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“On Being Sane in Insane Places”: A Cautionary Tale

A once-powerful indictment of mental incarceration turns out to be problematic.

Key points

  • An influential 1973 study reported that doctors couldn’t distinguish mental illness from mental wellness.
  • A 2019 book revealed that the researchers “exaggerated and fabricated” the study results.
  • To defeat stigma and to get resources to patients, we must begin with a factual understanding of the real history of mental health care.

America gets mental health wrong. While polls show that more people than ever are open to accepting mental illness as a biological reality and are willing to acknowledge both the suffering and the need for medical help, psychiatry, mental hospitals, and sufferers of mental illness are still stigmatized and underserved. It does not help that mental health practitioners receive less pay than other specializations, or that medical insurance is stingy when it comes to mental wellness.

The fact is, we have a long history of mistreating sufferers of mental illness and of stigmatizing those tasked with treating them.

In 2019, Susannah Cahalan published a remarkable book that is extremely telling of the process of stigmatization. In The Great Pretender, Cahalan set out to write an in-depth study of one of the most infamous studies of mental health treatment.

Influential 1973 Study

Published in the influential journal Science in 1973, “On Being Sane in Insane Places” tells a shocking story. It relates an experiment designed by David Rosenhan, a psychologist and professor at Stanford University, who asked a basic question: Can psychiatry distinguish between “insanity and sanity”?

Rosenhan and seven other volunteers entered different hospitals under the ruse of telling doctors that they heard “thud, empty, hollow” in their heads. Rosenhan then related how these “pseudopatients” went in and proceeded to behave normally. They were still diagnosed as schizophrenic. And it was no easy thing for them to get out.

This study confirmed what Americans had been told since the 19th century—that there was something seriously wrong with mental hospitals and the practitioners of mind science. Although psychiatry had received something of a makeover in the mid-20th century with the rise of the Freudians, mental hospitals were seen as scary places where people were strapped down, electroshocked, drugged, lobotomized, and confined. Rosenhan’s study told us that doctors couldn’t even distinguish mental illness from mental wellness. It confirmed all of our worst fears.

It didn’t help that this was also the high time of “antipsychiatry,” a moment in which the validity of psychiatry was questioned. In this era, we received a stream of accusatory tell-alls, shocking exposés, horrifying novels, and disturbing films about "asylums."

Historians of mental health have long related Rosenhan’s study as part of the great antipsychiatry wave of the 1960s and 1970s. This wave helped to drive an ongoing process of deinstitutionalization, in which patients were released from long-term care and often simply sent out into the streets. The logic went that even the streets were better than the asylum.

In The Great Pretender, Cahalan, who herself had once been misdiagnosed by doctors as schizophrenic when she really suffered from an autoimmune disorder, wanted to tell Rosenhan’s story in more detail than ever before. She got ahold of the late doctor's papers. And here’s when she ran into trouble.

Flaws in the Study

Rather than getting the intimate stories of the pseudopatients, Cahalan discovered that Rosenhan seriously “exaggerated and fabricated” his study. He modified what the volunteers experienced to suit his conclusions, he deleted positive experiences, and he even misled readers about his own self-incarceration. He'd really actually told doctors that he was suicidal and could hear things via radio waves. Any responsible physician would have committed such a person.

In other words, the study is impossibly flawed, if not outright deceptive.

Cahalan understands that the history of psychiatry is not one of triumphant progress. In her book, she includes stories of the treatment horrors (like icepick lobotomies) and numerous famous misdiagnoses. She even credits Rosenhan for inspiring change, at least to the extent of having “managed to expose truths.”

But this can’t cover up the clear problems of Rosenhan’s famous study.

As a historian of mental health treatments in popular culture, I’ve learned that what we are told about mental illness and psychiatry is often wrong. And, whether robed in fiction or told as purported “fact,” misstatements and fabrications contribute to a deep misunderstanding of what it means to suffer from mental illness and what current treatments actually do.

To give one example, electroconvulsive treatment (ECT) is nearly always shown in movies as involving resisting patients thrust down on a table and then zapped while fully conscious. This, to state what should be obvious, is not how ECT works.

Calahan’s book deserves a wide audience and hopefully will play a big part in rewriting the story of psychiatry and mental hospitals. Hinging mental wellness reforms on exaggeration and fabrication is no way to defeat stigma. The surest way to defeat it, and to get resources to suffering patients, is to begin with a factual understanding of the real history of mental health care.

References

Cahalan, S. (2019). The Great Pretender: The Undercover Mission that Changed Our Understanding of Madness. New York: Hachette.

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