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On Being Sane In Insane Places David L Rosenhan How do we know precisely what constitutes normality or mental illness Conventional wisdom suggests that specially trained professionals have the ability to make reasonably accurate diagnoses In this research however David Rosenhan provides evidence to challenge this assumption What is or is not normal may have much to do with the labels that are applied to people in particular settings If sanity and insanity exist how shall we know them The question is neither capricious nor itself insane However much we may be personally convinced that we can tell the normal from the abnormal the evidence is simply not compelling It is commonplace for example to read about murder trials wherein eminent psychiatrists for the defense are contradicted by equally eminent psychiatrists for the prosecution on the matter of the defendant s sanity More generally there are a great deal of conflicting data on the reliability utility and meaning of such terms as sanity insanity mental illness and schizophrenia Finally as early as 1934 Ruth Benedict suggested that normality and abnormality are not universal 1 What is viewed as normal in one culture may be seen as quite aberrant in another Thus notions of normality and abnormality may not be quite as accurate as people believe they are To raise questions regarding normality and abnormality is in no way to question the fact that some behaviors are deviant or odd Murder is deviant So too are hallucinations Nor does raising such questions deny the existence of the personal anguish that is often associated with mental illness Anxiety and depression exist Psychological suffering exists But normality and abnormality sanity and insanity and the diagnoses that flow from them may be less substantive than many believe them to be At its heart the question of whether the sane can be distinguished from the insane and whether degrees of insanity can be distinguished from each other is a simple matter Do the salient characteristics that lead to diagnoses reside in the patients themselves or in the environments and contexts in which observers find them From Bleuler through Kretchmer through the formulators of the recently revised Diagnostic and Statistical Manual of the American Psychiatric Association the belief has been strong that patients present symptoms that those symptoms can be categorized and implicitly that the sane are distinguishable from the insane More recently however this belief has been questioned Based in part on theoretical and anthropological considerations but also on philosophical legal and therapeutic ones the view has grown that psychological categorization of mental illness is useless at best and downright harmful misleading and pejorative at worst Psychiatric diagnoses in this view are in the minds of observers and are not valid summaries of characteristics displayed by the observed Gains can be made in deciding which of these is more nearly accurate by getting normal people that is people who do not have and have never suffered symptoms of serious psychiatric disorders admitted to psychiatric hospitals and then determining whether they were discovered to be sane and if so how If the sanity of such pseudopatients were always detected there would be prima facie evidence that a sane individual can be distinguished from the insane context in which he is found Normality and presumably abnormality is distinct enough that it can be recognized wherever it occurs for it is carried within the person If on the other hand the sanity of the pseudopatients were never discovered serious difficulties would arise for those who support traditional modes of psychiatric diagnosis Given that the hospital staff was not incompetent that the pseudopatient had been behaving as sanely as he had been out of the hospital and that it had never been previously suggested that he belonged in a psychiatric hospital such an unlikely outcome would support the view that psychiatric diagnosis betrays little about the patient but much about the environment in which an observer finds him This article describes such an experiment Eight sane people gained secret admission to 12 different hospitals Their diagnostic experiences constitute the data of the first part of this article the remainder is devoted to a description of their experiences in psychiatric institutions Too few psychiatrists and psychologists even those who have worked in such hospitals know what the experience is like They rarely talk about it with former patients perhaps because they distrust information coming from the previously insane Those who have worked in psychiatric hospitals are likely to have adapted so thoroughly to the settings that they are insensitive to the impact of that experience And while there have been occasional reports of researchers who submitted themselves to psychiatric hospitalization these researchers have commonly remained in the hospitals for short periods of time often with the knowledge of the hospital staff It is difficult to know the extent to which they were treated like patients or like research colleagues Nevertheless their reports about the inside of the psychiatric hospital have been valuable This article extends those efforts PSEUDOPATIENTS AND THEIR SETTINGS The eight pseudopatients were a varied group One was a psychology graduate student in his 20 s The remaining seven were older and established Among them were three psychologists a pediatrician a psychiatrist a painter and a housewife Three pseudopatients were women five were men All of them employed pseudonyms lest their alleged diagnoses embarrass them
later Those who were in mental health professions alleged another occupation in order to avoid the special attentions that might be accorded by staff as a matter of courtesy or caution to ailing colleagues 2 With the exception myself I was the first pseudopatient and my presence was known to the hospital administration and chief psychologist and so far as I can tell to them alone the presence of pseudopatients and the nature of the research program was not known to the hospital staffs 3 The settings are similarly varied In order to generalize the findings admission into a variety of hospitals was sought The 12 hospitals in the sample were located in five different states on the East and West coasts Some were old and shabby some were quite new Some had good staff patient ratios others were quite understaffed Only one was a strict private hospital All of the others were supported by state or federal funds or in one instance by university funds After calling the hospital for an appointment the pseudopatient arrived at the admissions office complaining that he had been hearing voices Asked what the voices said he replied that they were often unclear but as far as he could tell they said empty hollow and thud The voices were unfamiliar and were of the same sex as the pseudopatient The choice of these symptoms was occasioned by their apparent similarity to existential symptoms Such symptoms are alleged to arise from painful concerns about the perceived meaninglessness of one s life It is as if the hallucinating person were saying My life is empty and hollow The choice of these symptoms was also determined by the absence of a single report of existential psychoses in the literature Beyond alleging the symptoms and falsifying name vocation and employment no further alterations of person history or circumstances were made The significant events of the pseudopatient s life history were presented as they had actually occurred Relationships with parents and siblings with spouse and children with people at work and in school consistent with the aforementioned exceptions were described as they were or had been Frustrations and upsets were described along with joys and satisfactions These facts are important to remember If anything they strongly biased the subsequent results in favor of detecting insanity since none of their histories or current behaviors were seriously pathological in any way Immediately upon admission to the psychiatric ward the pseudopatient ceased simulating any symptoms of abnormality In some cases there was a brief period of mild nervousness and anxiety since none of the pseudopatients really believed that they would be admitted so easily Indeed their shared fear was that they would be immediately exposed as frauds and greatly embarrassed Moreover many of them had never visited a psychiatric ward even those who had nevertheless had some genuine fears about what might happen to them Their nervousness then was quite appropriate to the novelty of the hospital setting and it abated rapidly Apart from that short lived nervousness the pseudopatient behaved on the ward as he normally behaved The pseudopatient spoke to patients and staff as he might ordinarily Because there is uncommonly little to do on a psychiatric ward he attempted to engage others in conversation When asked by 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 which was not swallowed and to dining hall instructions Beyond such activities as were available to him on the admissions ward he spent his time writing down his observations about the ward its patients and the staff Initially these notes were written secretly but as it soon became clear that no one much cared they were subsequently written on standard tablets of paper in such public places as the dayroom No secret was made of these activities The pseudopatient very much as a true psychiatric patient entered a hospital with no foreknowledge of when he would be discharged Each was told that he would have to get out by his own devices essentially by convincing the staff that he was sane The psychological stresses associated with hospitalization were considerable and all but one of the pseudopatients desired to be discharged almost immediately after being admitted They were therefore motivated not only to behave sanely but to be paragons of cooperation That their behavior was in no way disruptive is confirmed by nursing reports which have been obtained on most of the patients These reports uniformly indicate that the patients were friendly cooperative and exhibited no abnormal indications THE NORMAL ARE NOT DETECTABLY SANE Despite their public show of sanity the pseudopatients were never detected Admitted except in one case with a diagnosis of schizophrenia 4 each was discharged with a diagnosis of schizophrenia in remission The label in remission should in no way be dismissed as a formality for at no time during any hospitalization had any question been raised about any pseudopatient s simulation Nor are there any indications in the hospital records that the pseudopatient s status was suspect Rather the evidence is strong that once labeled schizophrenic the pseudopatient was stuck with that label If the pseudopatient was to be discharged he must naturally be in remission but he was not sane nor in the institution s view had he ever been sane The uniform failure to recognize sanity cannot be attributed to the quality of the hospitals for although there were considerable variations among them several are considered excellent Nor can it be alleged that there was simply not enough time to
observe the pseudopatients Length of hospitalization ranged from 7 to 52 days with an average of 19 days The pseudopatients were not in fact carefully observed but this failure speaks more to traditions within psychiatric hospitals than to lack of opportunity Finally it cannot be said that the failure to recognize the pseudopatients sanity was due to the fact that they were not behaving sanely While there was clearly some tension present in all of them their daily visitors could detect no serious behavioral consequences nor indeed could other patients It was quite common for the patients to detect the pseudopatient s sanity During the first three hospitalizations when accurate counts were kept 35 of a total of 118 patients on the admissions ward voiced their suspicions some vigorously You re not crazy You re a journalist or a professor referring to the continual note taking You re checking up on the hospital While most of the patients were reassured by the pseudopatient s insistence that he had been sick before he came in but was fine now some continued to believe that the pseudopatient was sane throughout his hospitalization The fact that the patients often recognized normality when staff did not raises important questions Failure to detect sanity during the course of hospitalization may be due to the fact that physicians operate with a strong bias toward what statisticians call the Type 2 error This is to say that physicians are more inclined to call a healthy person sick a false positive Type 2 than a sick person healthy a false negative Type 1 The reasons for this are not hard to find it is clearly more dangerous to misdiagnose illness than health Better to err on the side of caution to suspect illness even among the healthy But what holds for medicine does not hold equally well for psychiatry Medical illnesses while unfortunate are not commonly pejorative Psychiatric diagnoses on the contrary carry with them personal legal and social stigmas It was therefore important to see whether the tendency toward diagnosing the sane insane could be reversed The following experiment was arranged at a research and teaching hospital whose staff had heard these findings but doubted that such an error could occur in their hospital The staff was informed that at some time during the following three months one or more pseudopatients would attempt to be admitted into the psychiatric hospital Each staff member was asked to rate each patient who presented himself at admissions or on the ward according to the likelihood that the patient was a pseudopatient A 10 point scale was used with a 1 and 2 reflecting high confidence that the patient was a pseudopatient Judgments were obtained on 193 patients who were admitted for psychiatric treatment All staff who had had sustained contact with or primary responsibility for the patient attendants nurses psychiatrists physicians and psychologists were asked to make judgments Forty one patients were alleged with high confidence to be pseudopatients by at least one member of the staff Twenty three were considered suspect by at least one psychiatrist Nineteen were suspected by one psychiatrist and one other staff member Actually no genuine pseudopatient at least from my group presented himself during this period The experiment is instructive It indicates that the tendency to designate sane people as insane can be reversed when the stakes in this case prestige and diagnostic acumen are high But what can be said of the 19 people who were suspected of being sane by one psychiatrist and another staff member Were these people truly sane or was it rather the case that in the course of avoiding the Type 2 error the staff tended to make more errors of the first sort calling the crazy sane There is no way of knowing But one thing is certain any diagnostic process that lends itself too readily to massive errors of this sort cannot be a very reliable one THE STICKINESS OF PSYCHODIAGNOSTIC LABELS Beyond the tendency to call the healthy sick a tendency that accounts better for diagnostic behavior on admission than it does for such behavior after a lengthy period of exposure the data speak to the massive role of labeling in psychiatric assessment Having once been labeled schizophrenic there is nothing the pseudopatient can do to overcome the tag The tag profoundly colors others perceptions of him and his behavior From one viewpoint these data are hardly surprising for it has long been known that elements are given meaning by the context in which they occur Gestalt psychology made the point vigorously and Asch 5 demonstrated that there are central personality traits such as warm versus cold which are so powerful that they markedly color the meaning of other information in forming an impression of a given personality Insane schizophrenic manic depressive and crazy are probably among the most powerful of such central traits Once a person is designated abnormal all of his other behaviors and characteristics are colored by that label Indeed that label is so powerful that many of the pseudopatients normal behaviors were overlooked entirely or profoundly misinterpreted Some examples may clarify this issue Earlier I indicated that there were no changes in the pseudopatient s personal history and current status beyond those of name employment and where necessary vocation Otherwise a veridical description of personal history and circumstances was offered Those circumstances were not psychotic How were they made consonant with the diagnosis modified in such a way as to bring them into accord with the circumstances of the pseudopatient s life as described by him
As far as I can determine diagnoses were in no way affected by the relative health of the circumstances of a pseudopatient s life Rather the reverse occurred the perception of his circumstances was shaped entirely by the diagnosis A clear example of such translation is found in the case of a pseudopatient who had had a close relationship with his mother but was rather remote from his father during his early childhood During adolescence and beyond however his father became a close friend while his relationship with his mother cooled His present relationship with his wife was characteristically close and warm Apart from occasional angry exchanges friction was minimal The children had rarely been spanked Surely there is nothing especially pathological about such a history Indeed many readers may see a similar pattern in their own experiences with no markedly deleterious consequences Observe however how such a history was translated in the psychopathological context this from the case summary prepared after the patient was discharged This white 39 year old male manifests a long history of considerable ambivalence in close relationships which begins in early childhood A warm relationship with his mother cools during his adolescence A distant relationship with his father is described as becoming very intense Affective stability is absent His attempts to control emotionality with his wife and children are punctuated by angry outbursts and in the case of the children spankings And while he says that he has several good friends one senses considerable ambivalence embedded in those relationships also The facts of the case were unintentionally distorted by the staff to achieve consistency with a popular theory of the dynamics of a schizophrenic reaction Nothing of an ambivalent nature had been described in relations with parents spouse or friends To the extent that ambivalence could be inferred it was probably not greater than is found in all human s relationships It is true the pseudopatient s relationships with his parents changed over time but in the ordinary context that would hardly be remarkable indeed it might very well be expected Clearly the meaning ascribed to his verbalizations that is ambivalence affective instability was determined by the diagnosis schizophrenia An entirely different meaning would have been ascribed if it were known that the man was normal All pseudopatients took extensive notes publicly Under ordinary circumstances such behavior would have raised questions in the minds of observers as in fact it did among patients Indeed it seemed so certain that the notes would elicit suspicion that elaborate precautions were taken to remove them from the ward each day But the precautions proved needless The closest any staff member came to questioning those notes occurred when one pseudopatient asked his physician what kind of medication he was receiving and began to write down the response You needn t write it he was told gently If you have trouble remembering just ask me again If no questions were asked of the pseudopatients how was their writing interpreted 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 Given that the patient is in the hospital he must be psychologically disturbed And given that he is disturbed continuous writing must be behavioral manifestation of that disturbance perhaps a subset of the compulsive behaviors that are sometimes correlated with schizophrenia One tacit characteristic of psychiatric diagnosis is that it locates the sources of aberration within the individual and only rarely within the complex of stimuli that surrounds him Consequently behaviors that are stimulated by the environment are commonly misattributed to the patient s disorder For example one kindly nurse found a pseudopatient pacing the long hospital corridors Nervous Mr X she asked No bored he said The notes kept by pseudopatients are full of patient behaviors that were misinterpreted by well intentioned staff Often enough a patient would go berserk because he had wittingly or unwittingly been mistreated by say an attendant A nurse coming upon the scene would rarely inquire even cursorily into the environmental stimuli of the patient s behavior Rather she assumed that his upset derived from his pathology not from his present interactions with other staff members Occasionally the staff might assume that the patient s family especially when they had recently visited or other patients had stimulated the outburst But never were the staff found to assume that one of themselves or the structure of the hospital had anything to do with a patient s behavior One psychiatrist pointed to a group of patients who were sitting outside the cafeteria entrance half an hour before lunchtime To a group of young residents he indicated that such behavior was characteristic of the oral acquisitive nature of the syndrome It seemed not to occur to him that there were very few things to anticipate in a psychiatric hospital besides eating A psychiatric label has a life and an influence of its own Once the impression has been formed that the patient is schizophrenic the expectation is that he will continue to be schizophrenic When a sufficient amount of time has passed during which the patient has done nothing bizarre he is considered to be in remission and available for discharge But the label endures beyond discharge with the unconfirmed expectation that he will behave as a schizophrenic again Such labels conferred by mental health professionals are as influential on the patient as they are on his relatives and friends and it should not surprise anyone that the diagnosis acts on all of them as a self fulfilling prophecy Eventually the patient himself accepts the diagnosis with all of its surplus meanings and expectations and behaves accordingly
The inferences to be made from these matters are quite simple Much as Zigler and Phillips have demonstrated that there is enormous overlap in the symptoms presented by patients who have been variously diagnosed 6 so there is enormous overlap in the behaviors of the sane and the insane The sane are not sane all of the time We lose our tempers for no good reason We are occasionally depressed or anxious again for no good reason And we may find it difficult to get along with one or another person again for no reason that we can specify Similarly the insane are not always insane Indeed it was the impression of the pseudopatients while living with them that they were sane for long periods of time that the bizarre behaviors upon which their diagnoses were allegedly predicated constituted only a small fraction of their total behavior If it makes no sense to label ourselves permanently depressed on the basis of an occasional depression then it takes better evidence than is presently available to label all patients insane or schizophrenic on the basis of bizarre behaviors or cognitions It seems more useful as Mischel 7 has pointed out to limit our discussions to behaviors the stimuli that provoke them and their correlates It is not known why powerful impressions of personality traits such as crazy or insane arise Conceivably when the origins of and stimuli that give rise to a behavior are remote or unknown or when the behavior strikes us as immutable trait labels regarding the behavior arise When on the other hand the origins and stimuli are known and available discourse is limited to the behavior itself Thus I may hallucinate because I am sleeping or I may hallucinate because I have ingested a peculiar drug These are termed sleep induced hallucinations or dreams and drug induced hallucinations respectively But when the stimuli to my hallucinations are unknown that is called craziness or schizophrenia as if that inference were somehow as illuminating as the others THE EXPERIENCE OF PSYCHIATRIC HOSPITALIZATION The term mental illness is of recent origin It was coined by people who were humane in their inclinations and who wanted very much to raise the station of and the public s sympathies toward the psychologically disturbed from that of witches and crazies to one that was akin to the physically ill And they were at least partially successful for the treatment of the mentally ill has improved considerably over the years But while treatment has improved it is doubtful that people really regard the mentally ill in the same way that they view the physically ill A broken leg is something one recovers from but mental illness allegedly endures forever A broken leg does not threaten the observer but a crazy schizophrenic There is by now a host of evidence that attitudes toward the mentally ill are characterized by fear hostility aloofness suspicion and dread The mentally ill are society s lepers That such attitudes infect the general population is perhaps not surprising only upsetting But that they affect the professionals attendants nurses physicians psychologists and social workers who treat and deal with the mentally ill is more disconcerting both because such attitudes are self evidently pernicious and because they are unwitting Most mental health professionals would insist that they are sympathetic toward the mentally ill that they are neither avoidant nor hostile But it is more likely that an exquisite ambivalence characterizes their relations with psychiatric patients such that their avowed impulses are only part of their entire attitude Negative attitudes are there too and can easily be detected Such attitudes should not surprise us They are the natural offspring of the labels patients wear and the places in which they are found Consider the structure of the typical psychiatric hospital Staff and patients are strictly segregated Staff have their own living space including their dining facilities bathrooms and assembly places The glassed quarters that contain the professional staff which the pseudopatients came to call the cage sit out on every dayroom The staff emerge primarily for care taking purposes to give medication to conduct therapy or group meeting to instruct or reprimand a patient Otherwise staff keep to themselves almost as if the disorder that afflicts their charges is somehow catching So much is patient staff segregation the rule that for four public 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 While it was not the case that all time spent out of the cage was spent mingling with patients attendants for example would occasionally emerge to watch television in the dayroom it was the only way in which one could gather reliable data on time for measuring The average amount of time spent by attendants outside of the cage was 11 3 percent range 3 to 52 percent This figure does not represent only time spent mingling with patients but also includes time spent on such chores as folding laundry supervising patients while they shave directing ward cleanup and sending patients to off ward activities It was the relatively rare attendant who spent time talking with patients or playing games with them It proved impossible to obtain a percent mingling time for nurses since the amount of time they spent out of the cage was too brief Rather we counted instances of emergence from the cage On the average daytime nurses emerged from the cage 11 5 times per shift including instances when they left the ward entirely range 4 to 39 times Later afternoon and night nurses were even less available emerging on the average 9 4 times per shift range 4 to 41 times Data on early morning nurses who arrived usually after midnight and departed at 8 a m are not available because patients were asleep during most of this period Physicians especially psychiatrists were even less available They were rarely seen on the wards Quite commonly they would be seen only when they arrived and departed with the remaining time being spend in their offices or in the cage On the
average physicians emerged on the ward 6 7 times per day range 1 to 17 times It proved difficult to make an accurate estimate in this regard since physicians often maintained hours that allowed them to come and go at different times The hierarchical organization of the psychiatric hospital has been commented on before but the latent meaning of that kind of organization is worth noting again Those with the most power have the least to do with patients and those with the least power are the most involved with them Recall however that the acquisition of role appropriate behaviors occurs mainly through the observation of others with the most powerful having the most influence Consequently it is understandable that attendants not only spend more time with patients than do any other members of the staff that is required by their station in the hierarchy but also insofar as they learn from their superior s behavior spend as little time with patients as they can Attendants are seen mainly in the cage which is where the models the action and the power are I turn now to a different set of studies these dealing with staff response to patient initiated contact It has long been known that the amount of time a person spends with you can be an index of your significance to him If he initiates and maintains eye contact there is reason to believe that he is considering your requests and needs If he pauses to chat or actually stops and talks there is added reason to infer that he is individuating you In four hospitals the pseudopatients approached the staff member with a request which took the following form Pardon me Mr or Dr or Mrs X could you tell me when I will be eligible for grounds privileges or when I will be presented at the staff meeting or when I am likely to be discharged While the content of the question varied according to the appropriateness of the target and the pseudopatient s apparent current needs the form was always a courteous and relevant request for information Care was taken never to approach a particular member of the staff more than once a day lest the staff member become suspicious or irritated R emember that the behavior of the pseudopatients was neither bizarre nor disruptive One could indeed engage in good conversation with them Minor differences between these four institutions were overwhelmed by the degree to which staff avoided continuing contacts that patients had initiated By far their most common response consisted of either a brief response to the question offered while they were on the move and with head averted or no response at all The encounter frequently took the following bizarre form pseudopatient Pardon me Dr X Could you tell me when I am eligible for grounds privileges physician Good morning Dave How are you today Moves off without waiting for a response POWERLESSNESS AND DEPERSONALIZATION Eye contact and verbal contact reflect concern and individuation their absence avoidance and depersonalization The data I have presented do not do justice to the rich daily encounters that grew up around matters of depersonalization and avoidance I have records of patients who were beaten by staff for the sin of having initiated verbal contact During my own experience for example one patient was beaten in the presence of other patients for having approached an attendant and told him I like you Occasionally punishment meted out to patients for misdemeanors seemed so excessive that it could not be justified by the most rational interpretations of psychiatric cannon Nevertheless they appeared to go unquestioned Tempers were often short A patient who had not heard a call for medication would be roundly excoriated and the morning attendants would often wake patients with Come on you m_ _ _ _ _ f _ _ _ _ _ s out of bed Neither anecdotal nor hard data can convey the overwhelming sense of powerlessness which invades the individual as he is continually exposed to the depersonalization of the psychiatric hospital It hardly matters which psychiatric hospital the excellent public ones and the very plush private hospital were better than the rural and shabby ones in this regard but again the features that psychiatric hospitals had in common overwhelmed by far their apparent differences Powerlessness was evident everywhere The patient is deprived of many of his legal rights by dint of his psychiatric commitment He is shorn of credibility by virtue of his psychiatric label His freedom of movement is restricted He cannot initiate contact with the staff but may only respond to such overtures as they make Personal privacy is minimal Patient quarters and possessions can be entered and examined by any staff member for whatever reason His personal history and anguish is available to any staff member often including the grey lady and candy striper volunteer who chooses to read his folder regardless of their therapeutic relationship to him His personal hygiene and waste evacuation are often monitored The water closets have no doors At times depersonalization reached such proportions that pseudopatients had the sense that they were invisible or at least unworthy of account Upon being admitted I and other pseudopatients took the initial physical examinations in a semipublic room where staff members went about their own business as if we were not there On the ward attendants delivered verbal and occasionally serious physical abuse to patients in the presence of others the pseudopatients who were writing it all down Abusive behavior on the other hand terminated quite abruptly when other staff members were known to be coming Staff are credible witnesses Patients are not
A nurse unbuttoned her uniform to adjust her brassiere in the present of an entire ward of viewing men One did not have the sense that she was being seductive Rather she didn t notice us A group of staff persons might point to a patient in the dayroom and discuss him animatedly as if he were not there One illuminating instance of depersonalization and invisibility occurred with regard to medication All told the pseudopatients were administered nearly 2100 pills including Elavil Stelazine Compazine and Thorazine to name but a few That such a variety of medications should have been administered to patients presenting identical symptoms is itself worthy of note Only two were swallowed The rest were either pocketed or deposited in the toilet The pseudopatients were not alone in this Although I have no precise records on how many patients rejected their medications the pseudopatients frequently found the medications of other patients in the toilet before they deposited their own As long as they were cooperative their behavior and the pseudopatients own in this matter as in other important matters went unnoticed throughout Reactions to such depersonalization among pseudopatients were intense Although they had come to the hospital as participant observers and were fully aware that they did not belong they nevertheless found themselves caught up in and fighting the process of depersonalization Some examples a graduate student in psychology asked his wife to bring his textbooks to the hospital so he could catch up on his homework this despite the elaborate precautions taken to conceal his professional association The same student who had trained for quite some time to get into the hospital and who had looked forward to the experience remembered some drag races that he had wanted to see on the weekend and insisted that he be discharged by that time Another pseudopatient attempted a romance with a nurse Subsequently he informed the staff that he was applying for admission to graduate school in psychology and was very likely to be admitted since a graduate professor was one of his regular hospital visitors The same person began to engage in psychotherapy with other patients all of this as a way of becoming a person in an impersonal environment THE SOURCES OF DEPERSONALIZATION What are the origins of depersonalization I have already mentioned two First are attitudes held by all of us toward the mentally ill including those who treat them attitudes characterized by fear distrust and horrible expectations on the one hand and benevolent intentions on the other Our ambivalence leads in this instance as in others to avoidance Second and not entirely separate the hierarchical structure of the psychiatric hospital facilitates depersonalization Those who are at the top have least to do with patients and their behavior inspires the rest of the staff Average daily contact with psychiatrists psychologists residents and physicians combined ranged from 3 9 to 25 1 minutes with an overall mean of 6 8 six pseudopatients over a total of 129 days of hospitalization Included in this average are time spent in the admissions interview ward meetings in the presence of a senior staff member group and individual psychotherapy contacts case presentation conferences and discharge meetings Clearly patients do not spend much time in interpersonal contact with doctoral staff And doctoral staff serve as models for nurses and attendants There are probably other sources Psychiatric installations are presently in serious financial straits Staff shortages are pervasive and that shortens patient contact Yet while financial stresses are realities too much can be made of them I have the impression that the psychological forces that result in depersonalization are much stronger than the fiscal ones and that the addition of more staff would not correspondingly improve patient care in this regard The incidence of staff meetings and the enormous amount of record keeping on patients for example have not been as substantially reduced as has patient contact Priorities exist even during hard times Patient contact is not a significant priority in the traditional psychiatric hospital and fiscal pressures do not account for this Avoidance and depersonalization may Heavy reliance upon psychotropic medication tacitly contributes to depersonalization by convincing staff that treatment is indeed being conducted and that further patient contact may not be necessary Even here however caution needs to be exercised in understanding the role of psychotropic drugs If patients were powerful rather than powerless if they were viewed as interesting individuals rather than diagnostic entities if they were socially significant rather than social lepers if their anguish truly and wholly compelled our sympathies and concerns would we not seek contact with them despite the availability of medications Perhaps for the pleasure of it all THE CONSEQUENCES OF LABELING AND DEPERSONALIZATION Whenever the ratio of what is known to what needs to be known approaches zero we tend to invent knowledge and assume that we understand more than we actually do We seem unable to acknowledge that we simply don t know The needs for diagnosis and remediation of behavioral and emotional problems are enormous But rather than acknowledge that we are just embarking on understanding we continue to label patients schizophrenic manic depressive and insane as if in those words we captured the essence of understanding The facts of the matter are that we have known for a long time that diagnoses are often not useful or reliable but we have nevertheless continued to use them We now know that we cannot distinguish sanity from insanity It is depressing to consider how that information will be used
Not merely depressing but frightening How many people one wonders are sane but not recognized as such in our psychiatric institutions How many have been needlessly stripped of their privileges of citizenship from the right to vote and drive to that of handling their own accounts How many have feigned insanity in order to avoid the criminal consequences of their behavior and conversely how many would rather stand trial than live interminably in a psychiatric hospital but are wrongly thought to be mentally ill How many have been stigmatized by well intentioned but nevertheless erroneous diagnoses On the last point recall again that a Type 2 error in psychiatric diagnosis does not have the same consequences it does in medical diagnosis A diagnosis of cancer that has been found to be in error is cause for celebration But psychiatric diagnoses are rarely found to be in error The label sticks a mark of inadequacy forever Finally how many patients might be sane outside the psychiatric hospital but seem insane in it not because craziness resides in them as it were but because they are responding to a bizarre setting one that may be unique to institutions which harbor nether people Goffman 8 calls the process of socialization to such institutions mortification an apt metaphor that includes the processes of depersonalization that have been described here And while it is impossible to know whether the pseudopatients responses to these processes are characteristic of all inmates they were after all not real patients it is difficult to believe that these processes of socialization to a psychiatric hospital provide useful attitudes or habits of response for living in the real world SUMMARY AND CONCLUSIONS It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals The hospital itself imposes a special environment in which the meaning of behavior can easily be misunderstood The consequences to patients hospitalized in such an environment the powerlessness depersonalization segregation mortification and self labeling seem undoubtedly countertherapeutic I do not even now understand this problem well enough to perceive solutions But two matters seem to have some promise The first concerns the proliferation of community mental health facilities of crisis intervention centers of the human potential movement and of behavior therapies that for all of their own problems tend to avoid psychiatric labels to focus on specific problems and behaviors and to retain the individual in a relatively non pejorative environment Clearly to the extent that we refrain from sending the distressed to insane places our impressions of them are less likely to be distorted The risk of distorted perceptions it seems to me is always present since we are much more sensitive to an individual s behaviors and verbalizations than we are to the subtle contextual stimuli than often promote them At issue here is a matter of magnitude And as I have shown the magnitude of distortion is exceedingly high in the extreme context that is a psychiatric hospital The second matter that might prove promising speaks to the need to increase the sensitivity of mental health workers and researchers to the Catch 22 position of psychiatric patients Simply reading materials in this area will be of help to some such workers and researchers For others directly experiencing the impact of psychiatric hospitalization will be of enormous use Clearly further research into the social psychology of such total institutions will both facilitate treatment and deepen understanding I and the other pseudopatients in the psychiatric setting had distinctly negative reactions We do not pretend to describe the subjective experiences of true patients Theirs may be different from ours particularly with the passage of time and the necessary process of adaptation to one s environment But we can and do speak to the relatively more objective indices of treatment within the hospital It could be a mistake and a very unfortunate one to consider that what happened to us derived from malice or stupidity on the part of the staff Quite the contrary our overwhelming impression of them was of people who really cared who were committed and who were uncommonly intelligent Where they failed as they sometimes did painfully it would be more accurate to attribute those failures to the environment in which they too found themselves than to personal callousness Their perceptions and behaviors were controlled by the situation rather than being motivated by a malicious disposition In a more benign environment one that was less attached to global diagnosis their behaviors and judgments might have been more benign and effective 1 R Benedict J Gen Psychol 10 1934 59 2 Beyond the personal difficulties that the pseudopatient is likely to experience in the hospital there are legal and social ones that combined require considerable attention before entry For example once admitted to a psychiatric institution it is difficult if not impossible to be discharged on short notice state law to the contrary notwithstanding I was not sensitive to these difficulties at the outset of the project nor to the personal and situational emergencies that can arise but later a writ of habeas corpus was prepared for each of the entering pseudopatients and an attorney was kept on call during every hospitalization I am grateful to John Kaplan and Robert Bartels for legal advice and assistance in these matters 3 However distasteful such concealment is it was a necessary first step to examining these questions Without concealment there would have been no way to know how valid these experiences were nor was there any way of knowing whether whatever detections occurred were a tribute to the diagnostic acumen of the hospital s rumor network Obviously since my concerns are general ones that
cut across individual hospitals and staffs I have respected their anonymity and have eliminated clues that might lead to their identification 4 Interestingly of the 12 admissions 11 were diagnosed as schizophrenic and one with the identical symptomatology as manicdepressive psychosis This diagnosis has more favorable prognosis and it was given by the private hospital in our sample One the relations between social class and psychiatric diagnosis see A deB Hollingshead and F C Redlich Social Class and Mental Illness A Community Study New York John Wiley 1958 5 S E Asch J Abnorm Soc Psychol 41 1946 Social Psychology Englewood Cliffs NF Prentice_Hall 1952 6 E Zigler and L Phillips J Abnorm Soc Psychol 63 1961 69 See also R K Freudenberg and J P Robertson A M A Arch Neurol Psychiatr 76 1956 14 7 W Mischel Personality and Assessment New York John Wiley 1968 8 E Goffman Asylums Garden City NY Doubleday 1961
How mad are you Have you left the gas on By Rob Liddell Producer Horizon Most people get anxious in their daily lives but where does the line between sanity and madness lie and is it easy to recognize Do you ever worry about leaving the gas on or arrive at work and worry that you ve not locked your front door Perhaps you get anxious before having to give a talk or wake up in the morning and are barely able to drag yourself out of bed These are normal reactions to the twists and turns of modern life But all these actions can also be seen as symptoms of mental illness Those with Obsessive Compulsive Disorder OCD know this only too well Classic symptoms of the illness include repeated checking of things like the gas and door locks It is motivated by a genuine and deep rooted fear that the person or their loved ones will be in grave danger if they don t check It s an emotion that everyone can relate to the idea of the house burning down is probably enough to get anyone out of bed just to check one more time But checking and rituals can quickly come to dominate a person s life Hours every day are taken up with compulsions which have a major impact on work and relationships Distinguishing between reactions that are generally considered healthy and those that are signs of a full blown mental disorder has always been a challenge for psychiatry the science of the mind The 10 volunteers are challenged to perform a stand up comic routine Most disorders have symptoms that in a milder form can just seem like character traits But how
pessimistic do you have to be before a psychiatrist would say you had depression How much insecurity makes you schizophrenic Just how hard is it to tell the difference between illness and health The BBC science series Horizon challenged three mental health experts to see if they could make that distinction Body image It selected 10 volunteers of all ages and backgrounds Half the group had a history of various mental disorders the other half didn t The question for the panel was simple who is who They were filmed during a week of activities ranging from group bonding exercises to specific psychological tests All were designed to explore some of the classic symptoms and traits of some major psychiatric disorders A distorted body image is a key symptom of eating disorders like Anorexia Nervosa and Bulimia Nervosa People living with these illnesses tend to see themselves differently to the way they actually are both in terms of body shape and weight But what complicates matters is that almost all of us do that to some extent The volunteers took photos of each other wearing white lycra suits and the images were stretched out of shape They were then asked to shrink them back to the way they saw themselves Yasmin 36 is an amateur rugby player and physically she is one of the larger members of the group Like all the other volunteers she was faced with an unflattering image of her headless body stretched She exaggerated her own size by only 8 which was less than anyone else in the group But what interested the panel was how she really agonized over it She said it was her least favorite task of the week by a very long way and she took twice as long to do the test as any of the others Even the panel felt uncomfortable watching her including Ian Hulatt a psychiatric nurse and mental health advisor to the Royal Collage of Those with eating disorders have a distorted body image Nursing But he felt her reaction was character not illness That was probably in response to how she feels about social messages about her being overweight in our culture he says That wasn t sufficiently out of context or unusual to make us feel it was pathological The volunteers are asked to clean out a cowshed The results of the group as a whole mimicked larger research studies showing that most people think they re bigger than they are Effectively when we look in the mirror we don t see a true picture of
ourselves reflected back Those with eating disorders tend to be on the extreme end of this scale Millions in Britain worry about the way they look count calories and diet Like many of the disorders explored by Horizon the facts are shocking 10 of adult women will be affected by Bulimia one in 10 of those with Anorexia are men Social Anxiety The test the volunteers found most challenging was performing a five minute stand up comedy routine on stage in a local pub Even at the first rehearsal there were no volunteers to go first and almost everyone in the group found the idea daunting Several exhibited signs of social anxiety One actually admitted feeling sick at the very thought of public speaking but ended up with a strong performance Another who appeared more relaxed beforehand ducked out early From what I saw there is no difference at all between people who have had mental health problems and have recovered and those that never have says Yasmin after the performances But the panel picked up several indications One volunteer displayed pessimism another had disjointed speech and another showed risk taking behavior But for the panel the biggest clue was not a true symptom One of the volunteers used a rationalization technique to cope with the situation imagining the worst that could happen and realizing it isn t that bad after all The panelists identified this as Cognitive Behavioral Therapy a sign she had undergone counseling The programmers explored major disorders including Depression Schizophrenia Bi Polar Disorder Obsessive Compulsive Disorder and Eating Disorders All of them are serious illnesses that have the power to devastate the lives of those affected by them But despite the seriousness of these illnesses identifying who has them was a real challenge for the panel of experts It makes a point the public need to realize that you cannot just look at someone and make assumptions says Mr Hulatt When someone has been labeled with a disorder or episode of mental illness it s very unhelpful to interpret everything they do through a poorly understood label The program found that it is wrong to assume they cannot lead normal lives This is coupled with the fact that mental illness is a problem that affects as many as one in four of the UK population yet it is often misunderstood shrouded in stereotype and stigma Making the two documentaries was a real eye opener In the course of the production we met some amazing people who have struggled with disorders and overcome them We met brave people with no history of mental illness who to explore the line between mental health and mental illness were willing to risk being labeled with an illness they do not have They all tell a powerful story that having a mental illness doesn t have to become your defining characteristic and apart in society
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