In 1973, a psychologist named David Rosenhan did something extraordinary. He and seven other perfectly healthy people walked into psychiatric hospitals across America complaining of hearing voices that said “empty,” “hollow,” and “thud.” All eight were admitted. Seven were diagnosed with schizophrenia, one with manic-depressive psychosis.
Here’s where it gets interesting: the moment they were admitted, they stopped faking any symptoms. They behaved completely normally. Took notes. Chatted with staff. Followed the routine. They were, by any reasonable measure, obviously sane.
But none of the staff noticed. Not one.
The pseudopatients were kept for an average of 19 days, some for nearly two months. And when they were finally released, their diagnoses weren’t “actually, you’re fine.” They were discharged with schizophrenia “in remission.” The diagnosis stuck, even though it had been wrong from the start.
Meanwhile, actual patients often recognised the pseudopatients as frauds. “You’re not crazy,” one said. “You’re a journalist or a professor checking up on the hospital.”
When the Label Becomes the Lens
What Rosenhan exposed wasn’t just diagnostic error. It was something more fundamental: once a label is applied, everything gets interpreted through that lens. When pseudopatients took notes for the study, staff recorded this as “patient engages in writing behaviour,” pathologising a completely normal activity because it was being done by someone with a diagnosis.
The diagnosis became self-reinforcing. It shaped what staff saw, how they interpreted behaviour, what questions they asked. Or didn’t ask.
In Part 1 of this series, I wrote about my experience as a counsellor watching more and more people arrive at therapy with ADHD self-diagnoses, and my concern that the label can foreclose exploration rather than open it up. But there’s a bigger question beneath that concern: what if the systems we’ve created are actually generating the symptoms we’re so quick to diagnose?
What if we’re not just mis-diagnosing the cage? What if we’re diagnosing the cage itself, and calling it a disorder?
It’s Not the Rat, It’s the Cage
Bruce Alexander’s Rat Park experiments in the late 1970s fundamentally challenged how we think about addiction and mental health. The standard model at the time was simple: addiction is about the substance. Rats in cages, given access to morphine-laced water, would drink compulsively until they died. Proof that addiction is chemical, biological, inevitable.
But Alexander asked a different question: what if the cage matters?
He built Rat Park, a large, enriched environment with space, social connection, activities, and things to explore. Then he gave these rats the same choice: plain water or morphine water. The Rat Park rats barely touched the drugs. Meanwhile, rats alone in barren cages drank the morphine compulsively.
It wasn’t about the rats’ brains. It was about their environment.
Now apply that to humans. Johann Hari, synthesising decades of research on depression and anxiety, found the same pattern: social disconnection, lack of meaningful work, childhood trauma, insecure housing, and poverty create symptoms we medicalise as disorders. We’re not chemically imbalanced. We’re living in barren cages and responding exactly as we should.
The Cross-Cultural Evidence
If ADHD were purely neurobiological, we’d expect to see relatively consistent rates across populations. But we don’t.
ADHD diagnosis rates in the US are 5-10 times higher than in many European countries. France has significantly lower rates, which some researchers attribute to different parenting approaches, less medicalisation of childhood behaviour, and different educational structures. Even within the US, diagnosis rates vary dramatically by state and socioeconomic status.
Studies of immigrant children show something particularly revealing: ADHD rates change based on cultural context, not genetics. A child might have low risk of diagnosis in their country of origin but high risk after moving to a Western country with different expectations about attention, behaviour, and productivity.
What does this tell us? That ADHD is at least partly about cultural expectations, tolerance for variation, educational structures, and what we define as “normal” rather than purely about individual neurology.
Peter Gray’s research on play deprivation adds another layer. He documents the dramatic decline in unstructured, child-directed play since the 1950s and its correlation with massive increases in anxiety, depression, and attention problems. Children today spend dramatically less time playing freely outdoors, taking risks, exploring, and managing their own activities. Instead, they’re in adult-supervised, structured environments from morning until night.
And we wonder why they struggle to self-regulate, manage boredom, and sustain attention on tasks they haven’t chosen?
Richard Louv’s work on “nature deficit disorder” shows similar patterns. Children disconnected from natural environments show increased rates of attention difficulties, anxiety, and behavioural problems. Time in nature improves attention span, reduces stress, and supports emotional regulation. Basically, the opposite of ADHD symptoms.
Children today are less free than they have ever been, and this lack of freedom is a major reason for the rise in mental disorders.
The ACE Connection
The Adverse Childhood Experiences (ACE) studies revealed something that should have transformed mental health care but largely hasn’t: childhood trauma and adversity create symptoms that look identical to psychiatric disorders.
Children who experience abuse, neglect, household dysfunction, or other adverse experiences are significantly more likely to develop attention problems, emotional dysregulation, impulsivity, and difficulty with relationships. Symptoms that look exactly like ADHD, or depression, or anxiety, or personality disorders.
Gabor Maté has spent decades arguing that what we call ADHD is often a response to developmental trauma and attachment disruption. The child’s nervous system adapts to survive an unpredictable or threatening environment by becoming hypervigilant, distractible, unable to settle. That’s not a disorder. That’s an intelligent adaptation that becomes problematic when the environment changes.
Bessel van der Kolk makes similar arguments about trauma responses being mis-diagnosed as primary psychiatric disorders. We’re treating symptoms as if they’re the problem rather than asking what created those symptoms in the first place.
Who Benefits From Medicalisation?
Here’s where it gets uncomfortable. There are powerful economic and political incentives to keep the focus on individual pathology rather than systemic conditions.
Pharmaceutical companies profit enormously from ADHD diagnoses. Stimulant medications are a multi-billion pound industry. Every new diagnosis is a potential customer for life.
Healthcare systems benefit from brief, standardised interventions that manage demand efficiently. It’s far cheaper to prescribe medication or deliver six sessions of CBT than to address poverty, improve schools, provide stable housing, create meaningful work, or redesign communities to support human connection and wellbeing.
Governments benefit because medicalisation deflects attention from policy failures. If mental health problems are individual disorders requiring individual treatment, we don’t have to ask uncomfortable questions about inequality, working conditions, education policy, or how we’ve organised society.
This isn’t conspiracy. It’s just how systems work. When there are strong incentives pushing in one direction, that’s the direction things tend to go. And right now, all the incentives favour locating problems in individual brains rather than in the cages we’re living in.
The Rosenhan Legacy
What haunts me about the Rosenhan experiment isn’t just the initial misdiagnosis. It’s what happened after.
The psychiatric establishment was embarrassed. So Rosenhan told one hospital he’d be sending more pseudopatients in the next three months and challenged them to identify the fakes. The hospital staff, now hypervigilant, identified 41 suspected pseudopatients out of 193 new admissions.
Rosenhan hadn’t sent anyone. All 193 were genuine patients.
The system couldn’t win. Either it admitted people who didn’t need admission, or it rejected people who did. The diagnostic categories themselves were the problem, creating a lens that distorted rather than clarified.
I think about this when I sit with clients who arrive convinced they have ADHD. I’m not trying to catch them out or prove they’re faking. But I am wondering: has the diagnosis already become the lens through which they, and everyone around them, interpret everything they do?
When they struggle to focus, is that evidence of ADHD? Or is it a normal human response to an overwhelming, distracting environment? When they’re restless and impulsive, is that pathology? Or is it a healthy nervous system protesting against constraints that don’t fit human needs?
The Deeper Question
In Part 1, I wrote about my frustration watching people reach for diagnostic explanations rather than exploring deeper questions about the human condition. But the research I’ve explored here points to an even more uncomfortable truth: we’ve created environments that are fundamentally incompatible with human wellbeing, and then we pathologise the people who struggle in those environments.
We’ve put children in educational systems designed for compliance and standardisation, then diagnosed the ones who can’t sit still. We’ve created work cultures that demand constant attention on boring tasks, then medicated the people who struggle. We’ve built communities without connection, nature, play, or meaning, then called the resulting distress a mental health epidemic.
Rat Park taught us that environment matters more than individual pathology. The cross-cultural evidence shows that ADHD rates are shaped by cultural factors, not just biology. The ACE studies reveal that trauma creates symptoms identical to psychiatric disorders.
So what are we actually treating? Disorders? Or intelligent responses to disordered environments?
In Part 3 of this series, I’ll explore what we’ve lost in modern life, what it’s costing us, and what reclaiming those losses might look like. Because I think the solution isn’t better diagnosis or better medication. It’s better cages.
Or ideally, no cages at all.
