Why we need a new approach to mental health care

Credit: World Federation for Mental Health

In 1973, Stanford University professor and psychiatrist, David Rosenhan, arranged for eight mentally healthy people (three women and five men, including himself) to present themselves at mental institutions and declare that they were hearing strange voices. All were certified mad even though their auditory hallucinations were feigned. The eight fake patients were checked in to different psychiatric hospitals and seven were diagnosed as paranoid schizophrenics.

Rosenhan’s subsequent landmark paper, On Being Sane in Insane Places, created a media sensation and a crisis in psychiatry. There was astonishment at the ease with which mental health practitioners had been duped by a made-up symptom. Psychiatrists, it seemed, unlike suspicious fellow patients, could not tell a phoney from a lunatic. Not one of Rosenhan’s “pseudopatients” was unmasked by hospital staff.

The Rosenhan experiment is considered an important and influential criticism of psychiatry. That eight perfectly sane subjects could fool doctors into believing that they were insane called into question the validity of psychiatric diagnosis. There was a “uniform failure to recognize sanity” in any of the pseudopatients, Rosenhan concluded, and not one of them was ever found out by the medical staff despite behaving normally while in hospital.

“It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals,” Rosenhan famously wrote at the outset of his report’s conclusion. He went on to say that the diagnosis of mental health patients was flawed because the classification system used at that time was not valid.

A disturbing aspect of the experiment was the claim by pseudopatients, as reported by one writer, that the staff was dehumanising and often brutal.

Conversations with staff were limited by their frequent absence. When the staff did have time to talk, they were often curt and dismissive. Orderlies would often be both physically and verbally abusive when other workers were absent. The pseudopatients reported they often felt invisible, as the staff would act like they weren’t even there.

There was a second part of Rosenhan’s study which also delivered a minor bombshell. A hospital – which had heard about Rosenhan’s initial test and claimed that similar errors would not occur there – was falsely informed that one or more imposters would attempt to be admitted as psychiatric patients. Staff at the hospital subsequently determined that 41 out of 193 patients were not genuine patients. In reality, Rosenhan had not sent a single imposter to the hospital.

While Rosenhan’s main experiment illustrated a failure to detect sanity, the secondary study demonstrated a failure to detect insanity. He starkly concluded that “one thing is certain: any diagnostic process that lends itself too readily to massive errors of this sort cannot be a very reliable one”.

One of Rosenhan’s key findings was that psychiatric labels tend to stick. Consequently, everything a patient does is interpreted in accordance with the diagnostic label applied. This is why the original diagnosis of schizophrenia biased the staff’s interpretation of patient behaviours. For example, pacing a corridor out of boredom was interpreted as “anxiety” by hospital staff.

Not surprisingly, Rosenhan’s unsettling findings were disputed by other psychiatrists who claimed that his study was flawed. However, the main message he sought to convey was the relative ease with which a person can be misdiagnosed as mentally ill and the significant difficulty in erasing that diagnosis. He argued that psychiatric labels tend to have a longevity that physical medical labels do not.

We have all experienced the extraordinary power of language to motivate and inspire. But words can also stigmatise and – at its core – Rosenhan’s study was about demonstrating the biasing power of psychiatric labels. I have seen this destructive power first-hand.

A member of my broader family suffers from poor mental health and her condition has been assigned numerous diagnostic labels throughout her life. Each of her labels has served as a cue that activates stigma and stereotypes and sometimes results in her being kept at arm’s length. Just as no one diagnosed with dementia wears it as a badge of honour, those diagnosed with a mental disorder equally know that they will likely suffer negative evaluations by others – a case of judging a book by its cover.

Moreover, a psychiatric label can become a self-fulling prophesy as patients act out the label. I have seen this first-hand with my above-mentioned family member who blames her “depression”, “bi-polar”, “melancholy”, or whatever other label is current at the time, for her actions during a depressive episode. “I can’t help my behaviour!” she will exclaim, “as people with my condition do these things”.

A final thing that I have witnessed with mental health patients is the apparent compulsory need for medications to be prescribed by the treating physician. In the Rosenhan experiment, the pseudopatients were administered more than 2,000 pills, including antipsychotics and antidepressants – which they largely discarded. Yet again, I have direct experience of the negative impact of pills on patients. Mental health drugs are powerful and often have side effects.

Many years ago, I provided a listening ear to a friend who was feeling down. During our chat, he revealed that he had been to see a psychiatrist for a heart-to-heart but that the doctor was more interested in pumping him with pills. As my friend rejected the prescribed medicine, the specialist said he could not see him again.

At end of the day, all my friend wanted and needed was a supportive shoulder to cry on and some genuine kindness. As portrayed by Robyn Williams in the movie, Patch Adams, a little kindness goes a long way when someone is under the weather. Following a traditional medical school education, Hunter “Patch” Adams rebelled against the pill-pushing model of medicine and pioneered a more humane approach based on laughter, love and caring as primary forms of medical treatment.

His style of care and disdain for the prevailing methods put him at odds with the norms of the established medical profession. Yet, his approach has merit. I think that every mental health specialist should watch the movie, Patch Adams, which provides a life lesson for psychiatrists. The movie’s underlying message may be a bitter pill for some doctors to swallow. However, when it comes to mental health, life should imitate art, particularly as the mental health effects of the coronavirus crisis have driven a marked rise in anxiety and depression in Australians.

Never again should pseudopatients be allowed to fly over the cuckoo’s nest!


Paul J. Thomas
Chief Executive Officer
Ductus Consulting

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