Journal of Abnormal Psychology

1975, Vol. 84, No. 5, 456-461

Reflections on Rosenhan's "On Being Sane in Insane Places"

Theodore Millon
University of Illinois at the Medical Center
Although the arguments that Rosenhan musters in his critique of diagnostic
labeling are compelling, the experiment employed to furnish empirical support
for his thesis is seriously flawed and the nosological alternative he proposes is
deficient logically. The most notable weakness is the failure of his study design
and methodology to provide a properly controlled test of the major hypothesis.
Further, the substantive assumptions underlying Rosenhan's proposal that syn-
drome labeling be disbanded in favor of labeling specific behaviors are seen as
both philosophically naive and inevitably misguiding.

The past two centuries in the history of
psychopathology have been rent by a recur-
ring internecine war, a waxing and waning
struggle between adherents to polar extremes
of a dichotomous philosophy of man: those
who may be designated "romantic humanists"
(e.g., Pinel, Feuchtersleben) set against those
characterized as "scientific dogmatists" (e.g.,
Griesinger, Kraepelin). Though secondary
issues often cloud allegiances, more often than
not the schism has been linked to contrasting
views concerning the primacy of psycho-
genesis (learned, psychodynamic, social influ-
ences) versus that of biogenesis (constitu-
tional, biochemical, or neurological defects).
Rosenhan (1973) takes a firm stand, aligning
himself unequivocally with our modern cadre
of humanists, popularly led by Goffman,
Laing, and Szasz. It should not be surprising
that an article forcefully propounding this
thesis, and one providing "hard" data pub-
lished in so prestigious a journal as Science,
evoked clamorous but divergent reactions.
Those entrenched in the romantic camp
have applauded the work, hailing its scien-
tific truth without examining its methodo-
logical merit. Others, who share Rosenhan's
critique of contemporary diagnostic practice,
lament the study's design weaknesses and the
undermining of a legitimate argument by
misguided and sweeping conclusions. Finally,
dogmatists of a biogenic persuasion have been
Requests for reprints should be sent to Theodore
Millon, Division of Psychology, Department of Psy-
chiatry, University of Illinois Medical Center, 912
S. Wood Street, Chicago, Illinois 60680.
456
cheered by what they see as a seriously flawed
experiment compounded by a series of ques-
tionable, naive, and erroneous inferences, all
of which enable them to dismiss the signifi-
cant issues to which Rosenhan's paper is
properly addressed.
Forgetting for the moment shortcomings of
methodology and interpretation, what are the
salient and valid points to which Rosenhan
gives form and substance? There are three,
and Rosenhan deserves more than modest
commendation for bringing them into sharp
relief. He has done this not only to stir an
otherwise preoccupied and all too often
complacent profession but to alert the intel-
ligent general scientist whose support is
needed to overcome the chronic indifference
and social injustices that plague the hospital-
ized "insane." First, there is a slavish adher-
ence to an outmoded psychiatric nomenclature
and classifkatory system, one devoid of an
internal logic, consisting of overlapping
and unreliable categories and totally lacking
in specific inclusion and exclusion criteria.
Second, facile yet immutable diagnostic judg-
ments are made on the basis of flimsy behav-
ioral data, generated largely by transient
circumstance, colored by contextual setting
and situational expectation, and interpreted in
line with preformed theoretical and etiological
biases of dubious validity. Third, procedures
of semi-arbitrary diagnostic labeling not only
contribute significantly to the dehumanizing
experiences that debase institutional life but
set the stage for enduring self-fulfilling
prophecies. Had Rosenhan restricted his ef-
forts solely to articulating and fleshing out
 REFLECTIONS ON ROSENHAN'S LABELING THESIS
these points, few would take issue with his
arguments; in fact, I venture to say it would
have been met with a uniformly favorable
response. Rather sadly, however, Rosenhan
sought to ennoble his thesis with a specious
experiment from which ill-advised inferences
and misguided conclusions were drawn.
What exactly warrants the epithets spe-
cious, ill-advised, and misguided? Several
explicit and implicit assertions in Rosenhan's
paper will be noted in the ensuing paragraphs,
each followed by a discussion of methodo-
logical and logical shortcomings, as well as
interpretations contrary to those presented.
The Methodology Employed Adequately
Tests the Hypothesis Proposed
Rosenhan claims to have verified the fol-
lowing implicit hypothesis: "We cannot dis-
tinguish the sane from the insane in psychi-
atric hospitals" (p. 257). Apart from the
misuse of the term "insane," the main experi-
ment by no means sustains Rosenhan's con-
clusion. At best, it supports the following
trivial finding: Confederates of an experi-
menter who know the hypothesis being tested
and who feign being psychologically dis-
turbed, consistent with that hypothesis, will
temporarily deceive unsuspecting clinicians
accustomed to working in mental institutions.
As Rosenhan knows well, marked effects
can be produced by experimenter bias and
demand, even in simple animal studies. In
human investigations, where subjects know
and favor the hypothesis, the probabilities
are appreciably increased that the results will
prove extremely congenial to the proposition
tested. Rosenhan's assurance that the pseudo-
patients acted normally while hospitalized and
were truthful concerning their past (one sub-
ject was dropped for modifying his back-
ground) is not sufficient to ensure that
demand and bias effects were adequately con-
trolled. That these confounding influences
were operative is strongly suggested by the
apparent unwillingness of all but one pseudo-
patient to actively pursue the recommenda-
tion "that he would have to get out by his
own devices, essentially by convincing the
staff that he was sane" (p. 252). Not one
457
pseudopatient rose up the day following ad-
mission and claimed that he was a normal
person involved in a research enterprise or,
to maintain the ruse, was "fully recovered"
from a transient aberration. On the contrary,
the behaviors they portrayed were standard
hospital-patient behaviors. Though reported
in cryptic fashion, it appears that the pseudo-
patients sat around quietly, acted coopera-
tively, said they were fine in response to staff
inquiries, and asked innocuous questions, such
as, "When will I be eligible for ground privi-
leges?" None of these would characterize a
sane person in that situation. Whether by
conscious intent or not, the hypothesis-wise
pseudopatients may very well have controlled
the duration of their hospital stay. Rosenhan's
failure to utilize blind controls as pseudo-
patients makes the meaning of his data highly
suspect and leaves open the question as to
whether he has tested the essence of his
thesis, that persons who act sane cannot
be distinguished from those who are truly
insane.
Are there study designs that could have
convincingly answered Rosenhan's thesis?
Several possibilities come to mind. Following
his basic admission procedure, a simple and
direct method would have been to ask sane
subjects to act as they normally do, present
themselves at a hospital admissions office,
feign nothing, describe the realities of their
life history and everyday behaviors, and then
inquire as to whether their symptoms justify
entrance as patients. I doubt whether any
would be admitted; if one or more were
labeled "schizophrenic" and institutionalized,
then Rosenhan's thesis would be persuasive.
To test both sides of the thesis, severely dis-
turbed insane patients should be brought to
admission offices of institutions other than
the one from which they came, be given
instructions to describe their current psycho-
logical state, and be asked to behave as they
characteristically do. I doubt whether a minor
fraction of them would be turned away as
sane; if they were, then Rosenhan would
have made a telling point.
As far as distinguishing sane from insane
following hospitalization, the most effective
test would be to introduce clinicians to a ward
458 THEODORE MILLON
composed equally of nonpatients and real
patients, and present them the task of dis-
charging approximately half of the patients
on the ward using the criteria of their appar-
ent normality. Only behavioral and interview
data would be available, and nonpatients
would be constrained from telling the staff
directly of their pseudostatus; otherwise, all
would act as they normally would. The
percentage of incorrect discharges would serve
to gauge the validity of the thesis.
The Clinical Judgments of the Admission
Staff Were Faulty and Careless
Implicit in Rosenhan's paper is an accusa-
tion that the decision to label as "schizo-
phrenic" and to institutionalize on the basis
of such tenuous data as a single hallucinatory
symptom indicate grievously inept and capri-
cious judgments on the part of admitting
staffs.
Before noting demurrers to Rosenhan's
assertion, it would be useful to note the sphere
of psychological science to which his study
has relevance. It is, in essence, an investiga-
tion of the role of institutional context and
set in diagnostic assessment; seen from this
perspective, it is a valid contribution of
intrinsic merit. Insofar as the data he reports
can be attributed to factors independent of
experimenter bias and demand, they demon-
strate, in dramatic and potentially tragic
form, the impact of clinical habits and
expectations. Clinicians, who function within
a hospital admission setting and are accus-
tomed to working with genuinely troubled
people, will unthinkingly assume that every
case is "sick" and that their task is to provide
a formal diagnosis based on whatever data
can be gleaned, regardless of their flimsy and
tenuous character. That such diagnoses are
often wanting, even ludicrous, and frequently
countertherapeutic, is lamentable.
Where Rosenhan goes astray is in con-
demning admitting clinicians for their osten-
sibly facile diagnoses and their attendant
decisions to institutionalize. It would be a
more accurate and charitable conclusion to
recognize that their failures were wholly
understable given the situational context,
their lack of guile concerning devious motives,
and their naive willingness to accept as
genuine the discomfort expressed by persons
who volunteered hospitalization. The decisions
to diagnose schizophrenia and to institutional-
ize were misguided by experimenter intention;
given this deception, these decisions were
neither inept nor capricious. Why?
If one must diagnose, and do so in accord
with the guidelines of the American Psychi-
atric Association's Diagnostic and Statistical
Manual (DSM), (a troubling constraint yet
one that admission officers must operate
within), and if neurological involvement or
transient drug effects can be excluded as plau-
sible alternatives, then the label schizophrenia
is the most reasonable diagnosis, given the
presenting complaints (e.g., distressful and
persisting auditory hallucinations, the ab-
sence of identifiable precipitants or severe
mood changes, existential estrangement). Con-
sidering the necessity of a DSM diagnosis,
these signs in composite suggest "acute
schizophrenic episode" as a logical designa-
tion. Whether descriptive syndrome labels
such as "schizophrenia" should be replaced in
the DSM with descriptive symptom labels
such as "hallucination" is another issue, which
will be considered later.
Concerning the decision to institutionalize
and to discharge conservatively, Rosenhan
asserts that in medicine, but not in psychi-
atry, it is "better to err on the side of cau-
tion." I fail to see why Type II errors are not
often advisable in psychiatry, and specifically
in the Rosenhan study. For example, if the
disconcerting symptoms presented by the
pseudopatients might reasonably be attributed
to brain disease, would this not justify a
detailed neurological workup that could be
managed best in a brief hospital stay?
Whether such studies were undertaken, in
fact, is not clear from Rosenhan's paper;
that they should have been explored as a
possible course is self-evident. On different
grounds entirely, there are powerful legal and
public, as well as medical, pressures on hos-
pital clinicians favoring the Type II option.
Thus, the occasional tragic violence of pre-
maturely released patients serves as a pain-
ful reminder to them of the wisdom of caution
in discharge policies.
 REFLECTIONS ON ROSENHAN'S LABELING THESIS
Pseudopatients Failed to be Identified as
"Sane" During their Period of
Instltutlonallzatlon
This assertion assumes that the normal
behavior exhibited by pseudopatients during
hospitalization would be noted as distinctive,
that is, discernibly different than that typi-
cally seen among real patients. One can only
wonder as to Rosenhan's acquaintance with
mental hospital settings, particularly short-
term admission wards. Here, little is seen of
the public's stereotyped image of chaotic,
regressed, and eccentric behaviors. What is
most notable among these patients is the
rapid abatement of subjective tension and
physical acting out, a quick return to nor-
mality among those who evidenced severe
psychological upsets only a few days earlier.
Moreover, if we examine the behaviors of
Rosenhan's pseudopatients, their initial symp-
toms and ensuing experiences were not
normal. They were "nervous" in response to
the "novelty of the hospital setting," they
informed suspicious fellow patients that they
were really "crazy" when they came to the
hospital, but were no longer so, they engaged
in secretive note writing, and they failed to
insist on immediate discharge when beginning
to "feel better."
Bypassing the fact that real and pseudo-
patients shared many commonalities in behav-
ior, it is puzzling that Rosenhan concludes
that they were not ultimately discerned as
different. Did the nurses unwittingly report
"no abnormal signs" when writing pseudo-
patient descriptions? Did not 35 of 118 fellow
patients display astuteness in detecting the
ruse and do so despite protestations by
pseudopatients that they were not feigning?
Most significantly, were not all 12 pseudopa-
tients discharged "in remission," a fact evi-
dencing not only a remarkably high degree
of diagnostic accuracy but one all the more
notable when contrasted with the negligible
proportion of genuine patients that are so
discharged?
Perhaps Rosenhan's concern relates to the
lengthy stay and slow discharge of several of
the pseudopatients. Here, again, accurate
interpretations are difficult given the problem-
atic effects of experimenter bias and demand
459
as factors prolonging the hospital period.
Rosenhan does, however, make a significant,
point in discussing this problem, although he
obscures it by minimizing its cogency. Re-
porting on patient-staff segregation in four
public hospitals, he notes that, on the average,
attendents spent less than 10% of their time
interacting with patients; nurses were simi-
larly unavailable, and physicians, especially
psychiatrists, even less so. Rosenhan properly
recognizes that the pitiful funding, under-
staffing, and Kafkaesque bureaucracy of these
institutions contribute to a dehumanized and
dehumanizing hierarchy in which those with
maximum power over the fate of patients are
the ones farthest removed from their daily
life. This is a compelling indictment and one
directly relevant to Rosenhan's thesis. Despite
his inclination to depreciate its significance
as a factor shaping his data, these deplorable
conditions are overwhelming constraints to
effective admission, treatment, and discharge
functions. That status professionals gravitate
to administrative posts, preferring to distance
themselves from direct patient care, is a sad
commentary on the reinforcement contin-
gencies of institutional life. Rosenhan would
have performed a more useful service had he
focused on the chronic social and economic
forces that undermine patient life, rather than
ascribing their poignant state to incidental
mislabeling by harried frontline staffs.
Success In Simulation Supports the Thesis
that "Mental Illness" Is a Myth
Though not persuaded by this proposition,
at least judging by explicit denials to that
effect, Rosenhan's study has been drawn into
the fruitless dispute over whether mental ill-
ness is or is not a myth. Adherents to this
doctrine cite the success of simulation as
proof of their contentions; dissidents show
their distaste for the thesis by gratuitous
arguments. As is evident in the peregrinations
of those with Munchausen's syndrome, sub-
jects can be trained to feign any number of
medical diseases (e.g., headache, colitis, back
pain, hiatus hernia, even a myocardial in-
farction) and, with reasonable confidence,
expect to dupe a significant proportion of
unsuspecting physicians. By no means would
460 THEODORE MILLON
such deceits prove that these diseases are, in
fact, mere myths, that is, insubstantial ailments
created by the spurious thinking of physi-
cians. The thrust of Rosenhan's argument is
not that mental illness is a myth, but rather
that diagnostic labeling, as we know it, is a
process fraught with error and one both coun-
tertherapeutic and dehumanizing,
Syndrome Labeling Should be Disbanded in
Favor of Labeling Specific Behaviors
Rosenhan is right in registering protest over
the all too common practice of clinicians who
seem content merely to label a patient as
fitting a category. Labeling is dangerous. It
entails a reification, an impression that
something has been identified as possessing
intrinsic properties both salient and durable.
Also, by virtue of deriving its official sanc-
tion from the approved classification system,
the belief is strengthened that a label desig-
nates a significant and valid attribute. Fur-
ther, what is reified suggests permanence, and
thus a label endures long after the symptoms
that gave rise to it have vanished. Because
psychiatric labels convey pejorative implica-
tions, they remain as stigmas, result in social
scapegoating and burdensome self-images,
and thereby set the stage for self-fulfilling
prophecies.
Rosenhan's paper errs, however, in failing
to distinguish labeling from diagnosis. Labels
are merely shorthand communications, formal
notations that potentially facilitate a limited
number of clinical and research objectives.
This facilitative potential may be realized if
the conceptual properties implicit in the label
derive from a testable theoretical system, and
if they embody the empirical consequences of
relevantly executed studies. The fact that
such systems and data are sorely lacking ac-
counts in great measure for our disillusion-
ment. Given these deficits, a psychiatric label
can serve only as a starting point and not an
end, an initiating hypothesis of an abstract
type or class .that must be elaborated and
further refined by individual diagnosis. Each
case, through detailed studies of life history,
current circumstance, and personality, be-
comes its own variant of the labeled class.
It is this process of individualizing the label
by integrating personally salient components
in a logical and theoretically relevant fashion
that distinguishes, and makes functional,
clinical diagnosis. Because some clinicians do
a bad job at it in no way condemns its
potential utility.
Returning to Rosenhan's critique of label-
ing per se, one cannot help but be puzzled and
chagrined by his statement that, had the
pseudopatients been labeled "hallucinating"
rather than "schizophrenic," there would have
been no further need to examine the issue.
Why not? Would not hallucinating become
reified over time into an entity, be given of-
ficial sanction, imply recurrence or perma-
nence, take on pejorative connotations, and
become self-fulfilling? Would the sane be any
safer from a new form of potential mislabel-
ing, and would hospitals be more functional
or clinicians more sensitive or humanistic?
I doubt it because the failings that Rosenhan
correctly proscribes would persist essentially
unchanged.
Rosenhan contends that "hallucinating" as
a label is more specific and tangible than such
conceptually hazy terms as schizophrenia, and
hence would be operationally definable and
less subject to misinterpretation. I agree with
the desire for explicit criteria, but find his
behaviorist epistemology unpersuasive. For
example, modern philosophers of science could
readily illustrate that the logical underpin-
nings of anything being operationally defined
are as tenuous conceptually as the hazy term
"schizophrenia." Moreover, the label "hallu-
cinating," which is attractive to Rosenhan
because it ostensibly requires minimal infer-
ence, represents an inner state and is, there-
fore, a dispositional concept. Behaviors char-
acterizing such inner states are, in fact,
subject to alternative inferences, that is, any
sample of behavior might signify that the pa-
tient is hallucinating, or is depressed or pro-
jecting. Which dispositional concept will be
chosen may merely be a matter of inferential
preference and this flexibility and arbitrari-
ness in inferential choice effectively undercuts
the presumed advantages of a label such as
"hallucinating." To be behavioristically rigor-
ous, Rosenhan should have proposed a label
that represented a pure, observational de-
scription such as, "responds to objectively
nonexistent stimuli," but that designation,
 REFLECTIONS ON ROSENHAN'S LABELING THESIS
I fear, would appear rather awkward in any
nosological schema.
Finally, there is the issue of single, isolated
symptom labels versus the synthesizing of
several symptoms into syndrome labels. A
rose may be a rose, but it is a different rose
if it is presented to your wife in a birthday
bouquet than if seen in passing as one among
many in a garden. Similarly, in medical sci-
ence it will be erroneous to code identical
fevers as equivalent because their significance
will differ depending on the configuration of
other presenting symptoms. Likewise, behav-
ioral signs cannot be abstracted from their
psychological and situational context without
leading to false equivalences. Rosenhan argues
convincingly, and I think properly, for the
notion that symptoms must be assessed in
terms of their situational covariates, that is,
the stimulus complex within which they occur.
461
That very principle applies with equal force
to the covariant behaviors, of which a par-
ticular symptom is but one. Hallucination 1
is simply not the same as Hallucination 2 if
they are part of different behavioral and
situational configurations. It is precisely this
patterned and multivariate cluster of be-
haviors, set within a comparably delineated
situational context, that can best serve as a
framework for developing new syndrome
groupings. Rosenhan should ask for nothing
less.
REFERENCES
American Psychiatric Association. Diagnostic and
Statistical Manual of Mental Disorders (2nd ed.).
Washington, D.C.: Author, 1968.
Rosenhan, D. L. On being sane in insane places.
Science, 1973, 170, 250-258.
(Received October 25, 1974)