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Dr. David Rosenhan had himself admitted as a ''mental patient'' in 1972 and wrote of his findings regarding the experience. He had a similar experience in relation to his study which is based on his similar experience. "(hat is )) or is not )) normal! may ha$e much to do with the la%els that are applied to people in particular settings. &f sanity and insanity exist' how shall we know them
Dr. David Rosenhan had himself admitted as a ''mental patient'' in 1972 and wrote of his findings regarding the experience. He had a similar experience in relation to his study which is based on his similar experience. "(hat is )) or is not )) normal! may ha$e much to do with the la%els that are applied to people in particular settings. &f sanity and insanity exist' how shall we know them
Dr. David Rosenhan had himself admitted as a ''mental patient'' in 1972 and wrote of his findings regarding the experience. He had a similar experience in relation to his study which is based on his similar experience. "(hat is )) or is not )) normal! may ha$e much to do with the la%els that are applied to people in particular settings. &f sanity and insanity exist' how shall we know them
Rosenhan personally had himself admitted as a ''mental patient'' in 1972
and wrote of his findings regarding the experience. Please note: In this piece by David Rosenhan all the footnotes have been added by me and speak of my own experience in relation to Rosenhan's study which is based on his similar experience... Patricia Lefave, Labelled, Delusional Disorder, (Paranoid) On Being Sane In Insane Places By David L. Rosenhan, PhD. Stanford University How do we know precisely what constitutes normality! or mental illness" #on$entional wisdom suggests that specially trained professionals ha$e the a%ility to make reasona%ly accurate diagnoses. &n this research' howe$er' Da$id Rosenhan pro$ides e$idence to challenge this assumption. (hat is )) or is not )) normal! may ha$e much to do with the la%els that are applied to people in particular settings. &f sanity and insanity exist' how shall we know them" *he +uestion is neither capricious nor itself insane. Howe$er much we may %e personally con$inced that we can tell the normal from the a%normal' the e$idence is simply not compelling. &t is commonplace' for example' to read a%out murder trials wherein eminent psychiatrists for the defense are contradicted %y e+ually eminent psychiatrists for the prosecution on the matter of the defendant,s sanity. -ore generally' there are a great deal of conflicting data on the relia%ility' utility' and meaning of such terms as sanity'! insanity'! mental illness'! and schi.ophrenia.! /inally' as early as 1901' 2Ruth3 4enedict suggested that normality and a%normality are not uni$ersal. (hat is $iewed as normal in one culture may %e seen as +uite a%errant in another. *hus' notions of normality and a%normality may not %e +uite as accurate as people %elie$e they are. *o raise +uestions regarding normality and a%normality is in no way to +uestion the fact that some %eha$iors are de$iant or odd. -urder is de$iant. 5o' too' are hallucinations. 6or does raising such +uestions deny the existence of the personal anguish that is often associated with mental illness.! 7nxiety and depression exist. 8sychological suffering exists. 4ut normality and a%normality' sanity and insanity' and the diagnoses that flow from them may %e less su%stanti$e than many %elie$e them to %e. 7t its heart' the +uestion of whether the sane can %e distinguished from the insane 9and whether degrees of insanity can %e distinguished from each other: is a simple matter; Do the salient characteristics that lead to diagnoses reside in the patients themsel$es or in the en$ironments and contexts in which o%ser$ers find them" /rom 4leuler' through <retchmer' through the formulators of the recently re$ised Diagnostic and 5tatistical -anual of the 7merican 8sychiatric 7ssociation' the %elief has %een strong that patients present symptoms' that those symptoms can %e categori.ed' and' implicitly' that the sane are distinguisha%le from the insane. -ore recently' howe$er' this %elief has %een +uestioned. 4ased in part on theoretical and anthropological considerations' %ut also on philosophical' legal' and therapeutic ones' the $iew has grown that psychological categori.ation of mental illness is useless at %est and downright harmful' misleading' and pe=orati$e at worst. Psychiatric diagnoses, in this view, are in the minds of oservers and are not valid s!mmaries of characteristics dis"layed y the oserved. 1 >ains can %e made in deciding which of these is more nearly accurate %y getting normal people 9that is' people who do not ha$e' and ha$e ne$er suffered' symptoms of serious psychiatric disorders: admitted to psychiatric hospitals and then determining whether they were disco$ered to %e sane and' if so' how. &f the sanity of such pseudo patients were always detected' there would %e prima facie e$idence that a sane indi$idual can %e distinguished from the insane context in which he is found. 6ormality 9and where$er it occurs' for it is carried within the person. &f' on the other hand' the sanity of the pseudo patients were ne$er disco$ered' serious difficulties would arise for those who support traditional modes of psychiatric diagnosis. >i$en that the hospital staff was not incompetent' that the pseudo patient had %een %eha$ing as sanely as he had %een out of the hospital' and that it had ne$er %een pre$iously suggested that he %elonged in a psychiatric hospital' such an unlikely outcome would support the $iew that psychiatric diagnosis %etrays little a%out the patient %ut much a%out the en$ironment in which an o%ser$er finds him. 2
*his article descri%es such an experiment. ?ight sane people gained secret admission to 12 different hospitals. *heir diagnostic experiences constitute the data of the first part of this article@ the remainder is de$oted to a 1 8erhaps this is the reason the o%ser$ed ones such as myself are told we are not 'allowed' to speak of our point of $iew and of our own experiences might ruin the illusion which is pri.ed so highly %y the o%ser$ers. 2 6ot so much a%out what we say %ut (H?R? we are when we say it. description of their experiences in psychiatric institutions. *oo few psychiatrists and psychologists' e$en those who ha$e worked in such hospitals' know what the experience is like. *hey rarely talk a%out it with former patients' perhaps %ecause they distrust information coming from the pre$iously insane. *hose who ha$e worked in psychiatric hospitals are likely to ha$e adapted so thoroughly to the settings that they are insensiti$e to the impact of that experience. 7nd while there ha$e %een occasional reports of researchers who su%mitted themsel$es to psychiatric hospitali.ation' these researchers ha$e commonly remained in the hospitals for short periods of time' often with the knowledge of the hospital staff. &t is difficult to know the extent to which they were treated like patients or like research colleagues. 6e$ertheless' their reports a%out the inside of the psychiatric hospital ha$e %een $alua%le. *his article extends those efforts. #$% &OR'(L (R% &O# D%#%)#(BL* S(&% Despite their pu%lic show! of sanity' the pseudo patients were ne$er detected. 7dmitted' except in one case' with a diagnosis of schi.ophrenia' each was discharged with a diagnosis of schi.ophrenia in remission.! *he la%el in remission! should in no way %e dismissed as a formality' for at no time during any hospitali.ation had any +uestion %een raised a%out any pseudo patient,s simulation. 6or are there any indications in the hospital records that the pseudo patient,s status was suspect. Rather' the e$idence is strong that' once la%eled schi.ophrenic' the pseudo patient was stuck with that la%el. &f the pseudo patient was to %e discharged' he must naturally %e in remission!@ %ut he was not sane' nor' in the institution,s $iew' had he e$er %een sane. #he !niform fail!re to recogni+e sanity 0 cannot %e attri%uted to the +uality of the hospitals' for' although there were considera%le $ariations among them' se$eral are considered excellent. 6or can it %e alleged that hospitali.ation ranged from 7 to A2 days' with an a$erage of 19 days. *he pseudo patients were not' in fact' carefully o%ser$ed' %ut this failure speaks more to traditions within psychiatric hospitals than to lack of opportunity. /inally' it cannot %e said that the failure to recogni.e the pseudo patients' sanity was due to the fact that they were not %eha$ing sanely. (hile there was clearly some tension present in all of them' their daily $isitors could 3 ?mphasis mine 8B detect no serious %eha$ioral conse+uencesCnor' indeed' could other patients. It was ,!ite common for the "atients to -detect. the "se!do "atient/s sanity. 1 During the first three hospitali.ations' when accurate counts were kept' 0A of a total of 11D patients on the admissions ward $oiced their suspicions' some $igorously. Eou,re not cra.y. Eou,re a =ournalist' or a professor 9referring to the continual note)taking:. Eou,re checking up on the hospital.! (hile most of the patients were reassured %y the pseudo patient,s insistence that he had %een sick %efore he came in %ut was fine now' some continued to %elie$e that the pseudo patient was sane throughout his hospitali.ation. *he fact that the patients often recogni.ed normality when staff did not raises important +uestions. /ailure to detect sanity during the course of hospitali.ation may %e due to the fact that physicians operate with a strong %ias toward what statisticians call the *ype 2 error. *his is to say that physicians are more inclined to call a healthy person sick 9a false positi$e' *ype 2: than a sick person healthy 9a false negati$e' *ype 1:. *he reasons for this are not hard to find; it is clearly more dangerous to misdiagnose illness than health. 4etter to err on the side of caution' to suspect illness e$en among the healthy. 4ut what holds for medicine does not hold e+ually well for psychiatry. -edical illnesses' while unfortunate' are not commonly pe=orati$e. Psychiatric diagnoses, on the contrary, carry with them "ersonal, legal, and social stigmas. A &t was therefore important to see whether the tendency toward diagnosing the sane insane could %e re$ersed. *he following experiment was arranged at a research and teaching hospital whose staff had heard these findings %ut dou%ted that such an error could occur in their F hospital. *he staff was informed that at some time during the following three months' one or more pseudo patients would attempt to %e admitted into the psychiatric hospital. ?ach staff mem%er was asked to rate each patient who presented himself at admissions or on the ward according to the likelihood that the patient was a pseudo patient. 7 1G)point scale was used' with a 1 and 2 reflecting high confidence that the patient was a pseudo patient. 4 7gain emphasis mine 8B 5 *et for the identified patient to complain that one's life is %eing destroyed is to in$ite further 'assessments' related to 'paranoia.' 6 it always seems to %e 'other' people perhaps' %ut certainly not #$%'. Hudgements were o%tained on 190 patients who were admitted for psychiatric treatment. 7ll staff who had had sustained contact with or primary responsi%ility for the patient I attendants' nurses' psychiatrists' physicians' and psychologists I were asked to make =udgments. /orty)one patients were alleged' with high confidence' to %e pseudo patients %y at least one mem%er of the staff. *wenty)three were considered suspect %y at least one psychiatrist. 6ineteen were suspected %y one psychiatrist and one other staff mem%er. 7ctually' no genuine pseudo patient 9at least from my group: presented himself during this period. *he experiment is instructi$e. &t indicates that the tendency to designate sane people as insane can %e re$ersed when the stakes 9in this case' prestige and diagnostic acumen: are high. B!t what can e said of the 01 "eo"le who were s!s"ected of eing -sane. y one "sychiatrist and another staff memer2 3ere these "eo"le tr!ly 4sane4 or was it rather the case that in the co!rse of avoiding the #y"e 5 error the staff tended to ma6e more errors of the first sort 7 calling the cra+y -sane.2 7 *here is no way of knowing. 4ut one thing is certain; any diagnostic process that lends itself too readily to massi$e errors of this sort cannot %e a $ery relia%le one. PS%UDOP(#I%&#S (&D #$%IR S%##I&8S *he eight pseudo patients were a $aried group. Jne was a psychology graduate student in his 2G,s. D *he remaining se$en were older and esta%lished.! 7mong them were three psychologists' a pediatrician' a psychiatrist' a painter' and a housewife. *hree pseudo patients were women' fi$e were men. 7ll of them employed pseudonyms' lest their alleged diagnoses em%arrass them later. 9
*hose who were in mental health professions alleged another occupation in order to a$oid the special attentions that might %e accorded %y staff' as a matter of courtesy or caution' to ailing colleagues. (ith the exception myself 9& was the first pseudo patient and my presence was known to the hospital administration and chief psychologist and' so far 7 Jr' is it =ust that this happens all the time to supposedly 'real' patients' who tell the psychiatrists and staff they are 'not sick' %ut who can not %e heard %ecause of this $ery pro%lem. 5aying one is not 'sick'' often meaning physically' is defined as one of the signs that one IS sick' meaning physically' *he tautology is e$er present to =ustify all outcomes and protect the system. 8B 8 I wonder if he said, "I know I could never get a psychiatric label cause I'm not sick." 9 Did they not understand it was just like having diabetes? as & can tell' to them alone:' the presence of pseudo patients and the nature of the research program was not known to the hospital staffs. *he settings are similarly $aried. &n order to generali.e the findings' admission into a $ariety of hospitals was sought. *he 12 hospitals in the sample were located in fi$e different states on the ?ast and (est coasts. 5ome were old and sha%%y' some were +uite new. 5ome had good staff) patient ratios' others were +uite understaffed. Jnly one was a strict pri$ate hospital. 7ll of the others were supported %y state or federal funds or' in one instance' %y uni$ersity funds. 7fter calling the hospital for an appointment' the pseudo patient arri$ed at the admissions office complaining that he had %een hearing $oices. 7sked what the $oices said' he replied that they were often unclear' %ut as far as he could tell they said empty'! hollow'! and thud.! *he $oices were unfamiliar and were of the same sex as the pseudo patient. *he choice of these symptoms was occasioned %y their apparent similarity to existential symptoms. 5uch symptoms are alleged to arise from painful concerns a%out the percei$ed meaninglessness of one,s life. 1G &t is as if the hallucinating person were saying' -y life is empty and hollow.! 11 *he choice of these symptoms was also determined %y the a%sence of a single report of existential psychoses in the literature. 4eyond alleging the symptoms and falsifying name' $ocation' and employment' no further alterations of person' history' or circumstances were made. *he significant e$ents of the pseudo patient,s life history were presented as they had actually occurred. Relationships with parents and si%lings' with spouse and children' with people at work and in school' consistent with the aforementioned exceptions' were descri%ed as they were or had %een. 12 /rustrations and upsets were descri%ed along with =oys and satisfactions. *hese facts are important to remem%er. &f anything' they strongly %iased the su%se+uent results in fa$or of detecting insanity' since none of their histories or current %eha$iors were seriously pathological in any way. &mmediately upon admission to the psychiatric ward' the pseudo patient ceased simulating any symptoms of a%normality. &n some cases' there was a %rief period of mild ner$ousness and anxiety' since none of the pseudo patients really %elie$ed that they would %e admitted so easily. 10 &ndeed' their shared fear was that they would %e immediately exposed as frauds and greatly em%arrassed. -oreo$er' many of them had ne$er $isited a 10 ell, they used to be. ith bio psych it is all pretty well defined as meaningless. 11 !ow we are not saying anything. e are just 'seeking attention"fame.' 12 #veryday reality in other words. 13 !one so blind as those who cannot see what's...right in front of them. psychiatric ward@ e$en those who had' ne$ertheless had some genuine fears a%out what might happen to them. *heir ner$ousness' then' was +uite appropriate to the no$elty of the hospital setting' and it a%ated rapidly. 11 7part from that short)li$ed ner$ousness' the pseudo patient %eha$ed on the ward as he normally! %eha$ed. *he pseudo patient spoke to patients and staff as he might ordinarily. 4ecause there is uncommonly little to do on a psychiatric ward' he attempted to engage others in con$ersation. (hen asked %y staff how he was feeling' he indicated that he was fine' that he no longer experienced symptoms. He responded to instructions from attendants' to calls for medication 9which was not swallowed:' and to dining) hall instructions. 4eyond such acti$ities as were a$aila%le to him on the admissions ward' he spent his time writing down his o%ser$ations a%out the ward' its patients' and the staff. 1A &nitially these notes were written secretly'! %ut as it soon %ecame clear that no one much cared' they were su%se+uently written on standard ta%lets of paper in such pu%lic places as the dayroom. 6o secret was made of these acti$ities. *he pseudo patient' $ery much as a true psychiatric patient' entered a hospital with no foreknowledge of when he would %e discharged. ?ach was told that he would ha$e to get out %y his own de$ices' essentially %y con$incing the staff that he was sane. 1F *he psychological stresses associated with hospitali.ation were considera%le' and all %ut one of the pseudo patients desired to %e discharged almost immediately after %eing admitted. *hey were' therefore' moti$ated not only to %eha$e sanely' %ut to %e paragons of cooperation. *hat their %eha$ior was in no way disrupti$e is confirmed %y nursing reports' which ha$e %een o%tained on most of the patients. *hese reports uniformly indicate that the patients were friendly'! cooperati$e'! and exhi%ited no a%normal indications.! 17
#$% S#I)9I&%SS O: PS*)$ODI(8&OS#I) L(B%LS 4eyond the tendency to call the healthy sick I a tendency that accounts %etter for diagnostic %eha$ior on admission than it does for such %eha$ior after a lengthy period of exposure I the data speak to the massi$e role of la%eling in psychiatric assessment. 1D Ha$ing once %een la%eled schi.ophrenic' there is nothing the pseudo patient can do to o$ercome the tag. *he tag 14 *hey <6?( they were going to get out. 15 ?gadsK writing %eha$ioursK 16 ?ndless tautologies here we comeK 17 $nfortunately 'normality' has nothing to do with it. 18 Ees & agree. >etting the la%el placed as +uickly as possi%le seems to %e the most important thing to the %io psychs. *he la%el gi$es the doctor control o$er the patient profoundly colors others, perceptions of him and his %eha$ior. 19 /rom one $iewpoint' these data are hardly surprising' for it has long %een known that elements are gi$en meaning %y the context 2G in which they occur. >estalt psychology made the point $igorously' and 7sch demonstrated that there are central! personality traits 9such as warm! $ersus cold!: which are so powerful that they markedly color the meaning of other information in forming an impression of a gi$en personality. &nsane'! schi.ophrenic'! manic)depressi$e'! and cra.y! are pro%a%ly among the most powerful of such central traits. Jnce a person is designated a%normal' all of his other %eha$iors and characteristics are colored %y that la%el. 21 &ndeed' that la%el is so powerful that many of the pseudopatients, normal %eha$iors were o$erlooked entirely or profoundly misinterpreted. 5ome examples may clarify this issue. ?arlier' & indicated that there were no changes in the pseudopatient,s personal history and current status %eyond those of name' employment' and' where necessary' $ocation. Jtherwise' a $eridical description of personal history and circumstances was offered. *hose circumstances were not psychotic. How were they made consonant with the diagnosis modified in such a way as to %ring them into accord with the circumstances of the pseudopatient,s life' as descri%ed %y him" 7s far as & can determine' diagnoses were in no way affected %y the relati$e health of the circumstances of a pseudopatient,s life. Rather' the re$erse 22
occurred; the perception of his circumstances was shaped entirely %y the diagnosis. 20 7 clear example of such translation is found in the case of a pseudopatient who had had a close relationship with his mother %ut was rather remote from his father during his early childhood. During adolescence and %eyond' howe$er' his father %ecame a close friend' while his relationship with his mother cooled. His present relationship with his wife was characteristically close and warm. 7part from occasional angry exchanges' friction was minimal. *he children had rarely %een spanked. 5urely there is 19 7fter & 98B: recei$ed my own la%el it was as if & had suddenly %ecome someone else. 5uddenly e$erything & said felt or did was up for 'interpretation' %y others. *hey now see me though the filter of their own %elief system. 20 -eaning connected to context. Did you get that part J<" Do you get it %etter if another 'doctor' tells you rather than a 'whack =o%' like me" 21 & concur %ased on personal experience 22 *he Lexact oppositeL was the phrase & used. Remem%er" Lschi.ophrenia is the exact opposite of what e$ery%ody %elie$es it is.L8B 23 47#<(7RD5. ?ffect defined as the cause. 8B L&t is a%out cause and effect. L(ho would you rather %e"L asks the training.9as used %y my own antagonist: nothing especially pathological a%out such a history. &ndeed' many readers may see a similar pattern in their own experiences' with no markedly deleterious conse+uences. J%ser$e' howe$er' how such a history was translated 21 in the psychopathological context' this from the case summary prepared after the patient was discharged. *his white 09)year)old male . . . manifests a long history of considera%le am%i$alence in close relationships' which %egins in early childhood. 7 warm relationship with his mother cools during his adolescence. 7 distant relationship with his father is descri%ed as %ecoming $ery intense. 7ffecti$e sta%ility is a%sent. His attempts to control emotionality with his wife and children are punctuated %y angry out%ursts and' in the case of the children' spankings. 7nd while he says that he has se$eral good friends' one senses considera%le am%i$alence em%edded in those relationships also . . . *he facts of the case were unintentionally distorted %y the staff to achie$e consistency with a popular theory of the dynamics of a schi.ophrenic reaction. 6othing of an am%i$alent nature had %een descri%ed in relations with parents' spouse' or friends. 2A *o the extent that am%i$alence could %e inferred' it was pro%a%ly not greater than is found in all human,s relationships. &t is true the pseudopatient,s relationships with his parents changed o$er time' %ut in the ordinary context that would hardly %e remarka%le I indeed' it might $ery well %e expected. #learly' the meaning ascri%ed to his $er%ali.ations 9that is' am%i$alence' affecti$e insta%ility: was determined %y the diagnosis; schi.ophrenia. 7n entirely different meaning 2F
would ha$e %een ascri%ed if it were known that the man was normal.! 7ll pseudopatients took extensi$e notes pu%licly. Mnder ordinary circumstances' such %eha$ior would ha$e raised +uestions in the minds of o%ser$ers' as' in fact' it did among patients. &ndeed' it seemed so certain that the notes would elicit suspicion that ela%orate precautions were taken to remo$e them from the ward each day. 4ut the precautions pro$ed needless. *he closest any staff mem%er came to +uestioning those notes occurred when one pseudopatient asked his physician what kind of medication he was recei$ing and %egan to write down the response. Eou needn,t write it'! he was told gently. &f you ha$e trou%le remem%ering' =ust ask me again.! 27 24 L*ranslatedL ' as if the o%$ious truth were a foreign language. like the 'interpretations' generated %y the est routine as well. 8B 25 and e$en if am%i$alence 3(S there' 3$* is the focus on one person and not the group as a whole' and why is am%i$alence experienced in all relationships defined as 'pathological' in some %ut not in others" 26 7nd #$(# is a%out meaning connected to a "remise isn't it" >ee...where ha$e we heard that %efore" 27 (riting %eha$iours 8B &f no +uestions were asked of the pseudopatients' how was their writing interpreted" 6ursing records for three patients indicate that the writing was seen as an aspect of their pathological %eha$ior. 8atient engaged in writing %eha$ior! was the daily nursing comment on one of the pseudopatients who was ne$er +uestioned a%out his writing. 2D >i$en that the patient is in the hospital' he must %e psychologically distur%ed. 29 7nd gi$en that he is distur%ed' continuous writing must %e %eha$ioral manifestation of that distur%ance' perhaps a su%set of the compulsi$e %eha$iors that are sometimes correlated with schi.ophrenia. 0G Jne tacit characteristic of psychiatric diagnosis is that it locates the sources of a%erration within the indi$idual and only rarely within the complex of stimuli that surrounds him. 01 #onse+uently' %eha$iors that are stimulated %y the en$ironment are commonly misattri%uted to the patient,s disorder. 02 /or example' one kindly nurse found a pseudopatient pacing the long hospital corridors. 6er$ous' -r. N"! she asked. 6o' %ored'! he said. *he notes kept %y pseudopatients are full of patient %eha$iors that were misinterpreted %y well)intentioned staff. Jften enough' a patient would go %erserk! %ecause he had' wittingly or unwittingly' %een mistreated %y' say' an attendant. 7 nurse coming upon the scene would rarely in+uire e$en cursorily into the en$ironmental stimuli of the patient,s %eha$ior. Rather' she ass!med 00 that his upset deri$ed from his pathology' not from his present interactions with other staff mem%ers. Jccasionally' the staff might assume that the patient,s family 9especially when they had recently $isited: or other patients had stimulated the out%urst. 4ut never were the staff found to assume that one of themselves or the str!ct!re of the hos"ital had anything to do with a patient,s %eha$ior. Jne psychiatrist pointed to a group of patients who were sitting outside the cafeteria entrance half an hour %efore lunchtime. *o a group of young residents he indicated that such %eha$ior was characteristic of the oral)ac+uisiti$e nature of the syndrome. 01 &t seemed not to occur to him that there were $ery few things to anticipate in a psychiatric hospital %esides eating. 28 6o one who %elie$es he or she already knows e$erything has any interest in asking or listening. ?$erything has %een made meaningless the minute the 'patient' has %een defined 75 the patient. *he same thing occurs with know)it)alls in families. 8B 29 (riting is part of the attempt to sort out all the contradictions with which the patient is %eing %om%arded %y others. ex cult mem%ers use this sorting method also. 8l 30 &magine there is no such 'disease' and keep reading. &magine it is the dysfunctional con =o% of 5J-? of those '%lameless others. 31 Eoo hoo. experts..are you H?7R&6> that J<" the est hole understands it. 8B 32 5u%=ecti$e >RJM8 pro=ection. 7 defence mechanism. &t's a%out responsi%ility. 8B 33 7nd what happens when we 'assume"L 34 /ormerly known 'as waiting for lunch.' 7 psychiatric la%el has a life and an influence of its own. Jnce the impression has %een formed that the patient is schi.ophrenic' the expectation is that he will continue to %e schi.ophrenic. (hen a sufficient amount of time has passed' during which the patient has done nothing %i.arre' he is considered to %e in remission and a$aila%le for discharge. 4ut the lael end!res eyond discharge, with the unconfirmed expectation that he will %eha$e as a schi.ophrenic again. 5uch la%els' conferred %y mental health professionals' are as infl!ential on the "atient as they are on his relatives and friends, 0A and it should not surprise anyone that the diagnosis acts on all of them as a self;f!lfilling "ro"hecy. 0F ?$entually' the patient himself accepts the diagnosis' with all of its surplus meanings and expectations' and %eha$es accordingly. 07 *he inferences to %e made from these matters are +uite simple. -uch as Oigler and 8hillips ha$e demonstrated that there is enormous o$erlap in the symptoms presented %y patients who ha$e %een $ariously diagnosed' so there is enormous o$erlap in the %eha$iors of the sane and the insane. *he sane are not sane! all of the time. (e lose our tempers for no good reason.! (e are occasionally depressed or anxious' again for no good reason. 0D 7nd we may find it difficult to get along with one or another person I again for no reason that we can specify. 5imilarly' the insane are not always insane. &ndeed' it was the impression of the pseudopatients while li$ing with them that they were sane for long periods of time I that the %i.arre %eha$iors upon which their diagnoses were allegedly predicated constituted only a small fraction of their total %eha$ior. &f it makes no sense to la%el oursel$es permanently depressed on the %asis of an occasional depression' then it takes %etter e$idence than is presently a$aila%le to la%el all patients insane or schi.ophrenic on the %asis of %i.arre %eha$iors or cognitions. &t seems more useful' as -ischel has pointed out' to limit our discussions to %eha$iors the stimuli that pro$oke them' and their correlates. &t is not known why powerful impressions of personality traits' such as cra.y! or insane'! arise. #oncei$a%ly' when the origins of and stimuli that gi$e rise to a %eha$ior are remote or unknown' or when the %eha$ior strikes us as immuta%le' trait la%els regarding the %eha$ior arise. (hen' on the other hand' the origins and stimuli are known and a$aila%le' discourse is 35 (ho are then trained to treat us 'as if.L 36 *hat's right. 8roduced with non stop pressure' stress and the constant in$alidation of the self righteous. 37 -ost of us do' %ut not all of us' and those of us who don't' are su%=ected to further 'treatment' and la%elled non compliant as & was. & told my reco$ery therapist that & was escaping this fate %y the skin of my teeth and & knew it. (e get se$eral different la%els for this same experience which seems to depend more on (HJ we get in the psychiatric crap shoot and not on Lsymptoms.' *hat is how su%=ecti$e the diagnoses are. 38 *his is also a $alue =udgement often %ased on &O patient input at all. limited to to the %eha$ior itself. 09 *hus' & may hallucinate %ecause & am sleeping' or & may hallucinate %ecause & ha$e ingested a peculiar drug. *hese are termed sleep)induced hallucinations' or dreams' and drug)induced hallucinations' respecti$ely. 4ut when the stimuli to my hallucinations are unknown' 1G that is called cra.iness' or schi.ophrenia Ias if that inference were somehow as illuminating as the others. #$% %<P%RI%&)% O: PS*)$I(#RI) $OSPI#(LI=(#IO& *he term mental illness! is of recent origin. &t was coined %y people who were humane in their inclinations and who wanted $ery much to raise the station of 9and the pu%lic,s sympathies toward: the psychologically distur%ed from that of witches and cra.ies! to one that was akin to the physically ill. 11
7nd they were at least partially successful' for the treatment of the mentally ill has impro$ed considera%ly o$er the years. 4ut while treatment has impro$ed' it is dou%tful that people really regard the mentally ill in the same way that they $iew the physically ill. 7 %roken leg is something one reco$ers from' %ut mental illness allegedly endures fore$er. 12 7 %roken leg does not threaten the o%ser$er' %ut a cra.y schi.ophrenic" *here is %y now a host of e$idence that attitudes toward the mentally ill are characteri.ed %y fear' hostility' aloofness' suspicion' and dread. 10 *he mentally ill are society,s lepers. *hat such attitudes infect the general population is perhaps not surprising' only upsetting. 4ut that they affect the professionals I attendants' nurses' physicians' psychologists and social workers I who treat and deal with the mentally ill is more disconcerting' %oth %ecause such attitudes are self) e$idently pernicious and %ecause they are unwitting. 11 -ost mental health 39 7s if external reality and other people were irrele$ant 40 Jr known %y me yet in$alidated %y the psychiatrist 41 *hat may well ha$e %een the intention %ut in' my experience +uite the opposite has happened. *he witch hunt remains and the insults like %eing called Lthe whack =o%L from a few feet away remains the reality. 8B 42 7t least' that is what psychiatry promotes isn't it"8B 43 *his is true for me for the last 1F years though there is always the pretence of acceptance and a facade of manners is $ery common from most. PL 44 &t is a lot more than =ust 'upsetting' to the psychiatri.ed one. &n fact' this group %eha$iour is often the $ery thing that triggers psychosis. *he lack of conscious awareness in the participants is what makes it an inescapa%le 'snare' for in speaking a%out this as reality' the psychiatri.ed one is not seen or heard as she really is. *his largely %ecause the group is %lind to itself@ well 'hidden' %ehind their group delusion which & ha$e named 5.7.#.5. *he same sort of phenomenon occurs in dysfunctional families and cults which & why & see the professionals would insist that they are sympathetic toward the mentally ill' that they are neither a$oidant nor hostile. 4ut it is more likely that an ex+uisite am%i$alence characterises their relations with psychiatric patients' such that their a$owed impulses are only part of their entire attitude. 1A
6egati$e attitudes are there too and can easily %e detected. 1F 5uch attitudes should not surprise us. *hey are the natural offspring of the la%els patients wear and the places in which they are found. 17 #onsider the structure of the typical psychiatric hospital. 5taff and patients are strictly segregated. 5taff ha$e their own li$ing space' including their dining facilities' %athrooms' and assem%ly places. *he glassed +uarters that contain the professional staff' which the pseudopatients came to call the cage'! sit out on e$ery dayroom. *he staff emerge primarily for care)taking purposes I to gi$e medication' to conduct therapy or group meeting' to instruct or reprimand a patient. Jtherwise' staff keep to themsel$es' almost as if the disorder that afflicts their charges is somehow catching. 1D
5o much is patient)staff segregation the rule that' for four pu%lic hospitals in which an attempt was made to measure the degree to which staff and patients mingle' it was necessary to use time out of the staff cage! as the operational measure. (hile it was not the case that all time spent out of the cage was spent mingling with patients 9attendants' for example' would occasionally emerge to watch tele$ision in the dayroom:' it was the only way in which one could gather relia%le data on time for measuring. *he a$erage amount of time spent %y attendants outside of the cage was 11.0 percent 9range' 0 to A2 percent:. *his figure does not represent only time spent mingling with patients' %ut also includes time spent on such chores as folding laundry' super$ising patients while they sha$e' directing ward cleanup' and sending patients to off)ward acti$ities. &t was the relati$ely rare attendant who spent time talking with patients or playing games with them. &t pro$ed impossi%le to o%tain a percent mingling time! for nurses' since the amount of time they spent out of the cage was too connections. 8B 45 *hat definitely speaks to my personal experience as well. 8B 46 (e who see them are used to %eing silenced for %eing a%le to do so. 8B 47 *hese attitudes are then taken up %y the rest of society including family and friends who then alter their own way of percei$ing the 'patient' so that it fits in with the la%elling and diagnostics of the 'experts.' Jn the recei$ing end of this it /??B5 like %eing pushed out of concrete reality and into the alternate one designed %y those who either cannot' or will not' face the truth. 8B 48 &t does a fantastic =o% of creating a 'them and us' illusion. (hile 6J faults can usually %e found in the staff' no matter how glaringly o%$ious they may %e' no end to the 'faults' are found in the patients' no matter how normally they may %e speaking' or acting. *his makes the experience as surreal as it gets. 8B %rief. Rather' we counted instances of emergence from the cage. Jn the a$erage' daytime nurses emerged from the cage 11.A times per shift' including instances when they left the ward entirely 9range' 1 to 09 times:. Bater afternoon and night nurses were e$en less a$aila%le' emerging on the a$erage 9.1 times per shift 9range' 1 to 11 times:. Data on early morning nurses' who arri$ed usually after midnight and departed at D a.m.' are not a$aila%le %ecause patients were asleep during most of this period. 8hysicians' especially psychiatrists' were e$en less a$aila%le. 19 *hey were rarely seen on the wards. Puite commonly' they would %e seen only when they arri$ed and departed' with the remaining time %eing spend in their offices or in the cage. AG Jn the a$erage' physicians emerged on the ward F.7 times per day 9range' 1 to 17 times:. &t pro$ed difficult to make an accurate estimate in this regard' since physicians often maintained hours that allowed them to come and go at different times. *he hierarchical organi.ation of the psychiatric hospital has %een commented on %efore' %ut the latent meaning of that kind of organi.ation is worth noting again. *hose with the most power ha$e the least to do with patients' and those with the least power are the most in$ol$ed with them. A1 Recall' howe$er' that the ac+uisition of role)appropriate %eha$iors occurs mainly through the o%ser$ation of others' with the most powerful ha$ing the most influence. #onse+uently' it is understanda%le that attendants not only spend more time with patients than do any other mem%ers of the staff I that is re+uired %y their station in the hierarchy I %ut' also' insofar as they learn from their superior,s %eha$ior' spend as little time with patients as they can. 7ttendants are seen mainly in the cage' which is where the models' the action' and the power are. A2
& turn now to a different set of studies' these dealing with staff response to patient)initiated contact. &t has long %een known that the amount of time a person spends with you can %e an index of your significance to him. &f he 49 -y in hospital one %arely spoke to me though he seemed to %e en=oying himself when he did. 8B 50 6urses' often %latantly dysfunctional in their own relationships' are $ery often the ones who do the diagnosing %y looking for 'signs' as suggested to them %y the psychiatrists. Ha$ing it suggested' they seem to find what they are told to look for. *hey are also $ery good at closing ranks and keeping the institution's 'secrets.'8B 51 & find this to %e as true today'9 2GG9:as it was when this was written. &t is also true that & was one of the people who spent the most time with indi$idual patients when & was working there as a LspecialL and was one of the people most openly scorned %y some of the staff for my efforts. 8B 52 & found 'dismissi$e' thinking and %eha$iour to represent the 'norm' among the hospital staff from the top down. 7n extraordinary le$el of arrogance is %uilt into the system as a whole and it now feeds upon itself. &t has %egun to attack it's own now whene$er a professional dares to speak against the system itself. 8B initiates and maintains eye contact' there is reason to %elie$e that he is considering your re+uests and needs. &f he pauses to chat or actually stops and talks' there is added reason to infer that he is indi$iduating you. &n four hospitals' the pseudopatients approached the staff mem%er with a re+uest which took the following form; 8ardon me' -r. Qor Dr. or -rs.R N' could you tell me when & will %e eligi%le for grounds pri$ileges"! 9or . . . when & will %e presented at the staff meeting"! or . . . when & am likely to %e discharged"!:. (hile the content of the +uestion $aried according to the appropriateness of the target and the pseudopatient,s 9apparent: current needs the form was always a courteous and rele$ant re+uest for information. #are was taken ne$er to approach a particular mem%er of the staff more than once a day' lest the staff mem%er %ecome suspicious or irritated . . . QRRemem%er that the %eha$ior of the pseudopatients was neither %i.arre nor disrupti$e. A0 Jne could indeed engage in good con$ersation with them. . . . -inor differences %etween these four institutions were o$erwhelmed %y the degree to which staff a$oided continuing contacts that patients had initiated. 4y far' their most common response consisted of either a %rief response to the +uestion' offered while they were on the mo$e! and with head a$erted' or no response at all. *he encounter fre+uently took the following %i.arre form; 9pseudopatient: 8ardon me' Dr. N. #ould you tell me when & am eligi%le for grounds pri$ileges"! 9physician: >ood morning' Da$e. How are you today" 9-o$es off without waiting for a response.: . . . PO3%RL%SS&%SS (&D D%P%RSO&(LI=(#IO& ?ye contact and $er%al contact reflect concern and indi$iduation@ their a%sence' a$oidance and depersonali.ation. A1 *he data & ha$e presented do not do =ustice to the rich daily encounters that grew up around matters of depersonali.ation and a$oidance. & ha$e records of patients who were %eaten %y staff for the sin of ha$ing initiated $er%al contact. AA During my 53 5ome psychiatrists and other physicians are now %eing diagnosed using this term as e$idence of a psychiatric illness. *he system is now closing on itself tightening the noose 9tautology: around the necks of it's own mem%ers. 54 *he people who were assessing and e$aluating me and others don't seem to see a person when they look at me %ut rather an 'o%=ect.' -y protagonist's $ersion of this is e$ident in the use of the word L&tem.L (e who are forced into this kind of position fre+uently state we feel 'in$isi%le' which is then heard as a self contained 'symptom.L 55 &n any other setting this would %e seen as %latant a%use %ut not when done to us 'attention seekers' who #J-8B7&6 of a%use =ust to 'seek attention.L 9(atch for the e$er present tautologies in this: own experience' for example' one patient was %eaten in the presence of other patients for ha$ing approached an attendant and told him' & like you.! Jccasionally' punishment meted out to patients for misdemeanors seemed so excessi$e that it could not %e =ustified %y the most rational interpretations of psychiatric cannon. AF 6e$ertheless' they appeared to go un+uestioned. *empers were often short. A7 7 patient who had not heard a call for medication would %e roundly excoriated' and the morning attendants would often wake patients with' #ome on' you mS S S S S f S S S S S s' out of %edK! AD 6either anecdotal nor hard! data can con$ey the o$erwhelming sense of powerlessness which in$ades the indi$idual as he is continually exposed to the depersonali.ation of the psychiatric hospital. &t hardly matters which psychiatric hospital A9 I the excellent pu%lic ones and the $ery plush pri$ate hospital were %etter than the rural and sha%%y ones in this regard' %ut' again' the features that psychiatric hospitals had in common o$erwhelmed %y far their apparent differences. 8owerlessness was e$ident e$erywhere. FG *he patient is depri$ed of many of his legal rights %y dint of his psychiatric commitment. He is shorn of credi%ility %y $irtue of his psychiatric la%el. F1 His freedom of mo$ement is restricted. He cannot initiate contact with the staff' %ut may only respond to such o$ertures as they make. F2 8ersonal pri$acy is minimal. 8atient +uarters and possessions can %e entered and examined %y any staff mem%er' for whate$er reason. F0 His personal history and anguish is 56 *he e$er present assumption is that all this is a%out the 'reason' of those not la%elled as the 'sick' one9s:. *he 'reason' is not logic@ it is group catharsis of suppressed emotion. 57 Ees and if & +uestion this staff %eha$iour' & am presumed to %e stupidTcra.y and seeing things that are not there. 58 *he patient howe$er' is expected to smile and and ha$e perfect manners underscoring the dou%le standard. 59 &n$alidation %y design and %y constant pressure. Jften this is what %rought the patient there in the first place. 60 7nd it still is e$ident to e$eryone except the staff. *hey are so used to doing it it feels normal to them. 61 Ees' people stop hearing you or taking anything you say at face $alue' =ust as they are taught to do. Jf course they are all sure they are right to %eha$e this way too. (e are %eing treated as less than human for our own good after all. *he psychological isolation is enough in itself to %reak a person down. *hat is though of as 'good' too much of the time as those who are losing their sense of self are so much easier to reprogramme according to the programmer's desires. Denying the humanity of the 'other' will excuse almost anything. 62 -uch like sla$e owner and sla$e. Jr =ailer and prisoner. 63 &f sThe complains he may well get told to stop %eing such a %a%y since the patient is not as 'real' as the nurse who would not tolerate such treatment personally. a$aila%le to any staff mem%er 9often including the grey lady! and candy striper! $olunteer: who chooses to read his folder' regardless of their therapeutic relationship to him. His personal hygiene and waste e$acuation are often monitored. *he water closets ha$e no doors. 7t times' depersonali.ation reached such proportions that pseudopatients had the sense that they were in$isi%le' F1 or at least unworthy of account. Mpon %eing admitted' & and other pseudopatients took the initial physical examinations in a semi)pu%lic room' where staff mem%ers went a%out their own %usiness as if we were not there. FA
Jn the ward' attendants deli$ered $er%al and occasionally serious physical a%use to patients in the presence of others 9the pseudopatients: who were writing it all down. FF 7%usi$e %eha$ior' on the other hand' terminated +uite a%ruptly when other staff mem%ers were known to %e coming. 5taff are credi%le witnesses. 8atients are not. 7 nurse un%uttoned her uniform to ad=ust her %rassiere in the presence of an entire ward of $iewing men. Jne did not ha$e the sense that she was %eing seducti$e. Rather' she didn,t notice us. 7 group of staff persons might point to a patient in the dayroom and discuss him animatedly' as if he were not there. F7 Jne illuminating instance of depersonali.ation and in$isi%ility occurred with regard to medication. 7ll told' the pseudopatients were administered nearly 21GG pills' including ?la$il' 5tela.ine' #ompa.ine' and *hora.ine' to name %ut a few. 9*hat such a $ariety of medications should ha$e %een administered to patients presenting identical symptoms is itself worthy of note.: FD Jnly two were swallowed. *he rest were either pocketed or deposited in the toilet. *he pseudopatients were not alone in this. 7lthough & ha$e no precise records on how many patients re=ected their medications' the pseudopatients fre+uently found the medications of other patients in the toilet %efore they deposited their own. 7s long as they were cooperati$e' their %eha$ior and the pseudopatients, own in this matter' as in other 64 5ay' where ha$e we heard that %efore" Jf course it may well %e 'interpreted' %y others as literal and then mocked from a few feet away.*he 'sane' BJU? mocking as part of their group catharsis. 65 it sure doesn't seem the same as 'dia%etes' to us... 66 (ell it is not like anyone who actually -7**?R5 is complaining though is it" &t is only some 'whack =o%' like me. 67 *hey might do it on the streets or %uses as well and so do other mem%ers of the community at large who tend to take their cues from the 'experts' and who don't +uestion their leaders or this group %eha$iour. 68 Ees as it suggests that what you get 'diagnosed' with and what 'medication' is for you has more to do with (HJ you get than (H7* you Lha$e.L important matters' went unnoticed throughout. F9 Reactions to such depersonali.ation among pseudopatients were intense. 7lthough they had come to the hospital as participant o%ser$ers and were fully aware that they did not %elong'! they ne$ertheless found themsel$es caught up in and fighting the process of depersonali.ation. 7G 5ome examples; a graduate student in psychology asked his wife to %ring his text%ooks to the hospital so he could catch up on his homework! I this despite the ela%orate precautions taken to conceal his professional association. *he same student' who had trained for +uite some time to get into the hospital' and who had looked forward to the experience' remem%ered! some drag races that he had wanted to see on the weekend and insisted that he %e discharged %y that time. 71 7nother pseudopatient attempted a romance with a nurse. 5u%se+uently' he informed the staff that he was applying for admission to graduate school in psychology and was $ery likely to %e admitted' since a graduate professor was one of his regular hospital $isitors. *he same person %egan to engage in psychotherapy with other patients I all of this as a way of %ecoming a person in an impersonal en$ironment. 72 #$% SOUR)%S O: D%P%RSO&(LI=(#IO& (hat are the origins of depersonali.ation" & ha$e already mentioned two. /irst are attitudes held %y all of us toward the mentally ill I including those who treat them I attitudes characteri.ed %y fear' distrust' 73 and horri%le expectations on the one hand' 71 and %ene$olent intentions on the other. 7A Jur am%i$alence leads' in this instance as in others' to a$oidance. 7F
69
4ecause it the illusions around the power and control issues that really matter in the situation =ust like in the dysfunctional family. . 70 &magine trying to fight that from the position of %eing psychiatri.ed when those you must fight ha$e *J*7B control o$er you. 71 *he fear of the psychological trap he was in was starting to %e felt e$en though in H&5 case he knew he could get out with help. &magine when it is R?7B and there is no escape possi%le. 72 (hen 'real' patients or prisoners or a%used children do this same thing it is called L5tockholm 5yndrome.! 73 I wouldn't %e letting her into my apartment if & were you. 9ad$ice from one of my smiling neigh%ours to another.: 74 & wouldn't %e doing this if you weren't making me do itK 75 (e're only trying to help you. Eou would think she would %e grateful... 76 *he e$er popular dysfunctional' 'no response at all' response...=ust ignore her. -ay%e she will gi$e up...Lcome J6 lady...gi$e it up...L 5econd' and not entirely separate' the hierarchical structure of the psychiatric hospital facilitates depersonali.ation. *hose who are at the top ha$e least to do with patients' 77 and their %eha$ior inspires the rest of the staff. 7D 7$erage daily contact with psychiatrists' psychologists' residents' and physicians com%ined ranged form 0.9 to 2A.1 minutes' with an o$erall mean of F.D 9six pseudopatients o$er a total of 129 days of hospitali.ation:. 79 &ncluded in this a$erage are time spent in the admissions inter$iew' ward meetings in the presence of a senior staff mem%er' group and indi$idual psychotherapy contacts' case presentation conferences and discharge meetings. #learly' patients do not spend much time in interpersonal contact with doctoral staff. 7nd doctoral staff ser$e as models for nurses and attendants. DG
*here are pro%a%ly other sources. 8sychiatric installations are presently in serious financial straits. 5taff shortages are per$asi$e' and that shortens patient contact. D1 Eet' while financial stresses are realities' too much can %e made of them. & ha$e the impression that the psychological forces that result in depersonali.ation are much stronger than the fiscal ones and that the addition of more staff would not correspondingly impro$e patient care in this regard. *he incidence of staff meetings and the enormous amount of record)keeping on patients' for example' ha$e not %een as su%stantially reduced as has patient contact. D2 8riorities exist' e$en during hard times. 8atient contact is not a significant priority in the traditional psychiatric hospital' and fiscal pressures do not account for this. 7$oidance and depersonali.ation may. Hea$y reliance upon psychotropic medication tacitly contri%utes to depersonali.ation %y con$incing staff that treatment is indeed %eing conducted and that further patient contact may not %e necessary. D0 ?$en here' howe$er' caution needs to %e exercised in understanding the role of psychotropic drugs. &f patients were powerful rather than powerless' if they were $iewed as interesting indi$iduals rather than diagnostic entities' if they 77 Eoo hoo...is my doctor e$er going to talk directly to me"" 78 &t's called' follow the authority for appro$al.. 79 'I&U#%SK 80 7nd nurses and attendants look for signs and sym%ols of madness e$erywhere as they are instructed to do. 81 *hey're late. *hey're late. /or a $ery important date. 6o time to say hello good%ye' they're late they're late' they're late... 82 J%=ectification allows for a %etter detachment from 'them.' 83 ?specially if 'treatment' reduces the awareness of the identified patient and keeps her 'managea%le.' were socially significant rather than social lepers' D1 if their anguish truly and wholly compelled our sympathies and concerns' would we not seek contact with them' despite the a$aila%ility of medications" 8erhaps for the pleasure of it all" (hat are the origins of depersonali.ation" & ha$e already mentioned two. /irst are attitudes held %y all of us toward the mentally ill I including those who treat them I attitudes characteri.ed %y fear' distrust' DA and horri%le expectations on the one hand DF ' and %ene$olent intentions on the other D7 . Jur am%i$alence leads' in this instance as in others' to a$oidance .DD 5econd' and not entirely separate' the hierarchical structure of the psychiatric hospital facilitates depersonali.ation. *hose who are at the top ha$e least to do with patients D9 ' and their %eha$ior inspires the rest of the staff. 9G 7$erage daily contact with psychiatrists' psychologists' residents' and physicians com%ined ranged from 0.9 to 2A.1 minutes' with an o$erall mean of F.D 91 9six pseudopatients o$er a total of 129 days of hospitali.ation:. &ncluded in this a$erage are time spent in the admissions inter$iew' ward meetings in the presence of a senior staff mem%er' group and indi$idual psychotherapy contacts' case presentation conferences and discharge meetings. #learly' patients do not spend much time in interpersonal contact with doctoral staff. 7nd doctoral staff ser$e as models for nurses and attendants. 92
*here are pro%a%ly other sources. 8sychiatric installations are presently in serious financial straits. 5taff shortages are per$asi$e' and that shortens patient contact. 90 Eet' while financial stresses are realities' too much can %e 84 &f they were people@ not disease processes... 85 & wouldn't %e letting her into my apartment if & were you. 9ad$ice from one of my smiling neigh%ours to another.: 86 Eou ne$er know what one of 'them' is going to do. L*hey can turn on you in an instant for no reason.L 87 (e're only trying to help you. 9you would think she would %e grateful...: . 88 *he e$er popular dysfunctional' 'no response at all' response...=ust ignore her. -ay%e she will gi$e up...Lcome J6 lady...gi$e it up...L &t is easier to achie$e 'detachment' if you see no person there. 89 Eoo hoo...is my doctor e$er going to talk directly to me"" 90 &t's called' follow the authority for appro$al 91 -&6M*?5K 92 7nd nurses and attendants look for signs and sym%ols of madness e$erywhere as they are instructed to do. 93 *hey're late. *hey're late. /or a $ery important date. 6o time to say hello good%ye' they're late they're late' they're late... made of them. & ha$e the impression that the psychological forces that result in depersonali.ation are much stronger than the fiscal ones and that the addition of more staff would not correspondingly impro$e patient care in this regard. *he incidence of staff meetings and the enormous amount of record)keeping on patients' for example' ha$e not %een as su%stantially reduced as has patient contact. 91 8riorities exist' e$en during hard times. 8atient contact is not a significant priority in the traditional psychiatric hospital' and fiscal pressures do not account for this. 7$oidance and depersonali.ation may. Hea$y reliance upon psychotropic medication tacitly contri%utes to depersonali.ation %y con$incing staff that treatment is indeed %eing conducted and that further patient contact may not %e necessary. 9A ?$en here' howe$er' caution needs to %e exercised in understanding the role of psychotropic drugs. &f patients were powerful rather than powerless' if they were $iewed as interesting indi$iduals rather than diagnostic entities' if they were socially significant rather than social lepers' 9F if their anguish truly and wholly compelled our sympathies and concerns' would we not seek contact with them' despite the a$aila%ility of medications" 8erhaps for the pleasure of it all" #$% )O&S%>U%&)%S O: L(B%LI&8 (&D D%P%RSO&(LI=(#IO&
(hene$er the ratio of what is known to what needs to %e known approaches .ero' we tend to in$ent knowledge! and assume that we understand more than we actually do. 97 (e seem una%le to acknowledge that we simply don,t know. 9D *he needs for diagnosis and remediation of %eha$ioral and emotional pro%lems are enormous. 99 4ut rather than acknowledge that we are =ust em%arking on understanding' we continue to la%el patients schi.ophrenic'! manic)depressi$e'! and insane'! as if in those words we captured the 94 J%=ectification allows for a %etter detachment from 'them.' 95 ?specially if 'treatment' reduces the awareness of the identified patient and keeps her 'managea%le.' 96 &f they were people not disease processes... 97 *he danger in that is in the defensi$e attitude of the 'knowledgea%le one' especially if he or she has too much concrete power. 98 *hat has %een my own experience with psychiatry as well. 99 *here is also an assumption that the 'patient's pro%lems exist as defined %y others and are self contained. essence of understanding. 1GG *he facts of the matter are that we ha$e known for a long time that diagnoses are often not useful or relia%le' %ut we ha$e ne$ertheless continued to use them. 1G1 (e now know that we cannot distinguish sanity from insanity. &t is depressing to consider how that information will %e used. 1G2
6ot merely depressing' %ut frightening. 1G0 How many people' one wonders' are sane !t not recogni+ed as s!ch in our psychiatric institutions" 1G1 How many ha$e %een needlessly stripped of their pri$ileges of citi.enship' from the right to $ote and dri$e to that of handling their own accounts" How many ha$e feigned insanity in order to a$oid the criminal conse+uences of their %eha$ior' and' con$ersely' how many would rather stand trial than li$e intermina%ly in a psychiatric hospital I %ut are wrongly thought to %e mentally ill" 1GA How many ha$e %een stigmati.ed %y well)intentioned' %ut ne$ertheless erroneous' diagnoses" 1GF Jn the last point' recall again that a *ype 2 error! in psychiatric diagnosis does not ha$e the same conse+uences it does in medical diagnosis. 7 diagnosis of cancer that has %een found to %e in error is cause for cele%ration. 4ut psychiatric diagnoses are rarely found to %e in error. 1G7 *he la%el sticks' a mark of inade+uacy fore$er. 1GD /inally' how many patients might %e sane! outside the psychiatric hospital %ut seem insane in it I not %ecause cra.iness resides in them' as it were' %ut %ecause they are responding to a %i.arre setting' 1G9 one that may %e uni+ue to institutions which har%or nether people" >offman calls the process of sociali.ation to such institutions mortification! I an apt metaphor that includes the processes of depersonali.ation that ha$e %een descri%ed here. 7nd while it is impossi%le to know whether the pseudopatients, responses to these processes are characteristic of all inmates I they were' after all' not real patients I it is difficult to %elie$e that these processes of sociali.ation to 100 (hat they really do is reduce another person to managea%le si.e and =ustify doing it. 101 *he 'de$il' they know... 102 &t seems to %e mostly ignored and denied 103 *ell us a%out it. &t is like talking to the wall. 104 & would say a lot more than most people think. -any could %e dri$en into psychosis under pressure like a fulfilled prophecy. 105 Right again on oth counts & would say 106 -y hand is raised on that one. Eou can't tell an employer that someone is cra.y and without prospect of reco$ery and expect it is not going to ha$e a negati$e impact. 107 (ell no one wants to get %lamed for anything. 5o it is 'unrealistic' of me to expect an admission or an apology is it not" *hat is what they tell me. 108 Hey..there she is...that whack =o%.! 109 *hat is putting it mildly. Don't worry' she can't see us.!..ha ha ha a psychiatric hospital pro$ide useful attitudes or ha%its of response for li$ing in the real world.! 11G SU''(R* (&D )O&)LUSIO&S &t is clear that we cannot distinguish the sane from the insane in psychiatric hospitals. 111 *he hospital itself imposes a special en$ironment in which the meaning of %eha$ior can easily %e misunderstood. 112 *he conse+uences to patients hospitali.ed in such an en$ironment I the powerlessness' depersonali.ation' segregation' mortification' and self)la%eling I seem undou%tedly counter)therapeutic. 110 & do not' e$en now' understand this pro%lem well enough to percei$e solutions. 111 4ut two matters seem to ha$e some promise. *he first concerns the proliferation of community mental health facilities' of crisis inter$ention centers' 11A of the human potential mo$ement' 11F and of %eha$ior therapies that' for all of their own pro%lems' tend to a$oid psychiatric la%els' to focus on specific pro%lems and %eha$iors' and to retain the indi$idual in a relati$ely non)pe=orati$e en$ironment. #learly' to the extent that we refrain from sending the distressed to insane places' our impressions of them are less likely to %e distorted. 117 9*he risk of distorted perceptions' it seems to me' is always present' since we are much more sensiti$e to an indi$idual,s %eha$iors and $er%ali.ations than we are to the su%tle contextual stimuli 11D that often promote them. 7t issue here is a matter of magnitude. 7nd' as & 110 8sychiatrists don't li$e in the real world. *hey li$e in their own psychiatric fantasy. -ost of 'us' learn how to nod and agree with authority though. &f only out of self preser$ation. 111 *ry to keep thinking; this is a psychiatrist saying this. 112 Ees. 4ecause it is gi$en a context %y those who see themsel$es as 'o%=ecti$e o%ser$ers' who %elie$e they already <6J( the 'patient' %y 'what they say' and they are not. *hey ha$e %een trained 4?/JR? the patient arri$es to hear a particular -?76&6>. 113 7nd those of us who DJ6'* accept the 'diagnosis' and la%elling get defined as 'non compliant' as & was. 114 & %elie$e a solution is to stay self focused and percei$e e$eryone on earth as ha$ing an inherently e+ual $alue as a human %eing. 6o one as either inferior or superior. 115 *hese also define the 'patient' %efore we walk in the door. ?specially in 2G1G when %io psych is trying to rule the world. 116 8otential to DJ and %elie$e (H7*" /or some it means to control others' not one's self. 117 -ay%e we could stop calling the world them and us!...-ay%e we could say &! a lot more. 118 & too see a %ig #J6*?N* pro%lem and little or no communication a%out much of anything. ha$e shown' the magnitude of distortion is exceedingly high in the extreme context that is a psychiatric hospital. 119 : *he second matter that might pro$e promising speaks to the need to increase the sensiti$ity of mental health workers and researchers to the )atch 55 position of psychiatric patients. 12G 5imply reading materials in this area will %e of help to some such workers and researchers. /or others' directly experiencing the impact of psychiatric hospitali.ation will %e of enormous use. 121 #learly' further research into the social psychology 122 of such total institutions will %oth facilitate treatment and deepen understanding. & and the other pseudopatients in the psychiatric setting had distinctly negati$e reactions. (e do not pretend to descri%e the su%=ecti$e experiences of true patients. 120 *heirs may %e different from ours' particularly with the passage of time and the necessary process of adaptation to one,s en$ironment. 121 4ut we can and do speak to the relati$ely more o%=ecti$e indices of treatment within the hospital. &t could %e a mistake' and a $ery unfortunate one' to consider that what happened to us deri$ed from malice or stupidity on the part of the staff. Puite the contrary' our o$erwhelming impression of them was of people who really cared' who were committed and who were uncommonly intelligent. 12A (here they failed' as they sometimes did painfully' it would %e more accurate to attri%ute those failures to the en$ironment in which they' too' found themsel$es than to personal callousness. *heir perceptions and %eha$iors were controlled %y the situation' 12F rather than %eing moti$ated %y a malicious disposition. &n a more %enign en$ironment' one that was less attached to glo%al diagnosis' 119 Ees the reality of the 5*7// is e$ery %it as distorted as the 'patient.' 120 Eou could %eat them o$er the head with it and most of them still won't get it. 121 Ees nothing like 'experienced experience' is there" 122 5J#&7B psychology for 7BB mem%ers of the group. & am with you there. &t is a%out groupthink and %eha$iour more than anything else. 123 Eou are pretty close %ut add to that an original condition of extreme real distress 9 for wahte$er reason: and what you get is an ?N7#?R47*?D condition and not 'help.' 124 7<7 5tockholm 5yndrome 125 Ees and that is what makes it so terrifying. &f the well intentioned will do this' what would the maliciously intentioned agree to do" 126 7s are the patient's when we recogni.e we are caught in an escape proof trap with no way out. their %eha$iors and =udgments might ha$e %een more %enign and effecti$e. 127 & thank (. -ischel' ?. Jrne' and -.5. Rosenhan for comments on an earlier draft of this manuscript. 5JMR#?; Da$id B. Rosenhan' Jn 4eing 5ane in &nsane 8laces'! 5cience' Uol. 179 9Han. 1970:' 2AG)2AD. #opyright 1970 %y the 7merican 7ssociation for the 7d$ancement of 5cience. Q1R R. 4enedict' H.>en. 8sychol.' 1G 91901:' A9. Q2R 4eyond the personal difficulties that the pseudo patient is likely to experience in the hospital' there are legal and social ones that' com%ined' re+uire considera%le attention %efore entry. /or example' once admitted to a psychiatric institution' it is difficult' if not impossi%le' to %e discharged on short notice' state law to the contrary notwithstanding. & was not sensiti$e to these difficulties at the outset of the pro=ect' nor to the personal and situational emergencies that can arise' %ut later a writ of ha%eas corpus was prepared for each of the entering pseudo patients and an attorney was kept on call! during e$ery hospitali.ation. 12D & am grateful to Hohn <aplan and Ro%ert 4artels for legal ad$ice and assistance in these matters. Q0R Howe$er distasteful such concealment is' it was a necessary first step to examining these +uestions. (ithout concealment' there would ha$e %een no way to know how $alid these experiences were@ nor was there any way of knowing whether whate$er detections occurred were a tri%ute to the diagnostic acumen of the hospital,s rumour network. J%$iously' since my concerns are general ones that cut across indi$idual hospitals and staffs' & ha$e respected their anonymity and ha$e eliminated clues that might lead to their identification. Q1R &nterestingly' of the 12 admissions' 11 were diagnosed as schi.ophrenic and one' with the identical symptomatology' as manic)depressi$e psychosis. 129 *his diagnosis has more fa$ora%le prognosis' and it was gi$en %y the pri$ate hospital in our sample. Jne the relations %etween social class and psychiatric diagnosis' see 7. de4. Hollingshead and /.#. Redlich' 5ocial #lass and -ental &llness; 7 #ommunity 5tudy 96ew Eork; Hohn (iley' 19AD:. 127 4eing human %eings talking to e+ual human %eings might do wonders. 128 8atients do not ha$e lawyers standing %y on retainer though do they" 129 *his one and 'personality disorders' are more popular in 2G1G QAR 5.?. 7sch' H. 7%norm. 5oc. 8sychol.' 11 9191F:' 5ocial 8sychology 9?nglewood #liffs' 6/; 8renticeSHall' 19A2:. QFR ?. Oigler and B. 8hillips' H. 7%norm. 5oc. 8sychol. F0' 919F1: F9. 5ee also R. <. /reuden%erg and H. 8. Ro%ertson' 7.-.7. 7rch. 6eurol. 8sychiatr.' 7F' 919AF:' 11 Q7R (. -ischel' 8ersonality and 7ssessment 96ew Eork@ Hohn (iley' 19FD:. QDR ?. >offman' 7sylums 9>arden #ity' 6E@ Dou%leday' 19F1: