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Unformatted text preview: 23 BEING SAN E IN INSANE PLACES DAVID L. ROSENHAN if sanity and insanity exist, how shall we know them? The question is nether capricious nor itself ir1~ sane. However much we may be personally con- vinced that we can tell the normal from the abnormal, the evidence is simply not compelling. It is commonplace, for example, to read about murw der trials wherein eminent psychiatrists for the defense are contradicted by equally eminent psy- chiatrists 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, Benedict suggested that normality and abnormality are not universal. What is viewed as normal in one culture may be seen as quite aber- rant in another. Thus, notions of normality and ab- normality may not be quite as accurate as people believe they are. To raise questions regarding nonnality and ab- normality 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 ques- tions 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 . . . is a sim— ple matter: do the salient characteristics that lead to diagnoses reside in the patients themselves or in the environments and contexts in which ob- servers find them? Gains can be made in deciding which of these is more nearly accurate by getting norrnai people . . . 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 . . . is distinct enough that it can be recognized wherever it oc- curs, 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 psy— chiatric diagnosis. This article describes such an experiment. Eight sane people [including the author] 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. PSEUDOPATIENTS AND THEIR SETTINGS The eight pseudopatients were a varied group. One was a psychology graduate student in his 20’s. The Source: David L. Rosenlian, “On Being Sane in Insane Places." Science, vol. 179 (January 19, 1973). pp. 250—258. © 1973 “American Association for. the Advancement of Science." Reprinted with permission, 148 ()L‘llufij—He if: 23 ROSENHAN BEING SANE 1N INSANE PLACES 149 remaining seven were older and “established.” Among them were three psychologists, a pediatri- cian, a psychiatrist, a painter, and a housewife. Three pseudopatients were women. five were men. The settings were similarly varied. In order to generalize the findings, admission into a variety of hospitals was sought. The 12 hospitals in the sam- ple were located in five different states on the East and West coasts. Some were old and shabby, some were quite new. Some were research«oriented, oth- ers not. Some had good staff—patient ratios, others were quite understaffed. Only one was a strictly 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 symp- tom was occasioned by their apparent similarity to existential symptoms. Such symptoms are al- leged 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. . . . immediately upon admission to this psychi~ atric ward, the pseudopatient ceased simulating any symptoms of abnormality. . . . [T]he 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 psy- chiatric 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 medica— tion {which was not swalloWed), and to dining-hall instructors. Beyond such activities as were avail- able 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 be came clear that no one much cared, they were sub- sequently 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 psy- chiatric patient, entered a hospital with no fore— knowledge 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 consider- able, and all but one of the pseudopatients de- sired to be discharged almost immediately after being admitted. They were, therefore, motivated not only to behave sanely, but to be paragons of cooperation. THE NORMAL ARE NOT DETECTABLY SANE Despite their public “show” of sanity, the pseudopa— tients were never detected. Admitted, except in one case, with a diagnosis of schizophrenia, 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 schizo- phrenic, 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 can- not 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 150 PART SIX SELF—TARGETED DEVIANCE time to observe the pseudopatients. Length of hospitalization ranged from 7 to 52 days. with an average of 19 days. Finally, it cannot be said that the failure to rec- ognize the pseudopatients’ sanity was due to the fact that they were not behaving sanely. While mere 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 pseudopatients’ 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 pro- fessor [referring to the continual note-taking]. You're checking up on the hospital," While most of the patients were reassured by the pseudo- patient’s insistence that he had been sick before he came in but was fine now, some continued to believe that the pseudopatient was sane through- out his hospitalization. The fact that the patients often recognized normality when staff did not raises important questions. THE STICKINESS OF PSYCHODIAGNOSTIC LABELS Beyond the tendency to call the healthy sick—a tendency that accounts better for diagnostic be- havior 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 as- sessment. Having once been labeled schizo— phrenic, there is nothing the pseudopatient can do to overcome the tag. The tag profoundly colors others’ perceptions of him and his behavior. . . . All pseudopatients took extensive notes pubw licly. Under ordinary circumstances, such behavior would have raised questions in the minds of ob- servers, as, in fact, it did among patients. Indeed, it seemed so certain that the notes would elicit sus- picion that elaborate precautions were taken to remove them from the ward each day. But the pre- cautions proved needless. The closest any staff member came to questioning these notes occurred when one pseudopatient asked his physician what kind of medication he was receiving and began to write dowa the response. “You needn’t write it,” he was told gently. “If you have trouble remem— bering, just ask me again.“ If no questions were asked of the pseudopa- tients, how was their writing interpreted? Nurs- ing records for three patients indicate that the writing was seen as an aspect of their pathologi- cal behavior. “Patient engages in writing behav- ior” was the daily nursing comment on one of the pseudopatients who was never questioned about his writing. Given that the patient is in the hospi— tal. he must be psychologically disturbed. And given that he is disturbed, continuous writing must be a behavioral manifestation. of that dis- turbance, perhaps a subset of the compulsive behaviors that are sometimes correlated with schizophrenia. 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 atten- dant. A nurse coming upon the scene would rarely inquire even cursorily into the environ- mental stimuli of the patient’s behavior. Rather, she assumed that his upset derived from pathol- ogy, not from his present interactions with other staff members. Occasionally, the staff might as- sume 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. 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 consid- ered to be in remission and available for discharge. 23 ROSENHAN BEENG SAN'E IN INSANE PLACES 151 But the label endures beyond discharge, with the unconfirmed expectation that he will behave as a schizophrenic again. 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. l have records of patients who were beaten by staff for the sin of having initiated ver- bal contact. During my own experience, for ex- ample, one patient was beaten in the presence of other patients for having approached an attendant and told him, I like you.” Occasionally, punish- ment meted out to patients for misdemeanors seemed so excessive that it could not be justified by the most radical interpretations of psychiatric canon. Nevertheless, they appeared to go unques- tioned. 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 psychi- atric hospitals had in common overwhelmed by far their apparent differences. I Powerlessness was evident everywhere. The Pdtlent is deprived of many of his legal rights by 911111 of his psychiatric commitment. He is shorn of credibility by virtue of his psychiatric label. His ftcedom of movement is restricted. He cannot ini- tiate contact with the staff, but may only respond ‘0 3110b 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. . . 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 may have no doors. A nurse unbuttoned her uniform to adjust her brassiere in the presence of an entire ward of view— ing 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. . . . THE CONSEQUENCES OF LABELING AND DEPERSONALIZATION . . . [Wle 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 em- barking on understanding, we continue to label pa- tients “schizophrenic,” “manic-depressive,” and “insane,” as if in those words we had captured the essence of understanding. The facts of the matter are that we have known for a long time that diag- noses are often not useful or reliable, but we have nevertheless continued to use them. We now know that we cannot distinguish insanity from sanity. It is depressing to consider how that information will be used. A Not merely depressing, but frightening. How many people, one wonders, are sane but not rec- ognized 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, con- versely, how many would rather stand trial than 152 PART SIX SELF-TARGETED DEVLANCE live interminany in a psychiatric hospital—-but are wrongly th0ught to be mentally ill? How many have been stigmatized by well—intentioned, but nevertheless erroneous, diagnoses? 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 calls the process of socialization to such institutions “mor- tification”—an apt metaphor that includes the processes of depersonalization that have been de- scribed 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 hos- pital itself imposes a special environment in which the meanings of behavior can easily be misunderstood. The consequences to patients hospitalized in such an environment—the pow- erlessness [and] depersonalization . . .—seem undoubtedly countertherapeutic. I do not, even now, understand this problem well enough to perceive solutions. But two mat- ters seem to have some promise. The first concerns the proliferation of community mental health fa- cilities, 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 rel- atively 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 per- ceptions, it seems to me, is always present, since we are much more sensitive to an individual’s be~ haviors and verbaljzations than we are to the sub— tle contextual stimuli that 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 promisu ing speaks to the need to increase the sensitivity of mental health workers and researchers to the Catch 22 position of psychiatric patient. Simply reading materials in this area will be of help to some such workers and researchers. For others, di— rectly experiencing the impact of psychiatric hos- pitalization 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 psychi- atric setting had distinctly negative reactions. We do not pretend to describe the subjective experi- ences 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 rel- atively more objective indices of treatment within the hospital. It could be a mistake, and a very un- fortunate one, to consider that what happened to us derived from malice or stupidity on the part of the staff. Quite the contrary, our overwhelming im- pression 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 at- tribute those failures to the environment in which they, too, found themselves than to personal cal- lousness. Their perceptions and behavior were controlled by the situation, rather than being mo— tivated by a malicious disposition. In a more be- nign environment, one that was less attached to global diagnosis, their behaviors and judgments might have been more benign and effective. ...
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