On Being Sane in Insane Places
Author(s): D. L. Rosenhan
Source: Science, New Series, Vol. 179, No. 4070 (Jan. 19, 1973), pp. 250-258
Published by: American Association for the Advancement of Science
Stable URL: http://www.jstor.org/stable/1735662
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(1965); ibid. 18, 254 (1969); M. J. D. White,
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Kettlewell, R. J. Berry, C. J. Cadbury,
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25, 449 (1969); J. A. Bishop, J. Anim. Ecol.
41, 209 (1972); G. Hewitt and F. M. Brown,
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22. C. P. Haskins, E. F. Haskins, J. J. A.
McLaughlan, R. E. Hewitt, in Vertebrate
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Hassan, D. P. Scoter, Ecology 52, 178 (1971).
For localized distribution and problem of
establishment see also: W. F. Blair, Ann.
N.Y. Acad. Sci. 44, 179 (1943); Evolution 4,
253 (1950); L. R. Dice, Amer. Natur. 74, 289
(1940); P. Labine, Evolution 20, 580 (1966);
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Zool. Fenn. 15, 1 (1952); P. K. Anderson,
Science 145, 177 (1964).
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Systematics, J. S. Huxley, Ed. (Oxford Univ.
Press, Oxford, 1940), p. 73.
25. The null point is the position at which
selection changes over from favoring one
type to favoring another.
26. J. A. Endler, in preparation.
27. L. M. Cook, Coefficients of Natural Selection
(Hutchinson Univ. Library, Biological Sciences No. 153, London, 1971); F. B. Livingstone, Amer. J. Phys. Anthropol. 31, 1 (1969).
28. W. C. Allee, A. E. Emerson, 0. Park, T.
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Chicago Press, Chicago, 1954); G. L. Clarke,
Elements of Ecology (Wiley, New York,
1954); R. Geiger, The Climate Near the
Ground (translation, Harvard Univ. Press,
29. Results for autosomal and sex-linked systems
do not differ for the models to be discussed,
except that, for a given amount of selection,
the sex-linked system is loss sensitive to
On Being Sane in Insane Places
D. L. Rosenhan
If sanity and insanity exist, how shall
we know them?
The question is neither capricious nor
itself insane. However much we may
be personally convinced that we can
tell the normal from the abnormal, the
evidence is simply not compelling. It is
commonplace, for example, to read
about murder trials wherein eminent
psychiatrists for the defense are con250
tradicted by equally eminent psychiatrists for the prosecution on the matter
of the defendant's sanity. More generally, there are a great deal of conflicting data on the reliability, utility, and
meaning of such terms as "sanity," "insanity," "mental illness," and "schizophrenia" (1). Finally, as early as 1934,
Benedict suggested that normality and
abnormality are not universal (2).
the effects of gene flow. This is because the
effective gene selection on males in sex-linked
loci makes the net selection stronger, compared to autosomal loci, for the population
as a whole. See C. C. Li, Population Genetics
(Univ. of Chicago Press, Chicago, 1955) for
a good discussion of sex-linkage and selection.
30. The equilibrium configurations are not significantly altered if the emigrants from the
end demes do not return, unless the number
of demes (d) is very small (J. A. Endler,
31. See, for example, the models of B. C.
Clarke [Amer. Natur. 100, 389 (1966)] and
those in (14).
32. This model incorporates Clarke's model of
frequency-dependence; see B. C. Clarke,
Evolution 18, 364 (1964).
33. R. A. Fisher and F. Yates, Statistical Tables
for Biological, Agricultural, and Medical Research (Oliver & Boyd, Edinburgh, 1948);
R. R. Sokal and F. J. Rohlf, Biometry
(Freeman, San Francisco, 1969).
34. See, for example, C. G. Johnson, Migration
and Dispersal of Insects by Flight (Methuen,
London, 1969); J. Antonovics, Amer. Sci. 59,
35. E. C. Pielou, An Introduction to Mathematical
Ecology (Wiley-Interscience, New York, 1969).
36. W. F. Blair, Contrib. Lab. Vertebrate Biol.
Univ. Mich. No. 36, 1 (1947).
37. P. A. Parsons, Genetica 33, 184 (1963).
38. G. Hewitt and B. John, Chromosoma 21,
140 (1967); Evolution 24, 169 (1970); G.
Hewitt, personal communication; H. Wolda,
J. Anim. Ecol. 38, 305, 623 (1969).
39. L. R. Dice, Contrib. Lab. Vertebrate Genet.
Univ. Mich. No. 8 (1939), p. 1; ibid. No. 15
(1941), p. 1.
40. I. C. J. Galbraith, Bull. Brit. Mus. Natur.
Hist. Zool. 4, 133 (1956).
41. I am grateful to the National Science Foundation for a graduate fellowship in support
of this study. I thank Prof. Alan Robertson
and the Institute of Animal Genetics, University of Edinburgh, for the Drosophila, and
for kindly providing me with fresh medium
throughout the study. Criticism of the manuscript by Professors John Bonner and Jane
Potter, Dr. Philip Ashmole, Peter Tuft, Dr.
David Noakes, Dr. John Godfrey, Dr. Caryl
P. Haskins, and M. C. Bathgate was very
welcome. In particular, I thank my supervisor,
Professor Bryan C. Clarke, for help and criticism throughout this study. Any errors or
omissions are entirely my own. I thank the
Edinburgh Regional Computing Center and
the Edinburgh University Zoology Department
for generous computer time allowances. I will
supply the specially written IMiP language
program upon request.
What is viewed as normal in one culture may be seen as quite aberrant in
another. Thus, notions of normality and
abnormality may not be quite as accurate as people believe they are.
To raise questions regarding normality and abnormality is in no way to
question the fact that some behaviors
are deviant or odd. Murder is deviant.
So, too, are hallucinations. Nor does
raising such questions deny the existence of the personal anguish that is
often associated with "mental illness."
Anxiety and depression exist. Psychological suffering exists. But normality
and abnormality, sanity and insanity,
and the diagnoses that flow from them
The author is professor of psychology and law
at Stanford University, Stanford, California 94305.
Portions of these data were presented to colloquiums of the psychology departments at the
University of California at Berkeley and at Santa
Barbara; University of Arizona, Tucson; and
Harvard University, Cambridge, Massachusetts.
SCIENCE, VOL. 179
may be less substantivethan many believe them to be.
At its heart, the question of whether
the sane can be distinguishedfrom the
insane (and whether degrees of insanity
can be distinguishedfrom each other)
is a simple matter: do the salient characteristicsthat lead to diagnoses reside
in the patients themselves or in the environments and contexts in which observers find them? From Bleuler,
throughKretchmer,throughthe formulators of the recently revised Diagnostic
This article describessuch an experiment. Eight sane people gained secret
admissionto 12 differenthospitals (6).
Their diagnostic experiences constitute
the data of the first part of this article;
the remainder is devoted to a description of their experiences in psychiatric
institutions. Too few psychiatrists and
psychologists, even those who have
worked in such hospitals, know what
the experience is like. They rarely talk
about it with former patients, perhaps
because they distrust information comand Statistical Manual of the American
ing from the previously insane. Those
Psychiatric Association, the belief has who have worked in psychiatric hospibeen strong that patients present symp- tals are likely to have adapted so thortoms, that those symptomscan be cate- oughly to the settings that they are
gorized, and, implicitly, that the sane insensitive to the impact of that expeare distinguishable from the insane. rience. And while there have been ocMore recently, however, this belief has casional reports of researchers who
been questioned.Based in part on theo- submittedthemselvesto psychiatrichosretical and anthropological considera- pitalization (7), these researchershave
tions, but also on philosophical, legal, commonly remainedin the hospitalsfor
and therapeutic ones, the view has short periods of time, often with the
grown that psychological categorization knowledge of the hospital staff. It is
of mental illness is useless at best and difficult to know the extent to which
downright harmful, misleading, and they were treated like patients or like
pejorative at worst. Psychiatric diag- research colleagues. Nevertheless, their
noses, in this view, are in the minds of reports about the inside of the psychithe observers and are not valid sum- atric hospital have been valuable. This
maries of characteristics displayed by article extends those efforts.
the observed (3-5).
Gains can be made in decidingwhich
of these is more nearly accurate by Pseudopatientsand Their Settings
getting normal people (that is, people
The eight pseudopatients were a
who do not have, and have never sufvaried
group. One was a psychology
disorders) admitted to psychiatric hos- graduate student in his 20's. The repitals and then determining whether maining seven were older and "estabthey were discoveredto be sane and, if lished." Among them were three psyso, how. If the sanity of such pseudo- chologists, a pediatrician,a psychiatrist,
patients were always detected, there a painter, and a housewife. Three
would be prima facie evidence that a pseudopatientswere women, five were
sane individual can be distinguished men. All of them employed pseudofrom the insane context in which he is nyms, lest their alleged diagnoses emfound. Normality (and presumablyab- barrassthem later. Those who were in
normality) is distinct enough that it mental health professions alleged ancan be recognized wherever it occurs, other occupation in order to avoid the
for it is carried within the person. If, special attentions that might be acon the other hand, the sanity of the corded by staff, as a matter of courtesy
pseudopatients were never discovered, or caution, to ailing colleagues (8).
serious difficultieswould arise for those With the exception of myself (I was the
who support traditional modes of psy- first pseudopatientand my presencewas
chiatric diagnosis. Given that the hospi- known to the hospital administratorand
tal staff was not incompetent, that the chief psychologist and, so far as I can
pseudopatient had been behaving as tell, to them alone), the presence of
sanely as he had been outside of the pseudopatientsand the natureof the rehospital, and that it had never been search program was not known to the
previously suggested that he belonged hospitalstaffs (9).
in a psychiatric hospital, such an unThe settings were similarlyvaried. In
likely outcome would support the view order to generalize the findings, admisthat psychiatric diagnosis betrays little sion into a variety of hospitals was
about the patient but much about the sought. The 12 hospitals in the sample
environmentin which an observerfinds were located in five different states on
the East and West coasts. Some were
19 JANUARY 1973
old and shabby, some were quite new.
Some were research-oriented, others
not. Some had good staff-patientratios,
others were quite understaffed. Only
one was a strictly private hospital. All
of the others were supported by state
or federal funds or, in one instance, by
After calling the hospital for an appointment,the pseudopatientarrived at
the admissions office complaining that
he had been hearingvoices. Asked what
the voices said, he replied that they
were often unclear, but as far as he
could tell they said "empty,""hollow,"
and "thud."The voices were unfamiliar
and were of the same sex as the pseudopatient. The choice of these symptoms
was occasioned by their apparent similarity to existential symptoms. Such
symptoms are alleged to arise from
painful concerns about the perceived
meaninglessnessof one's life. It is as
if the hallucinatingperson were saying,
"My life is empty and hollow." The
choice of these symptoms was also determined by the absence of a single
report of existential psychoses in the
Beyond alleging the symptoms and
falsifying name, vocation, and employment, no further alterationsof person,
history, or circumstances were made.
The significant events of the pseudopatient's life history were presented as
they had actually occurred. Relationships with parents and siblings, with
spouse and children, with people at
work and in school, consistent with the
aforementioned exceptions, were described as they were or had been. Frustrations and upsets were described
along with joys and satisfactions.These
facts are important to remember. If
anything, they strongly biased the subsequent results in favor of detecting
sanity, since none of their histories or
currentbehaviorswere seriously pathological in any way.
Immediately upon admission to the
psychiatric ward, the pseudopatient
ceased simulatingany symptoms of abnormality. In some cases, there was a
brief period of mild nervousness and
anxiety, since none of the pseudopatients really believed that they would be
admitted so easily. Indeed, their shared
fear was that they would be immediately exposed as frauds and greatly
embarrassed.Moreover, many of them
had never visited a psychiatric ward;
even those who had, nevertheless had
some genuine fears about what might
happen to them. Their nervousness,
then, was quite appropriateto the nov251
elty of the hospital setting, and it abated
Apart from that short-lived nervousness, the pseudopatient behaved on the
ward as he "normally" behaved. The
pseudopatient spoke to patients and
staff as he might ordinarily. Because
there is uncommonly little to do on a
psychiatric ward, he attempted to engage others in conversation. When
asked by staff how he was feeling, he
indicated that he was fine, that he no
longer experienced symptoms. He responded to instructions from attendants,
to calls for medication (which was not
swallowed), and to dining-hall instructions. Beyond such activities as were
available to him on the admissions
ward, he spent his time writing down
his observations about the ward, its
patients, and the staff. Initially these
notes were written "secretly," but as it
soon became clear that no one much
cared, they were subsequently written
on standard tablets of paper in such
public places as the dayroom. No secret
was made of these activities.
The pseudopatient, very much as a
true psychiatric patient, entered a hospital with no foreknowledge of when
he would be discharged. Each was told
that he would have to get out by his
own devices, essentially by convincing
the staff that he was sane. The psychological stresses associated with hospitalization were considerable, and all but
one of the pseudopatients desired to be
discharged almost immediately after
being admitted. They were, therefore,
motivated not only to behave sanely,
but to be paragons of cooperation. That
their behavior was in no way disruptive
is confirmed by nursing reports, which
have been obtained on most of the
patients. These reports uniformly indicate that the patients were "friendly,"
"cooperative," and "exhibited no abnormal indications."
The Normal Are Not Detectably Sane
Despite their public "show" of sanity,
the pseudopatients were never detected.
Admitted, except in one case, with a
diagnosis of schizophrenia (10), each
was discharged with a diagnosis of
schizophrenia "in remission." The label
"in remission" should in no way be
dismissed as a formality, for at no time
during any hospitalization had any
question been raised about any pseudopatient's simulatio ...
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