government and commercial organizations.

• 76 to 82 percent  confidence in national universities, research institutions and defense organizations to develop, use and govern AI in the best interest of the public.
• One-third  of respondents lack confidence in government and commercial organizations to develop, use and govern AI.

Responsible AI

There is strong global endorsement for principles that define trustworthy AI. Trust is contingent on assuring such principles are in place. People expect AI to be regulated with external, independent oversight — and they view current regulations and safeguards as inadequate.

• 97 percent  strongly endorse the principles for trustworthy AI.
• Three in four  would be more willing to trust an AI system when assurance mechanisms are in place.
• 71 percent  expect AI to be regulated.

AI in the workplace

Most people are comfortable using AI to augment work and inform managerial decision-making but want humans to retain control.

• About half  are willing to trust AI at work.
• Most people  are uncomfortable with or unsure about AI use for HR and people management.
• Two in Five  believe AI will replace jobs in their area of work.
• Younger people,  the university educated and managers are more trusting of AI at work.

People want to learn more about AI but currently have a low understanding. Those who understand AI better are more likely to trust it and perceive greater benefits.

• Half  of respondents feel they don’t understand AI or when and how it’s used.
• 45 percent  don’t know AI is used in social media.
• 85 percent  want to know more about AI.

About the study

This survey is the first deep-dive global examination of the public’s trust and attitudes towards AI use, and their expectations of its management and governance.

KPMG Australia worked with The University of Queensland to survey over 17,000 people from 17 countries leading in AI activity and readiness within each region: Australia, Brazil, Canada, China, Estonia, Finland, France, Germany, India, Israel, Japan, the Netherlands, Singapore, South Africa, South Korea, the United Kingdom, and the United States of America.

University of Queensland Researchers

Professor Nicole Gillespie, Dr Steve Lockey, Dr Caitlin Curtis and Dr Javad Pool. The University of Queensland team led the design, conduct, analysis and reporting of this research.

KPMG Australia

James Mabbott (Partner), Rita Fentener van Vlissingen (Associate Director, KPMG), Jessica Wyndham (Associate Director), and Richard Boele (Partner).

Acknowledgements

We are grateful for the insightful input, expertise and feedback on this research provided by Dr Ali Akbari, Dr Ian Opperman, Rossana Bianchi, Professor Shazia Sadiq, Mike Richmond, and Dr Morteza Namvar, and members of the Trust, Ethics and Governance Alliance at The University of Queensland, particularly Dr Natalie Smith, Associate Professor Martin Edwards, Dr Shannon Colville and Alex Macdade.

Our Insights

Trust in artificial intelligence: global insights 2023.

Global survey results exploring people’s trust in AI, responsible AI, expectations of AI governance, and benefits and risks for business and society.

Achieving Trustworthy AI: A Model for Trustworthy Artificial Intelligence

This KPMG and University of Queensland report provides an integrative model for organisations looking to design and deploy trustworthy AI systems.

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Europeans Used Cocaine Much Earlier Than Previously Thought, Study Finds

In human remains buried in an Italian crypt, researchers found evidence of cocaine use from the 17th century.

By Alexander Nazaryan

Descending for the first time into the large, vaulted crypt of a centuries-old hospital in Milan in 2019, Gaia Giordano grew overwhelmed.

“You see a floor of bone, full of bones,” said Ms. Giordano, a graduate student at the University of Milan.

In the 1600s, the crypt essentially served as a subterranean potter’s field for thousands of poor Milanese people who had sought help at the Ca’ Granda hospital. From that ancient burial ground, Ms. Giordano uncovered a surprising twist in the history of the European drug trade.

After analyzing the skulls and brain tissue of nine people who were buried there in the mid-1600s, Ms. Giordano and her collaborators found that two had most likely been using cocaine. The findings, reported in the October issue of the Journal of Archaeological Science, offer the earliest evidence of cocaine use in premodern Europe — some 200 years before a German chemist isolated the drug from the coca plant.

The findings suggest that the Milanese people had access to the same coca leaves that ancient South American civilizations had long used as a pain reliever, energy booster and appetite suppressant.

“We have evidence of coca leaves being used thousands of years ago,” said Christine VanPool, an anthropologist at the University of Missouri. No one knows exactly how or when coca reached Europeans. But Dr. VanPool believes that Spanish colonizers in South America may have been attracted to cocaine’s analgesic properties.

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Delaware is one of the worst states to move to, study says. Is this true?

Delawareans may see the First State as the best place to live, and it’s known as a retirement haven to many, but a new study paints Delaware as one of the worst states to move to. 

Here’s how the study defends its low ranking of Delaware.  

Worst states to move to 

Manifest Law, an employment and immigration law firm, conducted a study to determine which states are the worst to immigrate to in the United States.

Fifty factors – including crimes, disposable income and pupil-to-teacher ratios – were grouped into the categories of crime and arrests (weighted at 15.41%); economic indicators (23.71%); educational indicators (18.86%); housing availability and costs (19.4%); living costs (14.01%); and safety and infrastructure (8.62%). Each factor was scaled individually from 0 to 10, with the total score of each factor calculated per weighted category, resulting in the final ranking for each state. Negative variables like crime and arrests and living costs were inverted, meaning a higher rank is better, according to Manifest Law.  

The study places Delaware as the ninth worst state to immigrate to in the U.S., scoring a 48.4 out of 100.  

Delaware ranks above average in the categories of economic indicators (in 20th place) and safety and infrastructure (in 17th place). Despite these higher scores, Delaware’s overall ranking is brought down by low performances in the categories of educational indicators (placing at No. 46) and living costs (placing at No. 44). 

Photo-worthy views in Delaware: Of the 100 most breathtaking views in America, 2 are in Delaware. Have you seen them?

The other top 10 worst states to move to are:  

• Hawaii at No. 1, with a score of 38.29  
• Mississippi at No. 2, with a score of 42.10
• Louisiana at No. 3, with a score of 43.96
• New Mexico at No. 4, with a score of 44.65
• South Carolina at No. 5, with a score of 44.77 
• Nevada at No. 6, with a score of 47.11
• Arizona at No. 7, with a score of 47.21
• Arkansas at No. 8, with a score of 48.02
• California at No. 10, with a score of 48.22

The top 10 best states to immigrate to, according to Manifest Law, are:  

• Wyoming at No. 1, with a score of 66.77
• Minnesota at No. 2, with a score of 65.92
• Illinois at No. 3, with a score of 64.79
• North Dakota at No. 4, with a score of 64.07
• Iowa at No. 5, with a score of 63.80
• Nebraska at No. 6, with a score of 63.60
• Washington at No. 7, with a score of 62.84
• Connecticut at No. 8, with a score of 62.19
• New Hampshire at No. 9, with a score of 61.76
• South Dakota at No. 10, with a score of 61.83

Got a tip or a story idea? Contact Krys'tal Griffin at [email protected].   

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The world is pumping out 57 million tons of plastic pollution a year

A new study finds that every year people create 57 million tons of plastic pollution. The material ends up everywhere, from the deepest oceans to the highest peak to inside people’s bodies. More than two-thirds of it is in the Global South. (AP Video: Teresa de Miguel)

FILE - A man walks on a railway track littered with plastic and other waste materials on Earth Day in Mumbai, India, April 22, 2024. (AP Photo/Rafiq Maqbool, File)

FILE - City workers remove garbage floating on the Negro River, which has a rising water level due to rain, in Manaus, Amazonas state, Brazil, June 6, 2022. (AP Photo/Edmar Barros, File)

FILE - A volunteer stands on top of a pile of rubbish collected that day while participating in the Plastic Cup event near Tiszaroff, Hungary, Aug. 2, 2023. (AP Photo/Denes Erdos, File)

FILE - A volunteer picks up trash on a river which is covered with trash at Pecatu, Bali, Indonesia, March 22, 2024. (AP Photo/Firdia Lisnawati, File)

FILE - Nina Gomes recovers a discarded plastic bag from ocean waters, near Copacabana beach in Rio de Janeiro, Brazil, March 19, 2024. (AP Photo/Bruna Prado, File)

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The world creates 57 million tons of plastic pollution every year and spreads it from the deepest oceans to the highest mountaintop to the inside of people’s bodies, according to a new study that also said more than two-thirds of it comes from the Global South.

It’s enough pollution each year — about 52 million metric tons — to fill New York City’s Central Park with plastic waste as high as the Empire State Building, according to researchers at the University of Leeds in the United Kingdom. They examined waste produced on the local level at more than 50,000 cities and towns across the world for a study in Wednesday’s journal Nature.

The study examined plastic that goes into the open environment, not plastic that goes into landfills or is properly burned. For 15% of the world’s population, government fails to collect and dispose of waste, the study’s authors said — a big reason Southeast Asia and Sub-Saharan Africa produce the most plastic waste. That includes 255 million people in India, the study said.

Lagos, Nigeria, emitted the most plastic pollution of any city, according to study author Costas Velis, a Leeds environmental engineering professor. The other biggest plastic polluting cities are New Delhi; Luanda, Angola; Karachi, Pakistan and Al Qahirah, Egypt.

India leads the world in generating plastic pollution, producing 10.2 million tons a year (9.3 million metric tons), far more than double the next big-polluting nations, Nigeria and Indonesia. China, often villainized for pollution, ranks fourth but is making tremendous strides in reducing waste, Velis said. Other top plastic polluters are Pakistan, Bangladesh, Russia and Brazil. Those eight nations are responsible for more than half of the globe’s plastic pollution, according to the study’s data.

The United States ranks 90th in plastic pollution with more than 52,500 tons (47,600 metric tons) and the United Kingdom ranks 135th with nearly 5,100 tons (4,600 metric tons), according to the study.

In 2022, most of the world’s nations agreed to make the first legally binding treaty on plastics pollution, including in the oceans. Final treaty negotiations take place in South Korea in November.

The study used artificial intelligence to concentrate on plastics that were improperly burned — about 57% of the pollution — or just dumped. In both cases incredibly tiny microplastics, or nanoplastics, are what turn the problem from a visual annoyance at beaches and a marine life problem to a human health threat, Velis said.

Several studies this year have looked at how prevalent microplastics are in our drinking water and in people’s tissue, such as hearts , brains and testicles , with doctors and scientists still not quite sure what it means in terms of human health threats.

“The big time bomb of microplastics are these microplastics released in the Global South mainly,” Velis said. “We already have a huge dispersal problem. They are in the most remote places ... the peaks of Everest , in the Mariana Trench in the ocean, in what we breathe and what we eat and what we drink.”

He called it “everybody’s problem” and one that will haunt future generations.

“We shouldn’t put the blame, any blame, on the Global South,” Velis said. “And we shouldn’t praise ourselves about what we do in the Global North in any way.”

It’s just a lack of resources and ability of government to provide the necessary services to citizens, Velis said.

Outside experts worried that the study’s focus on pollution, rather than overall production, lets the plastics industry off the hook. Making plastics emits large amounts of greenhouse gas that contribute to climate change .

“These guys have defined plastic pollution in a much narrower way, as really just macroplastics that are emitted into the environment after the consumer, and it risks us losing our focus on the upstream and saying, hey now all we need to do is manage the waste better,” said Neil Tangri, senior director of science and policy at GAIA, a global network of advocacy organizations working on zero waste and environmental justice initiatives. “It’s necessary but it’s not the whole story.”

Theresa Karlsson, science and technical advisor to International Pollutants Elimination Network, another coalition of advocacy groups on environment, health and waste issues, called the volume of pollution identified by the study “alarming” and said it shows the amount of plastics being produced today is “unmanageable.”

But she said the study misses the significance of the global trade in plastic waste that has rich countries sending it to poor ones. The study said plastic waste trade is decreasing, with China banning waste imports. But Karlsson said overall waste trade is actually increasing and likely plastics with it. She cited EU waste exports going from 110,000 tons (100,000 metric tons) in 2004 to 1.4 million tons (1.3 million metric tons) in 2021.

Velis said the amount of plastic waste traded is small. Kara Lavender Law, an oceanography professor at the Sea Education Association who wasn’t involved in the study, agreed, based on U.S. plastic waste trends. She said this was otherwise one of the more comprehensive studies on plastic waste.

Officials in the plastics industry praised the study.

“This study underscores that uncollected and unmanaged plastic waste is the largest contributor to plastic pollution and that prioritizing adequate waste management is critical to ending plastic pollution,” Chris Jahn, council secretary of the International Council on Chemical Associations, said in a statement. In treaty negotiations, the industry opposes a cap on plastic production.

The United Nations projects that plastics production is likely to rise from about 440 million tons (400 million metric tons) a year to more than 1,200 million tons (1,100 million metric tons, saying “our planet is choking in plastic.”

Jennifer McDermott contributed from Providence, Rhode Island.

Follow Seth Borenstein on X at @borenbears

Read more of AP’s climate coverage at http://www.apnews.com/climate-and-environment

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