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Illness, Crisis & Loss

Rereading Rosenhan 0(0) 1–13

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DOI: 10.1177/1054137317690377
Ian Cummins1 journals.sagepub.com/home/icl

Abstract
Rosenhan’s pseudopatient experiment is one of the most famous psychological studies
or experiments that has ever been conducted. The experiment took place at the end
of a period in the 1960s which saw the intellectual base of psychiatry and psychiatric
institutions challenged. There were two parts of the experiment. The first looked at
the process of the psychiatric diagnosis; the second examined the experience of
patients’ on the wards. Rosenhan argued that psychiatric diagnosis is not consistently
reliable and it has to be viewed as situationally and culturally specific. This is the finding
that is most consistently highlighted from the work. However, this article argues that
the other elements to Rosenhan’s challenge to institutionalized psychiatric care—that
diagnosis is a label that shapes subsequent perceptions of behavior and that psychiatric
institutions are depersonalizing—have often been overlooked. Given the current crisis
in mental health-care provision, it is argued that this critique of institutional care needs
to be revisited. There is a danger that failings in current mental health provision will
lead to calls for a shift in the focus toward institutionalized provision of care. The
lessons of Rosenhan can be used not only to counter this but also as a basis for a value-
informed approach to the provision of institutionalized mental health care.

Keywords
psychiatric diagnosis, mental health, institutions

Introduction
David Rosenhan (1929–2012) was a professor of Law and Psychology at the
Stanford University from 1971 to his retirement in 1998. Prior to his appoint-
ment, he completed a BA in Mathematics in Yeshiva College in New York
followed by a Masters in Economics at the Columbia University. He subse-
quently undertook doctoral studies at Columbia and was awarded his PhD in

1
Department of Social Work, Salford University, UK
Corresponding Author:
Ian Cummins, Department of Social Work, Salford University, Salford M6 6PU, UK.
Email: i.d.cummins@salford.ac.uk
2 Illness, Crisis & Loss 0(0)

1958. He published more than 80 articles and books in a highly distinguished

academic career. His work sought to apply psychological insights to the pro-
cesses of the law. He examined the role of expert witnesses, jury selection, and
jury deliberation. It is his work in examining the basis and power of psychiatric
diagnosis, for which he is most widely remembered. The pseudopatient experi-
ment that he and other colleagues undertook is one of the most cited and dis-
cussed work in the field. This article will outline the experiment and the
controversies that it created. It will argue that the work remains very relevant
to contemporary mental health services. In particular, Rosenhan emphasized the
need to tackle the depersonalizing processes of psychiatry, which were and
remain most apparent in coercive, institutionalized settings.

The Rosenhan Study: A Brief Outline

Rosenhan’s (1973) paper which reports the findings of the experiment begins
with the famous question: ‘‘If sanity and insanity exist, how shall we know
them?’’
Rosenhan set out to test the validity and reliability of psychiatric diagnosis.
The experiment was carried out in the late 1960s after Szasz (1963, 1971) and
Laing’s (1959, 1967) initial challenge to the power of the psychiatric profession .
His work begins from the premise that terms such as normal, abnormal, and so
on are culturally generated and specific. He is clearly influenced by the work of
Becker (1963). Becker suggests that ‘‘social groups create deviance by making
the rules whose infraction constitutes deviance (p. 4).’’ He goes on to state that
‘‘deviance is not a quality that lies in the behavior itself, but in the interaction
between the person who commits an act and those that respond to it (p. 4).’’ The
deviant is, therefore, someone who has been labeled as such. Deviancy needs to
be understood as a relationship between the behavior, the individual, and the
wider society. What is regarded as normal in one culture or social setting may be
viewed as bizarre or strange in another. In the context of mental health services,
Rosenhan seeks to explore not only the validity and utility of terms such as
sanity and insanity but also their social impact. Psychiatry in the United States at
that time was largely dominated by the influence of Freudian and psycho-
dynamic approaches (Scull, 2015). The focus in these approaches is on personal,
particularly childhood experiences and their relationship with difficulties in adult
life. This provides an important context, in which, to place Rosenhan. His con-
cerns are with not only the power of diagnosis but also the dynamics of that
process.
Rosenhan and seven of his colleagues called hospitals and arranged an
appointment. When they arrived at the admission office, they complained of
hearing voices. The other information that they offered was that the voices
were indistinct but were saying empty, hollow, and thud and that the voice was
Cummins 3

the same sex as the pseudopatient. Rosenhan suggests that the symptoms were
chosen because they were closest to what he termed existential symptoms. These
symptoms were identified in cases where patients were said to be experiencing
profound concerns about the nature and meaning of existence. The other infor-
mation that pseudopatients provided about their personal circumstances—age,
marital status, and employment—was factually accurate. The pseudopatients
were admitted to 12 different hospitals in five different states over the course
of the experiment. On only one occasion were senior staff aware that they were
being admitted. The group comprised three women and five men. As Rosenhan
puts it, they were older and established. The group included three psychologists, a
pediatrician, a painter, and a housewife. Rosenhan suggested that these strong
social ties should have a strong bias against a diagnosis of insanity—prevailing
attitudes at the time being that mental illness would prevent individuals from
establishing such outwardly successful lives.
In 11 of the 12 admissions, the diagnosis was one of schizophrenia—in the
other, it was manic depressive illness. All the pseudopatients were prescribed
medication. They did not take it. The length of admission varied from 7 to 52
days, with an average of 19 days. When they were admitted to the wards, the
pseudopatients stopped the symptoms and behaved in what they termed a
normal fashion. The exception to this was the fact that the volunteers took
notes originally secretly but then openly. None of the pseudopatients was
detected by medical staff though their fellow patients were very suspicious of
them thinking that they might be journalists or academics. The note taking
seemed to be a keen factor here, but the group were all middle-class profes-
sionals whereas most inpatients were from more working-class backgrounds.
This occurred on the first three hospital admissions where 35 out of 118 patients
raised some concerns about the identity of the group.
Rosenhan and colleagues set out to examine the utility of psychiatric diag-
nosis. The study also reports the impact of being diagnosed. Finally, it also
examines the depersonalizing nature of institutional care. They argue that one
of the most powerful aspects of diagnosis is that it become a prism, through
which all behavior is interpreted. For example, staff did not ask the pseudopa-
tients why they were taking notes. They simply recorded in the medical notes
that they engaged in writing behavior. Rosenhan gives other examples to illustrate
this point. For example, the fact that patients were queuing early for lunch was
interpreted by one member of staff in Freudian terms. The pseudopatients
attempted to record the contact between staff and patients. Wards at that
time were dominated by the nursing station—called by all involved the cage.
They calculated that attendants spent on average 11.3% (ranges between 3%
and 52%) of their time outside the cage. Most of their time was spent on chores
or supervising patients rather than in direct contact or establishing relationships.
This trend was more apparent the higher up the psychiatric hierarchy of the time
4 Illness, Crisis & Loss 0(0)

that one went. On average, nurses appeared outside of the cage 11.5 times per
shift (ranges between 4 and 39 times). Psychiatrists were very rarely seen usually
only at formal ward rounds or making their way to and from their offices. As
Rosenhan concludes, those with the most power, professionally and over the
lives of the patients actually had the least direct personal contact with them. This
remains an ongoing feature of all forms of institutionalized care.
The experiment powerfully reports the depersonalizing effects of being an
inpatient. Their reports included patients’ accounts of being physically attacked
by staff. It is noted that these assaults took place openly in front of patients. It is
assumed that the staff were confident that any patient complaints would be
dismissed. However, abusive behavior would be halted if another member of
staff arrived. As Rosenhan notes, staff are much more likely to be seen as a
credible witnesses. These are ongoing issues in the context of institutional abuse.
At that time, psychiatric inpatients had few, if any, legal rights and could be
excluded from certain profession. In echoes of Goffman (1961), the lack of
personal privacy and dignity is highlighted. These are embedded in daily rou-
tines and practices—for example, there were no doors on toilet cubicles. Medical
bureaucracy means that the most intimate details of a patient’s personal and
family life were readily available to any staff member. The wards were generally
overcrowded and poorly staff. There appears to be little in the way of construct-
ive activity or therapeutic interventions. The daily routine is a very boring one
punctuated by meal and medication times.
On discharge, all the pseudopatients were described as being in remission.
Rosenhan notes that this is not the same as being well or cured. One of his
most powerful arguments is that it is, in effect, impossible to escape a psychiatric
diagnosis. This operates on two levels. The patient becomes the illness and vice
versa. For example, it is possible to describe someone diagnosed with schizo-
phrenia as schizophrenic—we would not describe a cancer patient as a cancer. In
addition, the stigma attached to mental illness means that diagnosis remains in
Rosenhan’s terms sticky. Once it has been attributed to an individual, it is hard
to shake off. Diagnosis also carries with it a series of assumptions about the
individual. These assumptions then have potentially very significant implications
for that individual and their role as a citizen. Despite progress in legal provisions
and some shifts in social attitudes, these assumptions remain deeply engrained in
popular culture. Rosenhan acknowledges there is a professional bias in oper-
ation—doctors are much more likely to err on the side of caution, that is, assess
a healthy person as sick than the reverse. In statistical terms, this constitutes a
Type 2 error or a false positive. When one hospital became aware of the pseu-
dopatients’ admissions, Rosenhan agreed that they would repeat the experiment.
Over a 3-month period, 41 out of 193 patients were identified by staff as pseu-
dopatients or imposters and a further 42 were considered suspect. In fact, no
pseudopatients were sent by Rosenhan in this period.
Cummins 5

Rosenhan’s Main Conclusions

Rosenhan concludes that diagnosis in psychiatry is inherently unreliable. It is
very reliant on the social and cultural context, in which the diagnosis takes place.
Nye (2003) argues that it should not be surprising, therefore, that minority,
marginalized, and oppressed groups are often overrepresented within mental
health systems. The label of mental illness is a very powerful one. He illustrates
the way that once a diagnosis has been given, then the behavior or personal
history of the individual is measured or reshaped via a stereotype. For example,
one of the pseudopatients reports his family and personal history which included
having a closer relationship with his mother than his father. This, as Rosenhan,
notes not exactly, an unusual pattern in 1950s American parenting, is seen as an
ambivalence in relationships. Rosenhan emphasizes that what he terms insanity
is not a permanent state. From their observations, the pseudopatients concluded
that their fellow patients were sane for long periods. However, the environment
and the power of labeling meant that this was never acknowledged.
The other major, but often overlooked theme in Rosenhan’s work is the
dehumanizing nature of hospital admission and life on the wards. As noted
earlier, the diagnosis once established was never challenged. In addition, there
were clearing incidences of violent behavior toward patients. The daily routine
was boring and repetitive. The physical conditions were shabby, and the food
served was poor. The issues have been consistently highlighted in research about
psychiatric care. At that time when he was writing, Rosenhan identified the
development of a more sympathetic approach to those detained in psychiatric
systems. Insanity as a term was being replaced by mental illness in common
usage. However, there were still an underlying series of negative and hostile
attitudes to the mentally ill. The Rosenhan experiment argues that these atti-
tudes were not just present among the general population but also the asylum
staff. While acknowledging that lack of resources was a factor in the poor
regimes on the ward, Rosenhan very tellingly concludes, ‘‘I have the impression
that psychological factors that result in depersonalization are much stronger
than the fiscal ones.’’
For Rosenhan, more money and other resources would not automatically
improve the experiences of patients, and a much broader shift in social and
cultural attitudes is required.

Critical Responses to Rosenhan

The most vocal response to Rosenhan came from Spitzer (1975). His critique will
be the starting point for a consideration of the broader issues that are raised by
the Rosenhan experiment. Spitzer was one of the key figures in the development
of the modern approach to the classification of mental disorders including the
6 Illness, Crisis & Loss 0(0)

writing of versions of Diagnostic and Statistical Manual of Mental Disorders

(DSM). He was chair of the task force of the American Psychiatric
Association that produced DSM-III in 1980. He was critical of the subsequent
development of the DSM. Spitzer was also a key figure in the moves that led to
the American Psychiatric Association voting to declassify homosexuality as a
mental illness.
Spitzer begins by questioning the fundamental premise of the Rosenhan. He
argues that sanity and insanity are not psychiatric classifications. They are not a
diagnosis that any psychiatrist would ever make. They are, rather, classifications
which vary significantly across legal jurisdictions. Spitzer is critical of the
strength of the claims that Rosenhan makes on the basis of such a small
sample. Kety (1974) puts forward a similar argument. He argues that if he
swallowed a quart of blood, went into a hospital and vomited it, then he
would initially be diagnosed with an ulcer on that basis. The subsequent discov-
ery of that he had swallowed the blood would not invalidate the whole of medi-
cine in this area. It would simply demonstrate that it is possible to mislead
doctors—a fact that it is well known and not in dispute. Spitzer (1975) highlights
the fact that the report of the experiment presents very little, if any, further
information about the behavior of the pseudopatients. The report implies that
the diagnosis was made solely on the basis of one symptom—hearing a voice.
There may have been other factors that influenced the final decision for admis-
sion. As Spitzer suggests, there was no reason for the psychiatrists to be par-
ticularly watchful of these particular patients. There may be other psychiatric
environments—the military or forensic psychiatry—where doctors need to be
more mindful of being misled by patients. Here, the psychiatrist had nothing to
suggest otherwise. The admission to hospital was an attempt to alleviate suffer-
ing and was a therapeutic intervention. It was an intervention that a humane
professional would make and the standard psychiatric one of that time. On the
basis of the professional knowledge and the psychiatric ethics of the period, it
would have be unusual not to admit the pseudopatients on the basis of their
presentations.
In his response to the Rosenhan paper, Spitzer (1975) argues that one of the
fundamental flaws in the argument is that the pseudopatients acted normally
while on the wards. He suggests that the normal response would have been to
identify yourself as a pseudopatient and asked to be discharged. There is some
mileage in this though logically one could take the argument and stage fur-
ther—would a normal person actually agree to take part in such an experiment.
Spitzer raises an important point here. An intriguing unknown is what would
have been the response of psychiatric staff in such circumstances. On discharge,
all the patients were said to be in remission. This is presented by Rosenhan as
evidence that the diagnosis is a permanent one. Spitzer disputes this pointing out
that in remission was very rarely used. He examined discharge reports at his own
hospital involving over 300 patients during a 12-month period. He could find
Cummins 7

none where the patient was described as being in remission. Thus, these patients
form a very distinct and rather unusual group. Spitzer does acknowledge that
there is a stigma attached to the label of mental illness. He sees the root of this is
not in the diagnosis but in the behaviors of the mentally ill. In effect, Spitzer
argues that stigma is the result of the failure of the mentally ill to conform to
social norms. He was writing at a time when the first wave of deinstitutional-
ization had taken place and there was something of a backlash against it. This
might help to put such comments in context. Spitzer concludes that Rosenhan
has underestimated the disagreement or inconsistency in diagnosis that occurs in
other areas of medicine. In addition, Rosenhan has not provided any alternative
to psychiatric diagnosis
Spitzer and Wilson (1975) in response to the furore that Rosenhan created
provided a defense or justification of the role of psychiatric diagnosis. They
suggest that rather than being a stigmatizing labeling tool, diagnosis has to be
understood as a form of professional discourse. It is a means, by which mental
health professionals communicate with each other—a short hand that provided
meaning. Alongside this role, it is a way of understanding and ultimately con-
trolling pathological processes and psychiatric disorder. This view of diagnosis is
one that essentially excludes the broader social implications. It might be valid for
the role of diagnosis within the psychiatric profession—and that is hugely debat-
able—but it fails to engage with the wider role of psychiatry in what Foucault
(1982) termed dividing practices.

Discussion
The question that now needs to be examined is what, if any, is the influence and
relevance of the Rosenhan experiment to contemporary mental health services.
To begin, the broader cultural legacy of the study has to be acknowledged. The
original paper has been cited well other three thousand times. The questions that
it raised about the nature and basis of diagnosis continued to be debated. There
is no space to examine the work of Spitzer in depth here. However, the increased
zeal of the classification of mental disorders and the expansion of DSM can be
seen as, in part, a response to Rosenhan’s work. The study is a staple of psych-
ology undergraduate courses and stands alongside others such as Milgram
(2009) and the Stanford Prison experiment (Haney & Zimbardo, 1998) as land-
mark studies within the discipline. Rosenhan, like the Milgram experiment is one
of those cultural tropes that is widely familiar, perhaps without the details of the
study being recalled or its broader significance being interrogated. It also, like
Milgram, raises profound philosophical and ethical questions, in particular
about the nature of power and authority. In her controversial book discussing
great psychological experiments, Slater (2005) claimed to have carried out her
own version of the experiment. The experiment has also received the ultimate
modern cultural acknowledge and been the basis for a classic episode of The
8 Illness, Crisis & Loss 0(0)

Simpsons (1991). In Series 3 Episode 1, Stark Raving Dad, Homer is sent to a

psychiatric unit for wearing a pink shirt to work. The episode plays with the
ideas of who is sane. On a much more serious note, there remains a strong
discourse, particularly in the media reporting of forensic psychiatry that it is
possible to hood wink naive mental health professionals and feign illness to
obtain better treatment or a reduced sentence. In the United Kingdom,
responses to the recent decision to move the multiple murderer, Peter Sutcliffe
from a forensic psychiatric hospital to a prison highlighted this (‘‘Yorkshire
Ripper Peter Sutcliffe,’’ 2016). It should be emphasized that Rosenhan did not
think that mental health professionals were naive and easily duped. Rather, the
experiment was seeking to explore the powerful impact of diagnosis.
Despite the fact that it is very small and somewhat ethically dubious, many
issues that are still relevant for mental health services remain in Rosenhan’s
study. It is difficult to believe that any Research Ethics panel would approve
such a study. It includes deception and puts individuals at risk. It would also
mean that precious resources from inpatient care would be used. The two fun-
damental areas that Rosenhan explores—the process and potential impact of
psychiatric diagnosis and the depersonalizing nature of psychiatric institu-
tions—remain key themes that need to be examined. There is a danger that
the iconic status of Rosenhan’s study means that there is a danger which is
not examined in real depth. In this process, its radical message may be obscured.
The potentially abusive or corrupting influence of institutional routines is at the
forefront of Rosenhan’s critique. The study should be read as a call for a
response to distress that is based on humanity and dignity.
Rosenhan was not the first to raise the problem of diagnosis. This is some-
thing that all is common to all the figures discussed in the chapters here. The
experiment that Rosenhan conducted brings these issues around diagnosis
together. The problem of diagnosis can be divided into a number of areas.
Spitzer’s response to Rosenhan that diagnosis is a form of technical discourse
between mental health professionals is, on one level, totally correct. However, it
is an inadequate response because it ignores the potential social and legal impli-
cations of such a diagnosis. One of the major issues that arises from this process
is that diagnosis is key to a number of interventions that are coercive (Moncrieff,
2010). If these diagnostic categories lack rigor, one has to consider how can
intervention based upon them be justified. In his argument with Spitzer,
Rosenhan noted the fact that the American Psychiatric Association voted on
whether homosexuality should be regarded as an illness was surely an evidence
that undermined this technocratic approach. The irony here being that Spitzer
had been at the forefront of the campaign.
Green (2013) and Pilgrim (2007) note that despite the consistent attacks on
the validity and consistency of psychiatric diagnosis, it remains very powerful.
The expansion of DSM does not seem to indicate that it will be marginalized at
any point in the near future. Bentall (2004) a leading critic of this neo-
Cummins 9

Kraepalian approach in mental health argues that one of the fundamental issues
is that the categories of diagnosis simply fail to capture the complexity of the
psychological distress that individuals experience. Terms such as schizophrenia,
psychosis, or depression are used across such a wider variety of human experience
and behavior that they can be rendered meaningless. Bentall’s work in particular
is a call for the abandonment of the process of diagnosis—in the sense that
people have to be categorized in some way when they are in distress or are
seeking help. Green (2013) argues that some form of classification is almost
inevitable. This may well be the case, the question then is how to insure that
these systems are flexible enough to allow for the complexity of human experi-
ence that they seek to encapsulate. In addition, they should not end in
themselves.
The work of Rosenhan is underpinned by a fundamental concern for his
fellow citizens who are experiencing mental distress. He makes it explicit by
raising questions about diagnosis that he is not seeking to deny the existence
of psychological distress. This work forces the reader to examine the context and
processes of diagnosis in mental health. Diagnosis can be seen as a form of
symbolic violence (Bourdieu, 1991, 1998). It creates what Goffman (1961)
would term a spoiled identity. It is very important to note that—as with other
forms of labeling—labels are identities that are not fixed. They can be seen as
sites of resistance. The powerful nature of the label means that it creates a desire
to overturn it or challenge what that might mean. This part of a process of
maintaining one’s identity—that is, the one that existed before diagnosis—or
creating a new one that incorporates mental illness but is not solely defined by
that aspect of one’s life. Sen (2007) highlights the fact that there is a danger of
using only aspect of a person’s identity as a means of classification. All of us
have many roles and identities. One of the real difficulties that Rosenhan high-
lighted was that psychiatric identities tend to remain fixed and can be
dominating.
The challenge to the psychiatric diagnosis is clearly one of the key aspects of
the Rosenhan experiment. It has to be acknowledged that it is a challenge that
organized psychiatry was able to respond to in a very powerful fashion. The
work of Spitzer and the development of later versions of DSM reflect this. The
second major theme of Rosenhan’s work, the importance of relational attitudes
within institutional settings, is often overlooked.
The moves toward deinstitutionalization and the resulting failures of com-
munity care have been the subject of much debate (Cummins, 2016; Knowles,
2000; Moon, 2000; Wolff, 2005). Scull (2015) argues that this has distorted our
view of mental health provision which has always been centered around institu-
tionalized forms of care. Recent community mental policies, from this perspec-
tive, are a break in this approach. The focus on the failings or gaps in
community mental health services has, in some senses, masked the fact that
institutional forms of care continue to have a central role in mental health
10 Illness, Crisis & Loss 0(0)

services. The majority of the limited mental health budget is still spent here.
Recent reports in the United Kingdom have highlighted the limited availability
of psychiatric beds. These are very important issues. However, there is a much
broader debate about the nature of mental health services that needs to take the
place.
Rosenhan and his fellow volunteers reported that the admission to hospital
was overshadowed by a negative and ultimately toxic organizational culture.
Violence toward inpatients occurred and there appeared to be no organizational
response. In addition, the picture painted of the wards is a drab one. There was
little constructive activity or therapeutic intervention. The staff, apart from the
orderlies, made few, if any, attempts to engage with patients in their care or
establish personal relationships. It might be tempting to see this as a portrait of
the old asylum that has been abolished. However, research shows that the
experiences for inpatients 40 years after Rosenhan can be a very negative one.
Quirk and Lelliot (2004) note that deinstitutionalization seems to have had a
detrimental effect on the care provided on acute psychiatric wards. This may be
because of a shift in resources and also organizational changes. It is still the case
that mental health units are closed worlds.
Jones et al.’s (2010) study of the experiences of inpatients highlighted that
wards were, often, not providing a safe and secure environment. If patients do
not feel safe, then the culture can never hope to be a therapeutic one. In this
work, patients reported feeling physical unsafe including accounts of violence,
bullying, intimidation, and racism. In addition, street drugs were easily avail-
able. The situation is more complex than this; 53% of those interviewed stated
that they would miss the ward. The authors suggest that this reflects the social
isolation that many patients feel when they are discharged. Despite these issues,
interviewees felt that the ward was able to provide some sense of security at a
time of crisis. This work echoes findings by Baker (2000) which identified similar
problems of safety on acute wards. This study also found that wards were phys-
ically dirty, and there was a lack of constructive activity. There was a lack of
opportunities to exercise or even just get fresh air. Few amenities were available
to enable families, particularly children to visit. Rosenhan makes it clear that
there was an often hostile relationship between staff and patients. The lack of
interaction between the two groups was a factor. However, he also suggests that
staff are not immune to the broader negative cultural views that remain deeply
embedded within much discourse (Cross, 2010).
As noted earlier, Rosenhan forcibly argues there are organizational and cul-
tural issues that are at the root of the poor care offered. It would be naı̈ve to think
that there are no resource issues involved here. However, work since Rosenhan
has emphasized that a culture of abuse develops in environments which are iso-
lated from the wider community where care is being provided for marginalized
groups. Great investment, though clearly welcome, will not in and of itself solve
these problems. The Royal College of Psychiatrists (2011) has produced guidance
Cummins 11

on how to judge the features of a good psychiatric ward. These features include a
maximum of 18 beds, a bed occupancy of rate of less than 85%, a proportionate
and respectful approach to risk, access to psychological interventions, and socially
and culturally sensitive care. The Care Quality Commission (2013) raised concerns
over the widespread use of blanket rules on mental health wards. These bans
include prohibiting the use of mobile phones or the Internet, smoking, and even
access to outdoor spaces that were secure. In nearly half of cases, the reason given
for these rules was hospital policy. Other reasons included historical incidents and
in 13% of cases no one actually knew. That a significant number of people could
not say why these rules were in place but enforced them just the same raises the
issue of power and how it can be abused, knowingly or unknowingly, in different
ways in mental health settings.

Conclusion
The Rosenhan study, as its critics have pointed out, has several methodological
flaws. The ethical issues have not been examined in such depth. It is clearly of its
time. In particular, there is little real attention paid to the views of service-users.
Genuine patients are part of the chorus, but their experiences never actually make
it to center stage. Issues of race and gender are not considered. Despite these
issues, the study raises many matters that are of ongoing concern for contempor-
ary mental health services and I would argue the broader society. As noted earlier,
institutuionalized, often coercive provision remains and is likely to remain a key
feature of mental health services. The experiences of this form of treatment need
to be understood from the perspectives of all those involved. There is actually
comparatively limited research that examines the ward or the impact of being an
inpatient, particularly research that is fully inclusive of service perspectives.
Rosenhan’s argument that diagnosis acts as a prism through which behavior is
analyzed remains valid. The label of mental health diagnosis within services and
also the wider cultural and social institutions, for example, media TV, film, and
the Courts, remains an incredibly powerful one.
The limitations of the study should not mask its strengths and ongoing rele-
vance for mental health services or other social welfare provision. The key mes-
sage is that all institutions have the potential to become toxic, damaging, and
abusive. The development of an abusive or antitherapeutic environment is not
solely related to the material or physical conditions. It is important that these
meet acceptable standards. However, the most important aspect of any institu-
tion is the organizational culture and the value base of the staff. When he gave
the eulogy at Professor Rosenhan’s funeral in 2012, Lee Shuman described his
most famous piece of work thus

. . . more than the report of an immensely inventive piece of research . . . it is a

proclamation, a moral outcry, a scream of pain and a demand that the world be
12 Illness, Crisis & Loss 0(0)

on witness to the consequences of wrongful diagnosis of ungrounded labeling of

institutions whose very design shapes errors of diagnosis.

It is impossible to create a therapeutic environment, which is not based on key

values such as dignity and respect. A lesson that was as valid and relevant when
Rosenhan published his seminal work, as it is now.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, author-
ship, and/or publication of this article.

Funding
The author received no financial support for the research, authorship, and/or publication
of this article.

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Author Biography
Ian Cummins qualified as a probation officer and worked as a mental health
social worker. His research focuses on mental health issues across the CJS. He is
particularly interested in policing and mental health. He argues that failings in
community care have led to the CJS taking on an increasing role in the provision
of mental health services.