When you break a bone, you can get an x-ray to see that the bone is broken, and get a cast to help it heal. When you get a big cut, you can see the blood and understand that you need stitches.

When you are struggling with mental health, what symptoms can you and others see? How do other people know what symptoms you are experiencing?

• What is the Rosenhan study on the influence of labels?
• What was Rosenhan's hypothesis, and what were the central questions in the study?
• What was the outcome of Rosenhan's study?
• Why is Rosenhan's study on the influence of labels useful?
• What are the strengths and weaknesses of Rosenhan's study?

The Rosenhan Study on the Influence of Labels

David Rosenhan, an American psychologist, conducted a study (1973) based on the idea that sanity and insanity are not that different from each other. He wondered if a person's symptoms lead to a diagnosis, or if the biases and training of the clinician determine the diagnosis. He also wanted to know if labels (i.e., diagnoses) lead hospital staff to interpret behaviors in a certain way.

Rosenhan developed his study to see if staff in a psychiatric section of a hospital would misdiagnose patients. His participants were three women and five men (including himself), all with no mental health problems or diagnoses. The study took place in 12 separate hospitals. Some of the psychiatric wards had a higher staff-to-patient ratio, some were older, one was private, and some were in different states.

As they were being interviewed by clinicians, the participants reported that they were hearing voices, which is a common symptom of schizophrenia. This was the only symptom the participants reported. The participants answered all other questions that the clinicians asked truthfully. At the time, that one symptom alone was enough for all of the participants to be admitted to the hospital!

Once the participants were admitted, they immediately stopped lying about hearing voices and acted completely normal. Rosenhan and his participants had to act well enough to be discharged. A condition of the study was that the participants could not choose to leave and go home; they had to wait until they were officially discharged by hospital staff. In other words, the hospital staff had to believe that the participants were well enough to leave.

Fig. 1. Rosenhan investigated whether doctors misdiagnosed pseudopatients.

Rosenhan's Hypothesis on the Influence of Labels

Rosenhan had several hypotheses or predictions about the outcome of this study:

• If the participants reported hearing voices, they would be diagnosed as schizophrenic.
• If the participants were diagnosed with schizophrenia, they would be admitted to the psychiatric section of a hospital.
• If the participants entered a psychiatric hospital for symptoms of schizophrenia, the hospital staff would be unable to determine that the participants in the study were not schizophrenic.
• If the hospital staff were unable to determine the participants were not schizophrenic, the participants would not be discharged from the hospital unless they were deemed to be better.

Rosenhan's Central Research Questions

Rosenhan's study centered on the validity of a mental health diagnosis. Would a trained professional who had dedicated years of their life to education and treatment of mental health disorders be able to determine if someone was lying? He wondered if any of the clinicians would be able to figure out the ruse, or if the impact of the label of schizophrenia would cloud the clinician's judgment.

Another question he focused on was the distinction between someone with a diagnosed mental illness and someone without one. Is there actually a difference? Can anyone really tell? Are mental health disorders just extreme examples of things that many people experience at some point in life? He wondered if the actions of his participants would be perceived differently simply if they were labeled as schizophrenic. He questioned how different those with mental health disorders actually are from the general population.

Fig. 2. Rosenhan researched the distinction between someone with and someone without a mental illness diagnosis.

The Outcome of the Influence of Labels Study

Rosenhan's results were in line with his predictions. In other words, he was able to affirm his hypotheses. None of the participants were identified by staff members as not having schizophrenia. The mental health clinicians were completely unable to tell the difference between the symptoms of actual patients and the lack of symptoms of participants in the study.

Even in the psychiatric hospital, the label of schizophrenia caused staff members and doctors to view and treat the participants differently than they would otherwise. The staff completely misinterpreted the stories and actions of the participants.

Rosenhan provides an example of a participant who told a psychiatrist about his relationship with his parents. Nothing bad ever happened, but he was closer to his mother growing up than his father. As he got older, he became closer to his father. Currently, he was close with his wife and rarely fought with her, and he rarely spanked his kids. All of this sounds pretty normal, right?

Despite the participant's lack of any mental health symptoms, the account from the psychiatrist reports,

The psychiatrist viewed the participant’s story and actions through the lens of the schizophrenic label. Other behaviors of participants were misinterpreted as well. A nurse saw a participant pacing the hallways and asked if he was nervous. He said that he was just bored. A participant got upset at a nurse, and another staff member assumed it was related to his mental health. It was just that the nurse was annoying the participant. The staff always viewed the behaviors of the patients as a result of their diagnosis rather than other, normal factors.

Fig. 3. Rosenhan concluded that diagnosis is influenced by clinical interpretations.

The Usefulness of the Influence of Labels Study

One interesting finding of the study was about the real patients in the hospitals. While the hospital staff members were completely unable to recognize that the participants in the study were not actually schizophrenic, many of the patients in the psychiatric ward had no problem seeing that the participants suffered from no mental health symptoms! Maybe the staff did not pay enough attention to the participants. If the staff treated the participants the same way they treat people in real life, would they have noticed that they seemed to be fine?

When the mental health clinicians in the hospitals were told that the participants were schizophrenic (even though they were not), their actions and attitudes were interpreted through the schizophrenic label. These clinicians even viewed the participants’ stories differently when they knew they were diagnosed with schizophrenia. This shows just how impactful a label can be.

Just like the doctors and nurses in the hospitals, we may view and treat people differently when we know about someone’s mental health struggles. It might cause us to treat them worse, or maybe with more compassion than we normally would. Either way, it changes the way we interact with them. Many mental health disorders are stigmatized. Those that suffer from them are viewed as crazy, and this impacts how they are treated by others.

The world has changed a lot since 1973. Rosenhan's study highlighted not only the misdiagnosis of mental disorders and the biases of clinicians, but also the ease of diagnosis and admittance to treatment. All someone had to do was say that they were hearing voices to be admitted to a psychiatric hospital.

Thankfully, this is not the case today in the US. Psychiatric hospitalization is treated more as a last resort than a first treatment. Scribner (2001) conducted a study similar to Rosenhan's, with updates to account for changes in culture and technology. He was unable to produce similar results. Rather than participants being diagnosed and admitted right away, they had a hard time getting admitted at all.

The Strengths and Weaknesses of Rosenhan's Study

A strength of the study is the wide variety of hospitals that Rosenhan selected for his study. They varied from small to large, old to new, public to private. Diversity in his selection of hospitals increased the generalizability of his study results.

Another strength of the study is that none of the clinicians knew they were part of the study. This allowed them to act as they always did and not change their behaviors because they knew they were being watched. If they knew they were part of a psychological study, they might have noticed an admitted participant who wasn't experiencing any symptoms.

A weakness of the study is how much time has passed and how much has changed since it was first published. This study was a product of its time, but the findings are unable to be replicated now. The majority of the study took place after the participants were admitted to a hospital, but this is difficult to achieve now. Given how difficult it can be to get treatment for mental health disorders today, the focus of a new study could be how to navigate the obstacles to getting treatment. Another weakness is that all of the hospitals were located in the United States. While this allows the results to be generalized across American hospitals, the results can only be applied within the US.