In the late 1960s, David Rosenhan sent sane volunteers into psychiatric hospitals across America to see whether doctors could tell who was truly ill.
Getting admitted turned out to be the easy part. Decades later, a journalist digging into his famous study found that his own account of it might not have been quite as he presented it...
[00:00:04] Hello, hello, hello, and welcome to English Learning for Curious Minds, by Leonardo English, the show where you can listen to fascinating stories and learn weird and wonderful things about the world at the same time as improving your English.
[00:00:21] I'm Alastair Budge, and this is the final part of our three-part mini-series on The Dark Side of Psychology.
[00:00:29] In part one, we looked at the Milgram experiment, and what it suggested about how ordinary people behave when an authority figure tells them to do harm.
[00:00:40] In part two, we turned to the work of Harry Harlow, the psychologist whose disturbing monkey experiments transformed our understanding of love.
[00:00:51] And today, in part three, we travel to early 1970s America for one of the most controversial studies in the history of psychiatry, both for what it revealed at the time, and for what a journalist revealed about it almost fifty years later.
[00:01:08] This is the story of The Rosenhan Experiment.
[00:01:13] "Thud" is the word we use in English to describe the sound a heavy object makes when it hits something else. It isn't a loud noise. It's different from a crash or a bang. It's a dull sound, the kind of sound a body might make if it hits the floor.
[00:01:36] And in 1969, a man in his late thirties walked up to the reception desk of a psychiatric hospital on the East Coast of the United States. He was clean and well-dressed. He seemed articulate. He gave his name as David Lurie, and explained that he had been hearing a voice.
[00:02:01] It says only one word, he told the receptionist.
[00:02:05] The word was "thud."
[00:02:09] Within hours, David Lurie was admitted to the hospital and diagnosed with schizophrenia.
[00:02:17] He would soon realise that getting in was the easy part.
[00:02:23] See, David Lurie was not a real person. The man's real name was David Rosenhan, and he was a Stanford psychology professor.
[00:02:35] He was one of eight perfectly sane people who, between 1969 and 1972, would talk their way into psychiatric hospitals across the United States, in order to find out what happened on the other side of the doors.
[00:02:54] Now, throughout history, societies across the world have dealt with people suffering from mental illnesses in different, often unkind, ways.
[00:03:06] In the United States, by the mid-1950s, there were around half a million people in psychiatric hospitals. Many had been there for years, even decades.
[00:03:19] Some had been committed by families who could not cope. Some had been committed by courts of law. Some had walked in voluntarily and never been allowed to leave.
[00:03:34] The diagnostic system that classified them was called the DSM-II, the Diagnostic and Statistical Manual of Mental Disorders, second edition.
[00:03:47] The idea behind it was to use a common language to diagnose someone with a mental disorder, so that it wasn't one psychiatrist's subjective opinion.
[00:04:00] To modern eyes, it is a strange document.
[00:04:04] The categories were vague and often overlapping. A patient diagnosed by one psychiatrist as schizophrenic might be diagnosed by another as manic-depressive, or as having a personality disorder, with no clear way of resolving the disagreement.
[00:04:24] And most famously, homosexuality was still listed as a mental disorder.
[00:04:32] The culture, meanwhile, had begun to question the assumed understanding of mental disorders.
[00:04:41] In 1962, Ken Kesey had published One Flew Over the Cuckoo's Nest, which became an Oscar-winning film in 1975.
[00:04:51] The Scottish psychiatrist R. D. Laing had argued that what we called schizophrenia was often a rational response to an intolerable family situation. The French philosopher Michel Foucault had published Madness and Civilisation, which was his history of how Western societies had used the diagnosis of madness as a tool of social control.
[00:05:18] In other words, people were getting more and more interested in the science behind mental illness, and more and more critical of the understanding of the day.
[00:05:30] And David Rosenhan was one of those people, someone who set out to conduct an experiment into mental illness. And specifically, whether psychiatric professionals at the time could distinguish between someone who was mentally ill and someone who was not.
[00:05:50] Rosenhan was a professor at Stanford, and an admired teacher. He was also, by all accounts, a charismatic and persuasive figure, the kind of man who could get other people to do unusual things for him.
[00:06:07] His experiment would go as follows. He would recruit a small group of so-called pseudopatients, people who were perfectly healthy but would present themselves at psychiatric hospitals.
[00:06:22] When they arrived, they would claim to hear voices.
[00:06:27] The voices, they would say, were unclear, but they could make out a single word. Either "thud," or "empty," or "hollow." That would be the only symptom they reported.
[00:06:43] In every other respect, their name, their occupation, their life's story, they would tell the truth.
[00:06:51] Eight pseudopatients took part.
[00:06:54] There was a psychology graduate student in his twenties, three psychologists, one of whom was Rosenhan himself, a paediatrician, a psychiatrist, a painter, and a housewife.
[00:07:07] Five men and three women.
[00:07:10] They presented themselves at twelve hospitals in five different states, on the East Coast and the West Coast, in old grand institutions and in shiny new ones. The idea was to get a representative cross-section.
[00:07:28] All eight were admitted.
[00:07:30] All but one were diagnosed with schizophrenia. The exception, at an expensive private hospital, was diagnosed with manic-depressive psychosis, which is the term for what we now call bipolar disorder.
[00:07:46] Once admitted, the rules were simple. They were to behave entirely normally. They were to drop the symptoms immediately. They were to be honest about everything, except the fact they had invented the voices in order to try to get into the hospital.
[00:08:04] The first real eye-opener for these pseudopatients was the hospitals themselves. They were strange places.
[00:08:14] The wards were enormously understaffed, with sometimes as few as one nurse for fifty patients.
[00:08:23] The staff rarely interacted with the patients beyond mealtimes and medication rounds.
[00:08:29] When they did interact, they often spoke as if the patients were not really there.
[00:08:36] One pseudopatient noted that a female nurse adjusted her bra in front of a day room full of male patients, with no apparent self-consciousness, as if they were furniture.
[00:08:50] Another noted that staff would walk straight past patients trying to talk to them, eyes fixed on the corridor ahead, pretending not to hear.
[00:09:01] The pseudopatients took continuous notes on what they observed. And they took these notes openly, sitting in the communal rooms with notebooks on their laps, talking to other patients and staff. None of the staff ever questioned this behaviour.
[00:09:19] But it did go into the patients' files. One nurse's note read, simply: "patient engages in writing behaviour", as if the act of writing had become a symptom of a mental disorder.
[00:09:34] Every interaction with staff was filtered through the diagnosis.
[00:09:40] A pseudopatient walking up and down the corridor was, according to one note, "pacing nervously." A pseudopatient who said he was bored was demonstrating "flat affect", which is when someone is unable to show outward emotion.
[00:09:57] And they found that getting themselves discharged was far harder than anticipated.
[00:10:05] A pseudopatient who asked when he could be discharged was being "uncooperative" or "denying his illness."
[00:10:14] Interestingly enough, the pseudopatients reported that the actual patients on the ward, the people with real mental illness, often saw through them immediately.
[00:10:26] "You're not crazy," one patient said to a pseudopatient on the third day. "You're a journalist, or a professor. You're checking up on the hospital."
[00:10:36] Of course, the patient, the one who was in the mental hospital, was right.
[00:10:43] Now, the pseudopatients did manage to get out eventually.
[00:10:47] They were detained for an average of nineteen days, with the longest stay being fifty-two days.
[00:10:55] They were given, between them, more than two thousand pills, which they secretly flushed down the toilet. And when they were eventually discharged, every single one was released with the same diagnosis: "schizophrenia in remission."
[00:11:15] They hadn't been cured, and there was no suggestion that the initial diagnosis had been incorrect. They were just temporarily not showing symptoms.
[00:11:27] The implication was devastating: the psychiatrists at twelve different hospitals had been unable to tell sane people from insane ones.
[00:11:39] Once they had been admitted, the pseudopatients could not get themselves out by behaving sanely, because every act of sanity was interpreted as a symptom of the illness they had been labelled with.
[00:11:53] It seemed like damning evidence that the prevailing diagnostic system was broken.
[00:12:01] In 1973, Rosenhan published his findings in the prestigious journal Science. The paper was titled "On Being Sane in Insane Places."
[00:12:14] And as you might imagine, it was a bombshell.
[00:12:19] After the publication, a well-known research and teaching hospital got in touch. Its staff had heard about Rosenhan's findings, and they were unimpressed. Nothing like that, they said, could happen at their institution.
[00:12:34] So Rosenhan proposed a test. Over the next three months, he would send pseudopatients to them. The staff were told to expect them, and every single person who came through the doors would be rated on a scale of one to ten, according to how likely they were to be a fake.
[00:12:57] Over those three months, 193 patients were admitted.
[00:13:03] Forty-one of them, more than one in five, were confidently identified as pseudopatients by at least one member of staff. Nineteen were suspected by a psychiatrist and a second member of staff.
[00:13:20] Then Rosenhan revealed that he had not sent a single pseudopatient.
[00:13:27] The reputation of American psychiatry took yet another battering. The paper was discussed in newspapers, on television and in medical journals.
[00:13:38] The American Psychiatric Association responded furiously, with established figures denouncing the study as methodologically flawed and morally questionable.
[00:13:51] But the damage was done.
[00:13:54] In 1980, the DSM, the framework and criteria for diagnosing mental illness, was updated again in the form of the DSM-III. The objective was to make sure that two psychiatrists examining the same patient would reach the same conclusion. The document came to four times the length of the DSM-II, its predecessor, and had specific, checklist-style criteria for every diagnosis.
[00:14:25] It wasn't perfect, of course, but it was a step forward.
[00:14:30] Now, this was part of a sweeping movement to change the treatment of people suffering from mental illness, a movement that had begun before Rosenhan.
[00:14:42] Specifically, there was a shift away from large state mental hospitals in favour of community-based care. Over the next two decades, hundreds of thousands of patients would be moved out of long-stay institutions.
[00:14:58] And as for Rosenhan, his study was taught as one of the foundational studies of social psychology to explain why the old asylum system had failed. It became part of the canon. It was cited thousands of times. The story of the eight pseudopatients was told and retold in textbooks and undergraduate lectures, and when Rosenhan died in 2012, he died a hero of modern psychiatry.
[00:15:30] But just a few years later came the twist: the study itself might not have happened, at least not in the way Rosenhan said it did.
[00:15:42] And this is thanks to the work of a woman called Susannah Cahalan.
[00:15:47] Now, Susannah Cahalan had no intention of "outing" Rosenhan. She had, herself, been the subject of a serious diagnostic failure.
[00:15:57] She was twenty-four years old at the time, and a successful young journalist at the New York Post.
[00:16:05] One day she started to feel strange.
[00:16:09] She became paranoid that her boyfriend was cheating on her. She became convinced that the people on television were sending her personal messages.
[00:16:18] Then came the seizures. She was sent to a psychiatrist who diagnosed her with bipolar disorder. Then with a psychotic episode. Then with schizophrenia. The doctors prepared paperwork to commit her to a psychiatric hospital.
[00:16:38] Her parents, in desperation, called in one more specialist, a neurologist.
[00:16:45] This neurologist asked her to draw a clock on a piece of paper. She drew all twelve numbers crammed onto the right side of the circle, leaving the left side completely blank.
[00:17:00] It was a classic sign of injury to one side of the brain. The autoimmune disease he then diagnosed was a condition that had only been identified in the medical literature a couple of years earlier. She got the right treatment, and she recovered fully. But without this diagnosis and this treatment, she would have been labelled as schizophrenic.
[00:17:25] The book she wrote about the experience, Brain on Fire, became a bestseller.
[00:17:31] She then intended to write a book about Rosenhan that celebrated him as a hero of American psychiatry, someone who had done invaluable work on how psychiatric patients are identified and diagnosed.
[00:17:47] So she set out to find the eight pseudopatients from the original study.
[00:17:53] But no matter how hard she looked, she could only find two of the original pseudopatients.
[00:18:01] Over years of investigation, working from Rosenhan's own papers, his correspondence, his notes, and the surviving medical records, she was able to confirm only Rosenhan himself and a graduate student named Bill Underwood.
[00:18:18] The remaining six pseudopatients were ghosts. There were references in the paper to a "Mrs. M." and a "Mr F" but no surviving record of who they actually were, or which hospitals they went to.
[00:18:33] Cahalan kept digging. She found Rosenhan's own admission record from Haverford State Hospital, the institution he had checked himself into.
[00:18:43] He had been admitted there. That was not up for debate. But the hospital records did not match his published account.
[00:18:52] According to Rosenhan, he had reported only the single word "thud."
[00:18:59] According to the actual medical chart, he had reported much more disturbing symptoms.
[00:19:05] He had said he could hear what other people were thinking. He had said he was sensitive to radio waves, and that he had tried to block the voices out by putting copper pots over his ears. He had said he had been having suicidal thoughts. And he had said all of this had been going on for months.
[00:19:26] These were not the symptoms of a man being unjustly admitted because of one ambiguous word.
[00:19:33] They were classic markers of severe psychiatric illness.
[00:19:39] Cahalan found Bill Underwood, the one other confirmed pseudopatient, and interviewed him.
[00:19:46] He was by then in his seventies.
[00:19:49] He remembered the experience vividly. The food, he said, was terrible. The boredom was overwhelming. He had written poems on toilet paper to pass the time. He had eventually got out only when his wife had come in with a lawyer, threatening legal action.
[00:20:06] The hospital had then released him, with the diagnosis "schizophrenia in remission."
[00:20:12] His account broadly matched what Rosenhan had described in the paper.
[00:20:16] But he was just one person.
[00:20:20] Cahalan, in fact, found a ninth person, someone who was sent to a hospital, but wasn't included in Rosenhan's paper because his experience of the hospital was actually very positive. It seemed that he'd been excluded because his case simply didn't match what Rosenhan had intended to show.
[00:20:42] Then there was the follow-up study, the one with the 41 false positives.
[00:20:47] Cahalan went looking for the hospital that had supposedly run it. She found references to it in Rosenhan's archives. But she could find no evidence that it had actually happened.
[00:21:01] The records did not exist. The staff who would have been involved had no memory of it. The newspaper coverage from the time, which would surely have noticed such a study, did not mention it.
[00:21:14] She also found something else. Rosenhan had become a celebrated figure on the back of the paper. He had been contracted to write a full book about the study, and paid a substantial advance. He had spent years promising to deliver the manuscript. But he'd never finished it.
[00:21:35] The publisher even sued him for the return of the advance. He died without ever explaining the eight pseudopatients.
[00:21:45] Cahalan's suspicion, which she hints at in her book, is that he could not.
[00:21:52] In the end, Cahalan concluded that Rosenhan had probably fabricated or substantially embellished much of his famous paper.
[00:22:01] Perhaps not all of it.
[00:22:03] The study had clearly involved at least two people, perhaps a few more.
[00:22:08] But the dramatic, twelve-hospital, eight-pseudopatient experiment that had reshaped psychiatry may never have happened, at least not as Rosenhan had described it.
[00:22:21] So where does this leave things, and what is the prevailing wisdom on Rosenhan and this experiment?
[00:22:28] Well, the Rosenhan study has not been fully discredited. It's possible some version of it happened. The questions it raised about diagnostic reliability were good questions. The reforms it helped produce, including the move to more specific diagnostic criteria, were arguably for the better.
[00:22:50] But the iconic version of the story, the one that was taught in every introductory psychology textbook for nearly half a century, was probably somewhere between "exaggerated" and, as one journal put it, "a spectacularly successful case of scientific fraud".
[00:23:11] OK, then, that is it for this episode, and with this comes an end to our three-part mini-series on The Dark Side of Psychology.
[00:23:20] I hope you enjoyed them, and that they shone a light on some unusual experiments into what makes us obey, love, and believe.
[00:23:28] You've been listening to English Learning for Curious Minds by Leonardo English.
[00:23:33] I'm Alastair Budge, you stay safe, and I'll catch you in the next episode.
[00:00:04] Hello, hello, hello, and welcome to English Learning for Curious Minds, by Leonardo English, the show where you can listen to fascinating stories and learn weird and wonderful things about the world at the same time as improving your English.
[00:00:21] I'm Alastair Budge, and this is the final part of our three-part mini-series on The Dark Side of Psychology.
[00:00:29] In part one, we looked at the Milgram experiment, and what it suggested about how ordinary people behave when an authority figure tells them to do harm.
[00:00:40] In part two, we turned to the work of Harry Harlow, the psychologist whose disturbing monkey experiments transformed our understanding of love.
[00:00:51] And today, in part three, we travel to early 1970s America for one of the most controversial studies in the history of psychiatry, both for what it revealed at the time, and for what a journalist revealed about it almost fifty years later.
[00:01:08] This is the story of The Rosenhan Experiment.
[00:01:13] "Thud" is the word we use in English to describe the sound a heavy object makes when it hits something else. It isn't a loud noise. It's different from a crash or a bang. It's a dull sound, the kind of sound a body might make if it hits the floor.
[00:01:36] And in 1969, a man in his late thirties walked up to the reception desk of a psychiatric hospital on the East Coast of the United States. He was clean and well-dressed. He seemed articulate. He gave his name as David Lurie, and explained that he had been hearing a voice.
[00:02:01] It says only one word, he told the receptionist.
[00:02:05] The word was "thud."
[00:02:09] Within hours, David Lurie was admitted to the hospital and diagnosed with schizophrenia.
[00:02:17] He would soon realise that getting in was the easy part.
[00:02:23] See, David Lurie was not a real person. The man's real name was David Rosenhan, and he was a Stanford psychology professor.
[00:02:35] He was one of eight perfectly sane people who, between 1969 and 1972, would talk their way into psychiatric hospitals across the United States, in order to find out what happened on the other side of the doors.
[00:02:54] Now, throughout history, societies across the world have dealt with people suffering from mental illnesses in different, often unkind, ways.
[00:03:06] In the United States, by the mid-1950s, there were around half a million people in psychiatric hospitals. Many had been there for years, even decades.
[00:03:19] Some had been committed by families who could not cope. Some had been committed by courts of law. Some had walked in voluntarily and never been allowed to leave.
[00:03:34] The diagnostic system that classified them was called the DSM-II, the Diagnostic and Statistical Manual of Mental Disorders, second edition.
[00:03:47] The idea behind it was to use a common language to diagnose someone with a mental disorder, so that it wasn't one psychiatrist's subjective opinion.
[00:04:00] To modern eyes, it is a strange document.
[00:04:04] The categories were vague and often overlapping. A patient diagnosed by one psychiatrist as schizophrenic might be diagnosed by another as manic-depressive, or as having a personality disorder, with no clear way of resolving the disagreement.
[00:04:24] And most famously, homosexuality was still listed as a mental disorder.
[00:04:32] The culture, meanwhile, had begun to question the assumed understanding of mental disorders.
[00:04:41] In 1962, Ken Kesey had published One Flew Over the Cuckoo's Nest, which became an Oscar-winning film in 1975.
[00:04:51] The Scottish psychiatrist R. D. Laing had argued that what we called schizophrenia was often a rational response to an intolerable family situation. The French philosopher Michel Foucault had published Madness and Civilisation, which was his history of how Western societies had used the diagnosis of madness as a tool of social control.
[00:05:18] In other words, people were getting more and more interested in the science behind mental illness, and more and more critical of the understanding of the day.
[00:05:30] And David Rosenhan was one of those people, someone who set out to conduct an experiment into mental illness. And specifically, whether psychiatric professionals at the time could distinguish between someone who was mentally ill and someone who was not.
[00:05:50] Rosenhan was a professor at Stanford, and an admired teacher. He was also, by all accounts, a charismatic and persuasive figure, the kind of man who could get other people to do unusual things for him.
[00:06:07] His experiment would go as follows. He would recruit a small group of so-called pseudopatients, people who were perfectly healthy but would present themselves at psychiatric hospitals.
[00:06:22] When they arrived, they would claim to hear voices.
[00:06:27] The voices, they would say, were unclear, but they could make out a single word. Either "thud," or "empty," or "hollow." That would be the only symptom they reported.
[00:06:43] In every other respect, their name, their occupation, their life's story, they would tell the truth.
[00:06:51] Eight pseudopatients took part.
[00:06:54] There was a psychology graduate student in his twenties, three psychologists, one of whom was Rosenhan himself, a paediatrician, a psychiatrist, a painter, and a housewife.
[00:07:07] Five men and three women.
[00:07:10] They presented themselves at twelve hospitals in five different states, on the East Coast and the West Coast, in old grand institutions and in shiny new ones. The idea was to get a representative cross-section.
[00:07:28] All eight were admitted.
[00:07:30] All but one were diagnosed with schizophrenia. The exception, at an expensive private hospital, was diagnosed with manic-depressive psychosis, which is the term for what we now call bipolar disorder.
[00:07:46] Once admitted, the rules were simple. They were to behave entirely normally. They were to drop the symptoms immediately. They were to be honest about everything, except the fact they had invented the voices in order to try to get into the hospital.
[00:08:04] The first real eye-opener for these pseudopatients was the hospitals themselves. They were strange places.
[00:08:14] The wards were enormously understaffed, with sometimes as few as one nurse for fifty patients.
[00:08:23] The staff rarely interacted with the patients beyond mealtimes and medication rounds.
[00:08:29] When they did interact, they often spoke as if the patients were not really there.
[00:08:36] One pseudopatient noted that a female nurse adjusted her bra in front of a day room full of male patients, with no apparent self-consciousness, as if they were furniture.
[00:08:50] Another noted that staff would walk straight past patients trying to talk to them, eyes fixed on the corridor ahead, pretending not to hear.
[00:09:01] The pseudopatients took continuous notes on what they observed. And they took these notes openly, sitting in the communal rooms with notebooks on their laps, talking to other patients and staff. None of the staff ever questioned this behaviour.
[00:09:19] But it did go into the patients' files. One nurse's note read, simply: "patient engages in writing behaviour", as if the act of writing had become a symptom of a mental disorder.
[00:09:34] Every interaction with staff was filtered through the diagnosis.
[00:09:40] A pseudopatient walking up and down the corridor was, according to one note, "pacing nervously." A pseudopatient who said he was bored was demonstrating "flat affect", which is when someone is unable to show outward emotion.
[00:09:57] And they found that getting themselves discharged was far harder than anticipated.
[00:10:05] A pseudopatient who asked when he could be discharged was being "uncooperative" or "denying his illness."
[00:10:14] Interestingly enough, the pseudopatients reported that the actual patients on the ward, the people with real mental illness, often saw through them immediately.
[00:10:26] "You're not crazy," one patient said to a pseudopatient on the third day. "You're a journalist, or a professor. You're checking up on the hospital."
[00:10:36] Of course, the patient, the one who was in the mental hospital, was right.
[00:10:43] Now, the pseudopatients did manage to get out eventually.
[00:10:47] They were detained for an average of nineteen days, with the longest stay being fifty-two days.
[00:10:55] They were given, between them, more than two thousand pills, which they secretly flushed down the toilet. And when they were eventually discharged, every single one was released with the same diagnosis: "schizophrenia in remission."
[00:11:15] They hadn't been cured, and there was no suggestion that the initial diagnosis had been incorrect. They were just temporarily not showing symptoms.
[00:11:27] The implication was devastating: the psychiatrists at twelve different hospitals had been unable to tell sane people from insane ones.
[00:11:39] Once they had been admitted, the pseudopatients could not get themselves out by behaving sanely, because every act of sanity was interpreted as a symptom of the illness they had been labelled with.
[00:11:53] It seemed like damning evidence that the prevailing diagnostic system was broken.
[00:12:01] In 1973, Rosenhan published his findings in the prestigious journal Science. The paper was titled "On Being Sane in Insane Places."
[00:12:14] And as you might imagine, it was a bombshell.
[00:12:19] After the publication, a well-known research and teaching hospital got in touch. Its staff had heard about Rosenhan's findings, and they were unimpressed. Nothing like that, they said, could happen at their institution.
[00:12:34] So Rosenhan proposed a test. Over the next three months, he would send pseudopatients to them. The staff were told to expect them, and every single person who came through the doors would be rated on a scale of one to ten, according to how likely they were to be a fake.
[00:12:57] Over those three months, 193 patients were admitted.
[00:13:03] Forty-one of them, more than one in five, were confidently identified as pseudopatients by at least one member of staff. Nineteen were suspected by a psychiatrist and a second member of staff.
[00:13:20] Then Rosenhan revealed that he had not sent a single pseudopatient.
[00:13:27] The reputation of American psychiatry took yet another battering. The paper was discussed in newspapers, on television and in medical journals.
[00:13:38] The American Psychiatric Association responded furiously, with established figures denouncing the study as methodologically flawed and morally questionable.
[00:13:51] But the damage was done.
[00:13:54] In 1980, the DSM, the framework and criteria for diagnosing mental illness, was updated again in the form of the DSM-III. The objective was to make sure that two psychiatrists examining the same patient would reach the same conclusion. The document came to four times the length of the DSM-II, its predecessor, and had specific, checklist-style criteria for every diagnosis.
[00:14:25] It wasn't perfect, of course, but it was a step forward.
[00:14:30] Now, this was part of a sweeping movement to change the treatment of people suffering from mental illness, a movement that had begun before Rosenhan.
[00:14:42] Specifically, there was a shift away from large state mental hospitals in favour of community-based care. Over the next two decades, hundreds of thousands of patients would be moved out of long-stay institutions.
[00:14:58] And as for Rosenhan, his study was taught as one of the foundational studies of social psychology to explain why the old asylum system had failed. It became part of the canon. It was cited thousands of times. The story of the eight pseudopatients was told and retold in textbooks and undergraduate lectures, and when Rosenhan died in 2012, he died a hero of modern psychiatry.
[00:15:30] But just a few years later came the twist: the study itself might not have happened, at least not in the way Rosenhan said it did.
[00:15:42] And this is thanks to the work of a woman called Susannah Cahalan.
[00:15:47] Now, Susannah Cahalan had no intention of "outing" Rosenhan. She had, herself, been the subject of a serious diagnostic failure.
[00:15:57] She was twenty-four years old at the time, and a successful young journalist at the New York Post.
[00:16:05] One day she started to feel strange.
[00:16:09] She became paranoid that her boyfriend was cheating on her. She became convinced that the people on television were sending her personal messages.
[00:16:18] Then came the seizures. She was sent to a psychiatrist who diagnosed her with bipolar disorder. Then with a psychotic episode. Then with schizophrenia. The doctors prepared paperwork to commit her to a psychiatric hospital.
[00:16:38] Her parents, in desperation, called in one more specialist, a neurologist.
[00:16:45] This neurologist asked her to draw a clock on a piece of paper. She drew all twelve numbers crammed onto the right side of the circle, leaving the left side completely blank.
[00:17:00] It was a classic sign of injury to one side of the brain. The autoimmune disease he then diagnosed was a condition that had only been identified in the medical literature a couple of years earlier. She got the right treatment, and she recovered fully. But without this diagnosis and this treatment, she would have been labelled as schizophrenic.
[00:17:25] The book she wrote about the experience, Brain on Fire, became a bestseller.
[00:17:31] She then intended to write a book about Rosenhan that celebrated him as a hero of American psychiatry, someone who had done invaluable work on how psychiatric patients are identified and diagnosed.
[00:17:47] So she set out to find the eight pseudopatients from the original study.
[00:17:53] But no matter how hard she looked, she could only find two of the original pseudopatients.
[00:18:01] Over years of investigation, working from Rosenhan's own papers, his correspondence, his notes, and the surviving medical records, she was able to confirm only Rosenhan himself and a graduate student named Bill Underwood.
[00:18:18] The remaining six pseudopatients were ghosts. There were references in the paper to a "Mrs. M." and a "Mr F" but no surviving record of who they actually were, or which hospitals they went to.
[00:18:33] Cahalan kept digging. She found Rosenhan's own admission record from Haverford State Hospital, the institution he had checked himself into.
[00:18:43] He had been admitted there. That was not up for debate. But the hospital records did not match his published account.
[00:18:52] According to Rosenhan, he had reported only the single word "thud."
[00:18:59] According to the actual medical chart, he had reported much more disturbing symptoms.
[00:19:05] He had said he could hear what other people were thinking. He had said he was sensitive to radio waves, and that he had tried to block the voices out by putting copper pots over his ears. He had said he had been having suicidal thoughts. And he had said all of this had been going on for months.
[00:19:26] These were not the symptoms of a man being unjustly admitted because of one ambiguous word.
[00:19:33] They were classic markers of severe psychiatric illness.
[00:19:39] Cahalan found Bill Underwood, the one other confirmed pseudopatient, and interviewed him.
[00:19:46] He was by then in his seventies.
[00:19:49] He remembered the experience vividly. The food, he said, was terrible. The boredom was overwhelming. He had written poems on toilet paper to pass the time. He had eventually got out only when his wife had come in with a lawyer, threatening legal action.
[00:20:06] The hospital had then released him, with the diagnosis "schizophrenia in remission."
[00:20:12] His account broadly matched what Rosenhan had described in the paper.
[00:20:16] But he was just one person.
[00:20:20] Cahalan, in fact, found a ninth person, someone who was sent to a hospital, but wasn't included in Rosenhan's paper because his experience of the hospital was actually very positive. It seemed that he'd been excluded because his case simply didn't match what Rosenhan had intended to show.
[00:20:42] Then there was the follow-up study, the one with the 41 false positives.
[00:20:47] Cahalan went looking for the hospital that had supposedly run it. She found references to it in Rosenhan's archives. But she could find no evidence that it had actually happened.
[00:21:01] The records did not exist. The staff who would have been involved had no memory of it. The newspaper coverage from the time, which would surely have noticed such a study, did not mention it.
[00:21:14] She also found something else. Rosenhan had become a celebrated figure on the back of the paper. He had been contracted to write a full book about the study, and paid a substantial advance. He had spent years promising to deliver the manuscript. But he'd never finished it.
[00:21:35] The publisher even sued him for the return of the advance. He died without ever explaining the eight pseudopatients.
[00:21:45] Cahalan's suspicion, which she hints at in her book, is that he could not.
[00:21:52] In the end, Cahalan concluded that Rosenhan had probably fabricated or substantially embellished much of his famous paper.
[00:22:01] Perhaps not all of it.
[00:22:03] The study had clearly involved at least two people, perhaps a few more.
[00:22:08] But the dramatic, twelve-hospital, eight-pseudopatient experiment that had reshaped psychiatry may never have happened, at least not as Rosenhan had described it.
[00:22:21] So where does this leave things, and what is the prevailing wisdom on Rosenhan and this experiment?
[00:22:28] Well, the Rosenhan study has not been fully discredited. It's possible some version of it happened. The questions it raised about diagnostic reliability were good questions. The reforms it helped produce, including the move to more specific diagnostic criteria, were arguably for the better.
[00:22:50] But the iconic version of the story, the one that was taught in every introductory psychology textbook for nearly half a century, was probably somewhere between "exaggerated" and, as one journal put it, "a spectacularly successful case of scientific fraud".
[00:23:11] OK, then, that is it for this episode, and with this comes an end to our three-part mini-series on The Dark Side of Psychology.
[00:23:20] I hope you enjoyed them, and that they shone a light on some unusual experiments into what makes us obey, love, and believe.
[00:23:28] You've been listening to English Learning for Curious Minds by Leonardo English.
[00:23:33] I'm Alastair Budge, you stay safe, and I'll catch you in the next episode.
[00:00:04] Hello, hello, hello, and welcome to English Learning for Curious Minds, by Leonardo English, the show where you can listen to fascinating stories and learn weird and wonderful things about the world at the same time as improving your English.
[00:00:21] I'm Alastair Budge, and this is the final part of our three-part mini-series on The Dark Side of Psychology.
[00:00:29] In part one, we looked at the Milgram experiment, and what it suggested about how ordinary people behave when an authority figure tells them to do harm.
[00:00:40] In part two, we turned to the work of Harry Harlow, the psychologist whose disturbing monkey experiments transformed our understanding of love.
[00:00:51] And today, in part three, we travel to early 1970s America for one of the most controversial studies in the history of psychiatry, both for what it revealed at the time, and for what a journalist revealed about it almost fifty years later.
[00:01:08] This is the story of The Rosenhan Experiment.
[00:01:13] "Thud" is the word we use in English to describe the sound a heavy object makes when it hits something else. It isn't a loud noise. It's different from a crash or a bang. It's a dull sound, the kind of sound a body might make if it hits the floor.
[00:01:36] And in 1969, a man in his late thirties walked up to the reception desk of a psychiatric hospital on the East Coast of the United States. He was clean and well-dressed. He seemed articulate. He gave his name as David Lurie, and explained that he had been hearing a voice.
[00:02:01] It says only one word, he told the receptionist.
[00:02:05] The word was "thud."
[00:02:09] Within hours, David Lurie was admitted to the hospital and diagnosed with schizophrenia.
[00:02:17] He would soon realise that getting in was the easy part.
[00:02:23] See, David Lurie was not a real person. The man's real name was David Rosenhan, and he was a Stanford psychology professor.
[00:02:35] He was one of eight perfectly sane people who, between 1969 and 1972, would talk their way into psychiatric hospitals across the United States, in order to find out what happened on the other side of the doors.
[00:02:54] Now, throughout history, societies across the world have dealt with people suffering from mental illnesses in different, often unkind, ways.
[00:03:06] In the United States, by the mid-1950s, there were around half a million people in psychiatric hospitals. Many had been there for years, even decades.
[00:03:19] Some had been committed by families who could not cope. Some had been committed by courts of law. Some had walked in voluntarily and never been allowed to leave.
[00:03:34] The diagnostic system that classified them was called the DSM-II, the Diagnostic and Statistical Manual of Mental Disorders, second edition.
[00:03:47] The idea behind it was to use a common language to diagnose someone with a mental disorder, so that it wasn't one psychiatrist's subjective opinion.
[00:04:00] To modern eyes, it is a strange document.
[00:04:04] The categories were vague and often overlapping. A patient diagnosed by one psychiatrist as schizophrenic might be diagnosed by another as manic-depressive, or as having a personality disorder, with no clear way of resolving the disagreement.
[00:04:24] And most famously, homosexuality was still listed as a mental disorder.
[00:04:32] The culture, meanwhile, had begun to question the assumed understanding of mental disorders.
[00:04:41] In 1962, Ken Kesey had published One Flew Over the Cuckoo's Nest, which became an Oscar-winning film in 1975.
[00:04:51] The Scottish psychiatrist R. D. Laing had argued that what we called schizophrenia was often a rational response to an intolerable family situation. The French philosopher Michel Foucault had published Madness and Civilisation, which was his history of how Western societies had used the diagnosis of madness as a tool of social control.
[00:05:18] In other words, people were getting more and more interested in the science behind mental illness, and more and more critical of the understanding of the day.
[00:05:30] And David Rosenhan was one of those people, someone who set out to conduct an experiment into mental illness. And specifically, whether psychiatric professionals at the time could distinguish between someone who was mentally ill and someone who was not.
[00:05:50] Rosenhan was a professor at Stanford, and an admired teacher. He was also, by all accounts, a charismatic and persuasive figure, the kind of man who could get other people to do unusual things for him.
[00:06:07] His experiment would go as follows. He would recruit a small group of so-called pseudopatients, people who were perfectly healthy but would present themselves at psychiatric hospitals.
[00:06:22] When they arrived, they would claim to hear voices.
[00:06:27] The voices, they would say, were unclear, but they could make out a single word. Either "thud," or "empty," or "hollow." That would be the only symptom they reported.
[00:06:43] In every other respect, their name, their occupation, their life's story, they would tell the truth.
[00:06:51] Eight pseudopatients took part.
[00:06:54] There was a psychology graduate student in his twenties, three psychologists, one of whom was Rosenhan himself, a paediatrician, a psychiatrist, a painter, and a housewife.
[00:07:07] Five men and three women.
[00:07:10] They presented themselves at twelve hospitals in five different states, on the East Coast and the West Coast, in old grand institutions and in shiny new ones. The idea was to get a representative cross-section.
[00:07:28] All eight were admitted.
[00:07:30] All but one were diagnosed with schizophrenia. The exception, at an expensive private hospital, was diagnosed with manic-depressive psychosis, which is the term for what we now call bipolar disorder.
[00:07:46] Once admitted, the rules were simple. They were to behave entirely normally. They were to drop the symptoms immediately. They were to be honest about everything, except the fact they had invented the voices in order to try to get into the hospital.
[00:08:04] The first real eye-opener for these pseudopatients was the hospitals themselves. They were strange places.
[00:08:14] The wards were enormously understaffed, with sometimes as few as one nurse for fifty patients.
[00:08:23] The staff rarely interacted with the patients beyond mealtimes and medication rounds.
[00:08:29] When they did interact, they often spoke as if the patients were not really there.
[00:08:36] One pseudopatient noted that a female nurse adjusted her bra in front of a day room full of male patients, with no apparent self-consciousness, as if they were furniture.
[00:08:50] Another noted that staff would walk straight past patients trying to talk to them, eyes fixed on the corridor ahead, pretending not to hear.
[00:09:01] The pseudopatients took continuous notes on what they observed. And they took these notes openly, sitting in the communal rooms with notebooks on their laps, talking to other patients and staff. None of the staff ever questioned this behaviour.
[00:09:19] But it did go into the patients' files. One nurse's note read, simply: "patient engages in writing behaviour", as if the act of writing had become a symptom of a mental disorder.
[00:09:34] Every interaction with staff was filtered through the diagnosis.
[00:09:40] A pseudopatient walking up and down the corridor was, according to one note, "pacing nervously." A pseudopatient who said he was bored was demonstrating "flat affect", which is when someone is unable to show outward emotion.
[00:09:57] And they found that getting themselves discharged was far harder than anticipated.
[00:10:05] A pseudopatient who asked when he could be discharged was being "uncooperative" or "denying his illness."
[00:10:14] Interestingly enough, the pseudopatients reported that the actual patients on the ward, the people with real mental illness, often saw through them immediately.
[00:10:26] "You're not crazy," one patient said to a pseudopatient on the third day. "You're a journalist, or a professor. You're checking up on the hospital."
[00:10:36] Of course, the patient, the one who was in the mental hospital, was right.
[00:10:43] Now, the pseudopatients did manage to get out eventually.
[00:10:47] They were detained for an average of nineteen days, with the longest stay being fifty-two days.
[00:10:55] They were given, between them, more than two thousand pills, which they secretly flushed down the toilet. And when they were eventually discharged, every single one was released with the same diagnosis: "schizophrenia in remission."
[00:11:15] They hadn't been cured, and there was no suggestion that the initial diagnosis had been incorrect. They were just temporarily not showing symptoms.
[00:11:27] The implication was devastating: the psychiatrists at twelve different hospitals had been unable to tell sane people from insane ones.
[00:11:39] Once they had been admitted, the pseudopatients could not get themselves out by behaving sanely, because every act of sanity was interpreted as a symptom of the illness they had been labelled with.
[00:11:53] It seemed like damning evidence that the prevailing diagnostic system was broken.
[00:12:01] In 1973, Rosenhan published his findings in the prestigious journal Science. The paper was titled "On Being Sane in Insane Places."
[00:12:14] And as you might imagine, it was a bombshell.
[00:12:19] After the publication, a well-known research and teaching hospital got in touch. Its staff had heard about Rosenhan's findings, and they were unimpressed. Nothing like that, they said, could happen at their institution.
[00:12:34] So Rosenhan proposed a test. Over the next three months, he would send pseudopatients to them. The staff were told to expect them, and every single person who came through the doors would be rated on a scale of one to ten, according to how likely they were to be a fake.
[00:12:57] Over those three months, 193 patients were admitted.
[00:13:03] Forty-one of them, more than one in five, were confidently identified as pseudopatients by at least one member of staff. Nineteen were suspected by a psychiatrist and a second member of staff.
[00:13:20] Then Rosenhan revealed that he had not sent a single pseudopatient.
[00:13:27] The reputation of American psychiatry took yet another battering. The paper was discussed in newspapers, on television and in medical journals.
[00:13:38] The American Psychiatric Association responded furiously, with established figures denouncing the study as methodologically flawed and morally questionable.
[00:13:51] But the damage was done.
[00:13:54] In 1980, the DSM, the framework and criteria for diagnosing mental illness, was updated again in the form of the DSM-III. The objective was to make sure that two psychiatrists examining the same patient would reach the same conclusion. The document came to four times the length of the DSM-II, its predecessor, and had specific, checklist-style criteria for every diagnosis.
[00:14:25] It wasn't perfect, of course, but it was a step forward.
[00:14:30] Now, this was part of a sweeping movement to change the treatment of people suffering from mental illness, a movement that had begun before Rosenhan.
[00:14:42] Specifically, there was a shift away from large state mental hospitals in favour of community-based care. Over the next two decades, hundreds of thousands of patients would be moved out of long-stay institutions.
[00:14:58] And as for Rosenhan, his study was taught as one of the foundational studies of social psychology to explain why the old asylum system had failed. It became part of the canon. It was cited thousands of times. The story of the eight pseudopatients was told and retold in textbooks and undergraduate lectures, and when Rosenhan died in 2012, he died a hero of modern psychiatry.
[00:15:30] But just a few years later came the twist: the study itself might not have happened, at least not in the way Rosenhan said it did.
[00:15:42] And this is thanks to the work of a woman called Susannah Cahalan.
[00:15:47] Now, Susannah Cahalan had no intention of "outing" Rosenhan. She had, herself, been the subject of a serious diagnostic failure.
[00:15:57] She was twenty-four years old at the time, and a successful young journalist at the New York Post.
[00:16:05] One day she started to feel strange.
[00:16:09] She became paranoid that her boyfriend was cheating on her. She became convinced that the people on television were sending her personal messages.
[00:16:18] Then came the seizures. She was sent to a psychiatrist who diagnosed her with bipolar disorder. Then with a psychotic episode. Then with schizophrenia. The doctors prepared paperwork to commit her to a psychiatric hospital.
[00:16:38] Her parents, in desperation, called in one more specialist, a neurologist.
[00:16:45] This neurologist asked her to draw a clock on a piece of paper. She drew all twelve numbers crammed onto the right side of the circle, leaving the left side completely blank.
[00:17:00] It was a classic sign of injury to one side of the brain. The autoimmune disease he then diagnosed was a condition that had only been identified in the medical literature a couple of years earlier. She got the right treatment, and she recovered fully. But without this diagnosis and this treatment, she would have been labelled as schizophrenic.
[00:17:25] The book she wrote about the experience, Brain on Fire, became a bestseller.
[00:17:31] She then intended to write a book about Rosenhan that celebrated him as a hero of American psychiatry, someone who had done invaluable work on how psychiatric patients are identified and diagnosed.
[00:17:47] So she set out to find the eight pseudopatients from the original study.
[00:17:53] But no matter how hard she looked, she could only find two of the original pseudopatients.
[00:18:01] Over years of investigation, working from Rosenhan's own papers, his correspondence, his notes, and the surviving medical records, she was able to confirm only Rosenhan himself and a graduate student named Bill Underwood.
[00:18:18] The remaining six pseudopatients were ghosts. There were references in the paper to a "Mrs. M." and a "Mr F" but no surviving record of who they actually were, or which hospitals they went to.
[00:18:33] Cahalan kept digging. She found Rosenhan's own admission record from Haverford State Hospital, the institution he had checked himself into.
[00:18:43] He had been admitted there. That was not up for debate. But the hospital records did not match his published account.
[00:18:52] According to Rosenhan, he had reported only the single word "thud."
[00:18:59] According to the actual medical chart, he had reported much more disturbing symptoms.
[00:19:05] He had said he could hear what other people were thinking. He had said he was sensitive to radio waves, and that he had tried to block the voices out by putting copper pots over his ears. He had said he had been having suicidal thoughts. And he had said all of this had been going on for months.
[00:19:26] These were not the symptoms of a man being unjustly admitted because of one ambiguous word.
[00:19:33] They were classic markers of severe psychiatric illness.
[00:19:39] Cahalan found Bill Underwood, the one other confirmed pseudopatient, and interviewed him.
[00:19:46] He was by then in his seventies.
[00:19:49] He remembered the experience vividly. The food, he said, was terrible. The boredom was overwhelming. He had written poems on toilet paper to pass the time. He had eventually got out only when his wife had come in with a lawyer, threatening legal action.
[00:20:06] The hospital had then released him, with the diagnosis "schizophrenia in remission."
[00:20:12] His account broadly matched what Rosenhan had described in the paper.
[00:20:16] But he was just one person.
[00:20:20] Cahalan, in fact, found a ninth person, someone who was sent to a hospital, but wasn't included in Rosenhan's paper because his experience of the hospital was actually very positive. It seemed that he'd been excluded because his case simply didn't match what Rosenhan had intended to show.
[00:20:42] Then there was the follow-up study, the one with the 41 false positives.
[00:20:47] Cahalan went looking for the hospital that had supposedly run it. She found references to it in Rosenhan's archives. But she could find no evidence that it had actually happened.
[00:21:01] The records did not exist. The staff who would have been involved had no memory of it. The newspaper coverage from the time, which would surely have noticed such a study, did not mention it.
[00:21:14] She also found something else. Rosenhan had become a celebrated figure on the back of the paper. He had been contracted to write a full book about the study, and paid a substantial advance. He had spent years promising to deliver the manuscript. But he'd never finished it.
[00:21:35] The publisher even sued him for the return of the advance. He died without ever explaining the eight pseudopatients.
[00:21:45] Cahalan's suspicion, which she hints at in her book, is that he could not.
[00:21:52] In the end, Cahalan concluded that Rosenhan had probably fabricated or substantially embellished much of his famous paper.
[00:22:01] Perhaps not all of it.
[00:22:03] The study had clearly involved at least two people, perhaps a few more.
[00:22:08] But the dramatic, twelve-hospital, eight-pseudopatient experiment that had reshaped psychiatry may never have happened, at least not as Rosenhan had described it.
[00:22:21] So where does this leave things, and what is the prevailing wisdom on Rosenhan and this experiment?
[00:22:28] Well, the Rosenhan study has not been fully discredited. It's possible some version of it happened. The questions it raised about diagnostic reliability were good questions. The reforms it helped produce, including the move to more specific diagnostic criteria, were arguably for the better.
[00:22:50] But the iconic version of the story, the one that was taught in every introductory psychology textbook for nearly half a century, was probably somewhere between "exaggerated" and, as one journal put it, "a spectacularly successful case of scientific fraud".
[00:23:11] OK, then, that is it for this episode, and with this comes an end to our three-part mini-series on The Dark Side of Psychology.
[00:23:20] I hope you enjoyed them, and that they shone a light on some unusual experiments into what makes us obey, love, and believe.
[00:23:28] You've been listening to English Learning for Curious Minds by Leonardo English.
[00:23:33] I'm Alastair Budge, you stay safe, and I'll catch you in the next episode.
