On Being Sane in Insane Places

David L. Rosenhan’s “On Being Sane in Insane Places” is compact but far-reaching in scope, intertwining empirical investigation with a sociohistorical argument. The target audience for Rosenhan’s essay is twofold: the psychiatric community and the informed public. Published in the prestigious journal Science, the essay implicitly speaks to Rosenhan’s peers in the scientific community, evidencing its academic pedigree. However, the reach and implications of his study extend far beyond the confines of academia, encouraging the layperson to rethink their attitudes toward people with mental illnesses.

Core to this is Rosenhan’s exploration of The Subjectivity of Mental Health Terminology. A behavior that seems pathological to one person or in one context may resonate completely differently elsewhere. For example, where a psychiatrist sees some patients’ habit of waiting outside the dining hall as evidence of an “oral-acquisitive nature,” Rosenhan suggests that the patients may simply be looking forward to one of the few highlights of their day: “It seemed not to occur to [the psychiatrist] that there were very few things to anticipate in a psychiatric hospital besides eating” (253). Conversely, Rosenhan implies that some behavior treated as “normal” is actually quite strange, such as the following response to a pseudopatient’s question about grounds privileges: “(physician) ‘Good morning, Dave. How are you today?’ (Moves off without waiting for a response” (255). Rosenhan calls this interaction “bizarre,” yet the preoccupation of hospital staff combined with the dehumanization of patients causes it to appear “normal” to the doctor and his peers. Such detailed observations seek to engage the reader’s sense of critical thinking, prompting questions about the very foundation of what is considered “normal” and “abnormal” and the ways in which such concepts are situationally bounded.

A closely related theme is The Unreliability of Psychiatric Diagnoses. As Rosenhan explains, his critique of the medical model of mental illness does not deny the existence of psychiatric symptoms: Hallucinations, for example, are a real phenomenon. However, Rosenhan’s study raises questions about whether such phenomena meaningfully correlate with particular psychiatric diagnoses. Though the pseudopatients misrepresented their symptoms, the ease with which healthy individuals were misdiagnosed as mentally ill implies significant holes in the diagnostic process, as does the experiment’s inversion, where hospital staff confidently identified “real” psychiatric patients as pseudopatients. The experiment serves as a metaphor for the dangers of complacency in broader diagnostic practice. It underscores the need for a more nuanced, empathetic, and individualized understanding of mental health rather than reliance on oversimplified and often inaccurate labels.

The Stigmatization and Dehumanization in Mental Health Care is all the more reason to question the labels’ utility, according to Rosenhan. This theme is particularly resonant in the context of the 1970s, a period marked by a growing awareness of individual rights and the potential for institutional abuse. Rosenhan’s accounts of the experiences of pseudopatients in psychiatric hospitals shed light on the loss of identity and agency that often accompanies a psychiatric diagnosis. As Rosenhan explains, mental health diagnoses are “pejorative” in a way other diagnoses are not; they are seen not merely as misfortunes but also as marks of disgrace or reproach. This choice of word emphasizes the negative connotations that society attaches to mental illness, which can lead to prejudicial attitudes and discrimination, even among medical staff. Moreover, because mental health conditions manifest partly through behavior, all of the patients’ actions become subject to a paradoxical combination of scrutiny and apathy. This is evident, for example, in Rosenhan’s discussion of staff responses to the pseudopatients’ notetaking:

Nursing records for three patients indicate that the writing was seen as an aspect of their pathological behavior. ‘Patient engaged in writing behavior’ was the daily nursing comment on one of the pseudopatients who was never questioned about his writing (253).

This passage reveals how a psychiatric diagnosis can flatten a person into a stereotype. The phrase “patient engages in writing behavior” (253) is a clinical observation; the choice of the word “behavior” immediately medicalizes the act of writing, transforming what could be a sign of creativity or (as was actually the case) a hidden agenda into a symptom of mental illness. The failure to seek any alternative explanation for the pseudopatients’ actions caused staff to overlook the obvious—that the pseudopatients were in fact mentally healthy—and indicts the psychiatric establishment for failing to approach people with mental illnesses as humans first and patients second.

The essay employs figurative language to broaden its relevance and appeal. In the above anecdote, for example, the choice to focus on “continuous writing” as a point of misunderstanding between staff and patients serves as a synecdoche (a part that represents a whole) for the marginalization of patients’ voices and perspectives. Similarly, the particular psychiatric hospitals Rosenhan describes evoke the broader psychiatric system, representing both the physical and conceptual space where diagnoses are made and identities are shaped or altered. The pseudopatients are not just individuals but stand-ins for anyone who could potentially fall victim to misdiagnosis and the resulting loss of autonomy and identity. Other forms of figurative language appeal to readers’ emotions. For example, Rosenhan’s reference to a patient being “shorn of credibility” by virtue of hospitalization uses language associated with sheep farming to suggest patients’ dehumanization (256), the stripping of their agency and rights to an animal-like status.

Such devices contribute to the restrained sense of urgency that characterizes Rosenhan’s tone throughout the essay, as do narrative techniques that actively engage the reader. For example, his use of rhetorical questions involves the audience in a dialogue, urging readers to ponder the ethical and practical implications of psychiatric diagnoses from the first line: “If sanity and insanity exist, how shall we know them?” (250). Likewise, while the essay’s structure reflects the scientific method in its progression from hypothesis to experiment to results and discussion, Rosenhan enriches his analysis with subjective accounts from the pseudopatients—including Rosenhan himself, who is present throughout the text in a way scientific researchers conventionally are not. This mirrors Rosenhan’s goals: to provide a more complete picture of the impact of psychiatric systems on individuals and to inject such humanity back into mental health care practice.