PSEUDOPATIENTS AND THEIR SETTINGS

[Guest guest]

On Being Sane In Insane Places

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, 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 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 form 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 counter-

therapeutic.

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.

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* I thank W. Mischel, E. Orne, and M.S. Rosenhan for comments on an

earlier draft of this manuscript.

SOURCE: L. Rosenhan, " On Being Sane in Insane Places, "

Science, Vol. 179 (Jan. 1973), 250-258.

Copyright 1973 by the American Association for the Advancement of

Science.

[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 Kaplan and 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 manic-

depressive 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: 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. , J. Abnorm. Soc. Psychol. 63, (1961)

69. See also R. K. Freudenberg and J. P. on, A.M.A. Arch.

Neurol. Psychiatr., 76, (1956), 14.

[7] W. Mischel, Personality and Assessment (New York; Wiley,

1968).

[8] E. Goffman, Asylums (Garden City, NY; Doubleday, 1961).