32 pages • 1 hour read
David L. RosenhanOn Being Sane in Insane Places
Nonfiction | Essay / Speech | Adult | Published in 1973A modern alternative to SparkNotes and CliffsNotes, SuperSummary offers high-quality Study Guides with detailed chapter summaries and analysis of major themes, characters, and more.
Themes
The Unreliability of Psychiatric Diagnoses
“On Being Sane in Insane Places” centers on the unreliability of psychiatric diagnosis. The 1970s were marked by an emerging skepticism toward the unquestioned authority of medical professionals and a burgeoning awareness of the rights of mental health patients. David L. Rosenhan’s study dovetails with these societal trends, probing the trustworthiness of psychiatric diagnoses and the consequences of their unreliability.
In fact, Rosenhan’s experiment was only possible because of that unreliability. By reporting auditory hallucinations, Rosenhan and his colleagues successfully gained admission to psychiatric hospitals. Rosenhan implies that even at this stage, confronted with the pseudopatients’ outright falsehoods, the system might have detected their status as mentally healthy: The pseudopatients reported hearing words that communicated a sense of existential purposelessness, and these words were chosen in part by the “absence of a single report of existential psychoses in the literature” (251). This already raises doubts about the diagnostic process, which ought to have flagged the pseudopatients’ reports as unusual, even on its own terms. That it did not points to the malleability of purportedly objective diagnostic criteria, as does the fact that one of the pseudopatients received a diagnosis of “manic-depression” (bipolar disorder) rather than schizophrenia despite presenting with exactly the same “symptoms” as every other subject. In a note following the essay, Rosenhan observes that the pseudopatient who received this diagnosis went to a private hospital catering to a more elite clientele. The implication is that his perceived social class weighed strongly in the diagnosis, presumably because practitioners are less willing to saddle higher-income patients with the more stigmatizing diagnosis of schizophrenia, which (as Rosenhan observes) has a relatively poor prognosis.
Rosenhan’s account of the pseudopatients’ subsequent hospitalization only deepens his critique. Their “normal” behavior was consistently misinterpreted as symptomatic of mental illness; for example, a nurse who approached one pacing pseudopatient assumed that he was anxious when in fact he was simply bored. The pseudopatients’ initial diagnoses were never revised; when they were discharged, they were described simply as being “in remission.” The phrase indicates that within the psychiatric institution’s framework, the pseudopatient could never be categorized as mentally healthy; they could only ever aspire to a lessened state of their diagnosed condition. The possibility of false diagnosis or transient illness was not even entertained.
The psychiatric system’s apparent inability to course-correct exacerbates what Rosenhan presents as the central problem with psychiatric labels: They do not describe anything tangible. The diagnostic criteria are slippery and open to interpretation in large part because the causes of mental illness remain unknown:
I may hallucinate because I am sleeping […]. These are termed sleep-induced hallucinations […]. But when the stimuli to my hallucinations are unknown, that is called craziness, or schizophrenia—as if that inference were somehow as illuminating as the others (254).
In the absence of real understanding of mental illness, Rosenhan advocates for a reevaluation of the methods and ethics in psychiatric diagnosis, emphasizing the necessity for a more holistic understanding of mental health—one that takes into account factors like environment and focuses on describing behaviors rather than people.
The Subjectivity of Mental Health Terminology
Beyond examining the unreliable nature of psychiatric diagnoses, Rosenhan also engages in a philosophical exploration of the constructs of “sanity” and “insanity,” presenting a challenge that extends beyond psychiatric practices to our fundamental understanding of these concepts. Rosenhan’s study culminates in a strong assertion: “It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals” (257). His stance paralleled contemporaneous existential and postmodern philosophical movements that emphasized the subjective nature of reality and the limitations of human knowledge. Rosenhan’s inquiry dovetailed with these philosophical currents, confronting the binary thinking prevalent in discussions of mental health.
For example, while Rosenhan does not deny the existence of psychiatric symptoms that are (from a strictly numerical perspective) “abnormal,” he questions whether it makes sense to conceptualize these symptoms in terms of discrete states like “sanity” and “insanity.” As Rosenhan notes, everyone at times behaves in ways that are strange or out of character:
The ‘sane’ are not sane all the time. We lose our tempers ‘for no good reason.’ We are occasionally depressed or anxious, again for no good reason. And we may find it difficult to get along with one or another person—again for no reason that we can specify. Similarly, the insane are not always insane (254).
Rosenhan here implies that “sanity” exists on a continuum; the only difference between someone who is mentally healthy and someone who is mentally ill, he suggests, is the amount of time each spends engaging in “abnormal” behavior. This holds true even for symptoms or behaviors conventionally understood to be signs of “severe” mental illness—e.g., hallucinations, which Rosenhan notes can be induced by everything from drugs to sleep.
Moreover, Rosenhan suggests that “sanity” and “insanity” are context-dependent, both in the sense that environment shapes behavior and in the sense that it shapes the perception of behavior. As environments marked by routine dehumanization, the psychiatric hospitals Rosenhan profiles provide ample opportunity to explore this idea. He recounts, for example, how staff would dismiss patients’ outbursts over mistreatment: “A nurse coming upon the scene would rarely inquire even cursorily into the environmental stimuli of the patient’s behavior. Rather, she assumed that his upset derived from his pathology” (253). In a hierarchical hospital environment that takes for granted patients’ illness and privileges their compliance, what would otherwise seem rational—resistance to injustice—becomes a sign of “insanity.” Rosenhan further implies that this tends to exacerbate whatever “real” symptoms a patient may have, as the experience of being in such a topsy-turvy (“insane,” as his title suggests) environment is both frustrating and disorienting.
Rosenhan thus invites readers to reassess the fluid and often ambiguous nature of what society considers “sane” or “insane.” In doing so, he urges a more empathetic and flexible approach to those with mental illnesses, who Rosenhan suggests are not categorically different than anyone else. More broadly, he underlines the importance of acknowledging and accepting the complexity and diversity of mental experiences.
Stigmatization and Dehumanization in Mental Health Care
Another theme throughout the essay is the stigmatization and dehumanization of people with mental illnesses. Despite the onset of the deinstitutionalization movement in the late 1950s, many individuals with mental illnesses were still confined to large, impersonal psychiatric hospitals as of the 1970s. These institutions were widely criticized for substandard conditions and a lack of personalized care, often resulting in patient isolation from society. Moreover, mental illness carried a heavy stigma during this era and was commonly associated with danger and unpredictability, partly due to sensationalized media portrayals. Emerging in this context, Rosenhan’s essay offers a lens for understanding how psychiatric labels can dehumanize individuals and perpetuate societal prejudices.
Rosenhan’s observation that “the tag profoundly colors others’ perceptions of [a person] and his behavior” encapsulates the transformative impact of diagnostic labels on individual identity (253). The use of the term “colors” implies a distortion of reality, reflecting societal biases and misunderstandings about mental illness. What that distortion consists of becomes clear in Rosenhan’s discussion of the efforts to normalize mental illness by treating it as a medical problem:
[I]t is doubtful that people really regard the mentally ill in the same way that they view the physically ill. A broken leg is something one recovers from, but mental illness allegedly endures forever. A broken leg does not threaten the observer, but a crazy schizophrenic? There is by now a host of evidence that attitudes toward the mentally ill are characterized by fear, hostility, aloofness, suspicion, and dread. The mentally ill are society’s lepers (254).
Besides highlighting the negative emotions associated with mental illness, the passage uses the allusion to leprosy to highlight the extent of the problem, leprosy being a disease that once led to severe social ostracization (that leprosy was itself a physical condition also suggests the futility of trying to rehabilitate mental illnesses’ image along those lines). The rhetorical question “[…] but a crazy schizophrenic?” (254) aims to provoke the reader, challenging them to confront their own biases. Rosenhan’s choice of the word “crazy” is deliberate, reflecting the harsh and often inaccurate labels society places on individuals with mental illness.
However, it is not merely laypeople who need this reminder. Rosenhan suggests that bias against mental health conditions is widespread even among those who specialize in psychiatry/psychology. This has serious implications for conditions within psychiatric hospitals; the essay recounts instances of patients being punished or even abused for simply speaking to hospital workers. While Rosenhan suggests that such mistreatment springs partly from broader societal views of mental illness, he also argues that the hospital environment facilitates dehumanization. For example, physical separation between patients and staff limits opportunities to engage with one another simply as people and exacerbates the tendency toward hierarchical relationships implicit in hospital structure. If the essay calls for a reconceptualization of mental illness, it therefore also calls for a reconceptualization of the spaces in which treatment of mental illness occurs.
