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'Dr. Rosenhan personally had himself admitted as a ''mental patient'' in 1972and wrote of his findings regarding the experience.
Please note:In this piece by David Rosenhan all the footnoteshavebeen added by meand speak of my ownexperience in relation to
Rosenhan's study which is based on his similar experience...
Patricia Lefave, Labelled, Delusional Disorder, (Paranoid)
On Being Sane In Insane PlacesBy David L. Rosenhan, PhD.Stanford University
How do we know precisely what constitutes normality! or mental illness"#on$entional wisdom suggests that specially trained professionals ha$e the
a%ility to make reasona%ly accurate diagnoses. &n this research howe$er
Da$id Rosenhan pro$ides e$idence to challenge this assumption. (hat is ))or is not )) normal! may ha$e much to do with the la%els that are applied to
people in particular settings.
&f sanity and insanity exist how shall we know them"
*he +uestion is neither capricious nor itself insane. Howe$er much we may%e personally con$inced that we can tell the normal from the a%normal the
e$idence is simply not compelling. &t is commonplace for example to read
a%out murder trials wherein eminent psychiatrists for the defense arecontradicted %y e+ually eminent psychiatrists for the prosecution on the
matter of the defendant,s sanity. -ore generally there are a great deal ofconflicting data on the relia%ility utility and meaning of such terms as
sanity! insanity! mental illness! and schiophrenia.!
/inally as early as 190 Ruth3 4enedict suggested that normality and
a%normality are not uni$ersal.
(hat is $iewed as normal in one culture may %e seen as +uite a%errant in
another. *hus notions of normality and a%normality may not %e +uite as
accurate as people %elie$e they are.
*o raise +uestions regarding normality and a%normality is in no way to+uestion the fact that some %eha$iors are de$iant or odd. -urder is de$iant.
5o too are hallucinations. 6or does raising such +uestions deny the
existence of the personal anguish that is often associated with mentalillness.! nxiety and depression exist. 8sychological suffering exists. 4ut
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normality and a%normality sanity and insanity and the diagnoses that flowfrom them may %e less su%stanti$e than many %elie$e them to %e.
t its heart the +uestion of whether the sane can %e distinguished from the
insane and whether degrees of insanity can %e distinguished from each
other: is a simple matter; Do the salient characteristics that lead todiagnoses reside in the patients themsel$es or in the en$ironments and
contexts in which o%ser$ers find them" /rom 4leuler through
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description of their experiences in psychiatric institutions. *oo fewpsychiatrists and psychologists e$en those who ha$e worked in such
hospitals know what the experience is like. *hey rarely talk a%out it withformer patients perhaps %ecause they distrust information coming from the
pre$iously insane. *hose who ha$e worked in psychiatric hospitals are likely
to ha$e adapted so thoroughly to the settings that they are insensiti$e to theimpact of that experience. nd while there ha$e %een occasional reports of
researchers who su%mitted themsel$es to psychiatric hospitaliation theseresearchers ha$e commonly remained in the hospitals for short periods of
time often with the knowledge of the hospital staff. &t is difficult to know the
extent to which they were treated like patients or like research colleagues.6e$ertheless their reports a%out the inside of the psychiatric hospital ha$e
%een $alua%le. *his article extends those efforts.
#$% &OR'(L (R% &O# D%#%)#(BL* S(&%
Despite their pu%lic show! of sanity the pseudo patients were ne$er
detected. dmitted except in one case with a diagnosis of schiophrenia
each was discharged with a diagnosis of schiophrenia in remission.! *he
la%el in remission! should in no way %e dismissed as a formality for at no
time during any hospitaliation had any +uestion %een raised a%out any
pseudo patient,s simulation. 6or are there any indications in the hospital
records that the pseudo patient,s status was suspect. Rather the e$idence is
strong that once la%eled schiophrenic the pseudo patient was stuck with
that la%el. &f the pseudo patient was to %e discharged he must naturally %ein remission!@ %ut he was not sane nor in the institution,s $iew had he
e$er %een sane.
#he !niform fail!re to recogni+e sanity0cannot %e attri%uted to the
+uality of the hospitals for although there were considera%le $ariations
among them se$eral are considered excellent. 6or can it %e alleged that
hospitaliation ranged from 7 to A2 days with an a$erage of 19 days. *he
pseudo patients were not in fact carefully o%ser$ed %ut this failure speaks
more to traditions within psychiatric hospitals than to lack of opportunity.
/inally it cannot %e said that the failure to recognie the pseudo patients'
sanity was due to the fact that they were not %eha$ing sanely. (hile there
was clearly some tension present in all of them their daily $isitors could
3?mphasis mine 8B
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detect no serious %eha$ioral conse+uencesCnor indeed could other
patients. It was !ite common for the "atients to -detect the "se!do
"atient/s sanity.During the first three hospitaliations when accurate
counts were kept 0A of a total of 11 patients on the admissions ward
$oiced their suspicions some $igorously. Eou,re not cray. Eou,re a=ournalist or a professor referring to the continual note)taking:. Eou,re
checking up on the hospital.! (hile most of the patients were reassured %y
the pseudo patient,s insistence that he had %een sick %efore he came in %ut
was fine now some continued to %elie$e that the pseudo patient was sane
throughout his hospitaliation. *he fact that the patients often recognied
normality when staff did not raises important +uestions.
/ailure to detect sanity during the course of hospitaliation may %e due to
the fact that physicians operate with a strong %ias toward what statisticianscall the *ype 2 error. *his is to say that physicians are more inclined to call a
healthy person sick a false positi$e *ype 2: than a sick person healthy a
false negati$e *ype 1:. *he reasons for this are not hard to find; it is clearly
more dangerous to misdiagnose illness than health. 4etter to err on the side
of caution to suspect illness e$en among the healthy.
4ut what holds for medicine does not hold e+ually well for psychiatry.
-edical illnesses while unfortunate are not commonly pe=orati$e.
Psychiatric diagnoses, on the contrary, carry with them "ersonal,
legal, and social stigmas. A&t was therefore important to see whether the
tendency toward diagnosing the sane insane could %e re$ersed. *he
following experiment was arranged at a research and teaching hospital
whose staff had heard these findings %ut dou%ted that such an error could
occur in theirFhospital. *he staff was informed that at some time during the
following three months one or more pseudo patients would attempt to %e
admitted into the psychiatric hospital. ?ach staff mem%er was asked to rate
each patient who presented himself at admissions or on the ward according
to the likelihood that the patient was a pseudo patient. 1G)point scale was
used with a 1 and 2 reflecting high confidence that the patient was a
pseudo patient.
4gain emphasis mine 8B
5*et for the identified patient to complain that one's life is %eing destroyed is to in$ite
further 'assessments' related to 'paranoia.'
6it always seems to %e 'other' people perhaps %ut certainly not #$%'.
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udgements were o%tained on 190 patients who were admitted for
psychiatric treatment. ll staff who had had sustained contact with or
primary responsi%ility for the patient I attendants nurses psychiatrists
physicians and psychologists I were asked to make =udgments. /orty)one
patients were alleged with high confidence to %e pseudo patients %y atleast one mem%er of the staff. *wenty)three were considered suspect %y at
least one psychiatrist. 6ineteen were suspected %y one psychiatrist and one
other staff mem%er. ctually no genuine pseudo patient at least from my
group: presented himself during this period.
*he experiment is instructi$e. &t indicates that the tendency to designate
sane people as insane can %e re$ersed when the stakes in this case
prestige and diagnostic acumen: are high. B!t what can e said of the 01"eo"le who were s!s"ected of eing -sane y one "sychiatrist and
another staff memer2 3ere these "eo"le tr!ly 4sane4 or was itrather the case that in the co!rse of avoiding the #y"e 5 error the
staff tended to ma6e more errors of the first sort 7 calling the cra+y
-sane27*here is no way of knowing. 4ut one thing is certain; anydiagnostic process that lends itself too readily to massi$e errors of this sort
cannot %e a $ery relia%le one.
PS%UDOP(#I%S (&D #$%IR S%##I&8S
*he eight pseudo patients were a $aried group. Jne was a psychology
graduate student in his 2G,s. *he remaining se$en were older andesta%lished.! mong them were three psychologists a pediatrician apsychiatrist a painter and a housewife. *hree pseudo patients were women
fi$e were men. ll of them employed pseudonyms lest their alleged
diagnoses em%arrass them later.9*hose who were in mental health professions alleged another occupation in
order to a$oid the special attentions that might %e accorded %y staff as amatter of courtesy or caution to ailing colleagues.
(ith the exception myself & was the first pseudo patient and my presence
was known to the hospital administration and chief psychologist and so far
7Jr is it =ust that this happens all the time to supposedly 'real' patients who tell thepsychiatrists and staff they are 'not sick' %ut who can not %e heard %ecause of this $erypro%lem. 5aying one is not 'sick' often meaning physically is defined as one of the signs
that one ISsick meaning physically *he tautology is e$er present to =ustify all outcomesand protect the system. 8B
8I wonder if he said, "I know I could never get a psychiatric label cause I'm not sick."9Did they not understand it was just like having diabetes?
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as & can tell to them alone: the presence of pseudo patients and the natureof the research program was not known to the hospital staffs.
*he settings are similarly $aried. &n order to generalie the findings
admission into a $ariety of hospitals was sought. *he 12 hospitals in the
sample were located in fi$e different states on the ?ast and (est coasts.5ome were old and sha%%y some were +uite new. 5ome had good staff)
patient ratios others were +uite understaffed. Jnly one was a strict pri$atehospital. ll of the others were supported %y state or federal funds or in one
instance %y uni$ersity funds.
fter calling the hospital for an appointment the pseudo patient arri$ed at
the admissions office complaining that he had %een hearing $oices. skedwhat the $oices said he replied that they were often unclear %ut as far as
he could tell they said empty! hollow! and thud.! *he $oices were
unfamiliar and were of the same sex as the pseudo patient. *he choice ofthese symptoms was occasioned %y their apparent similarity to existential
symptoms. 5uch symptoms are alleged to arise from painful concerns a%outthe percei$ed meaninglessness of one,s life.1G&t is as if the hallucinating
person were saying -y life is empty and hollow.! 11*he choice of thesesymptoms was also determined %y the a%sence of a single report of
existential psychoses in the literature.
4eyond alleging the symptoms and falsifying name $ocation andemployment no further alterations of person history or circumstances were
made. *he significant e$ents of the pseudo patient,s life history werepresented as they had actually occurred. Relationships with parents and
si%lings with spouse and children with people at work and in schoolconsistent with the aforementioned exceptions were descri%ed as they wereor had %een. 12/rustrations and upsets were descri%ed along with =oys and
satisfactions. *hese facts are important to remem%er. &f anything theystrongly %iased the su%se+uent results in fa$or of detecting insanity since
none of their histories or current %eha$iors were seriously pathological in
any way.
&mmediately upon admission to the psychiatric ward the pseudo patientceased simulating any symptoms of a%normality. &n some cases there was a
%rief period of mild ner$ousness and anxiety since none of the pseudopatients really %elie$ed that they would %e admitted so easily.10&ndeed theirshared fear was that they would %e immediately exposed as frauds and
greatly em%arrassed. -oreo$er many of them had ne$er $isited a
10ell, they used to be. ith bio psych it is all pretty well defined as meaningless.11!ow we are not saying anything. e are just 'seeking attentionfame.'12#veryday reality in other words.
13!one so blind as those who cannot see what's...right in front of them.
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psychiatric ward@ e$en those who had ne$ertheless had some genuine fearsa%out what might happen to them. *heir ner$ousness then was +uite
appropriate to the no$elty of the hospital setting and it a%ated rapidly. 1
part from that short)li$ed ner$ousness the pseudo patient %eha$ed on the
ward as he normally! %eha$ed. *he pseudo patient spoke to patients andstaff as he might ordinarily. 4ecause there is uncommonly little to do on a
psychiatric ward he attempted to engage others in con$ersation. (henasked %y staff how he was feeling he indicated that he was fine that he no
longer experienced symptoms. He responded to instructions from
attendants to calls for medication which was not swallowed: and todining)hall instructions. 4eyond such acti$ities as were a$aila%le to him on the
admissions ward he spent his time writing down his o%ser$ations a%out theward its patients and the staff.1A&nitially these notes were written
secretly! %ut as it soon %ecame clear that no one much cared they were
su%se+uently written on standard ta%lets of paper in such pu%lic places asthe dayroom. 6o secret was made of these acti$ities.
*he pseudo patient $ery much as a true psychiatric patient entered a
hospital with no foreknowledge of when he would %e discharged. ?ach wastold that he would ha$e to get out %y his own de$ices essentially %y
con$incing the staff that he was sane. 1F*he psychological stresses
associated with hospitaliation were considera%le and all %ut one of thepseudo patients desired to %e discharged almost immediately after %eing
admitted. *hey were therefore moti$ated not only to %eha$e sanely %ut to%e paragons of cooperation. *hat their %eha$ior was in no way disrupti$e is
confirmed %y nursing reports which ha$e %een o%tained on most of thepatients. *hese reports uniformly indicate that the patients were friendly!cooperati$e! and exhi%ited no a%normal indications.!17
#$% S#I)9I&%SS O PS*)$ODI(8&OS#I) L(B%LS
4eyond the tendency to call the healthy sick I a tendency that accounts
%etter for diagnostic %eha$ior on admission than it does for such %eha$ior
after a lengthy period of exposure I the data speak to the massi$e role of
la%eling in psychiatric assessment. 1Ha$ing once %een la%eled schiophrenicthere is nothing the pseudo patient can do to o$ercome the tag. *he tag
14*hey etting the la%el placed as +uickly as possi%le seems to %e the most
important thing to the %io psychs. *he la%el gi$es the doctor control o$er the patient
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profoundly colors others, perceptions of him and his %eha$ior. 19
/rom one $iewpoint these data are hardly surprising for it has long %eenknown that elements are gi$en meaning %y the context2Gin which they
occur. >estalt psychology made the point $igorously and sch
demonstrated that there are central! personality traits such as warm!$ersus cold!: which are so powerful that they markedly color the meaning
of other information in forming an impression of a gi$en personality.&nsane! schiophrenic! manic)depressi$e! and cray! are pro%a%ly
among the most powerful of such central traits. Jnce a person is designateda%normal all of his other %eha$iors and characteristics are colored %y that
la%el. 21&ndeed that la%el is so powerful that many of the pseudopatients,
normal %eha$iors were o$erlooked entirely or profoundly misinterpreted.5ome examples may clarify this issue.
?arlier & indicated that there were no changes in the pseudopatient,s
personal history and current status %eyond those of name employment
and where necessary $ocation. Jtherwise a $eridical description of
personal history and circumstances was offered. *hose circumstances were
not psychotic. How were they made consonant with the diagnosis modified in
such a way as to %ring them into accord with the circumstances of the
pseudopatient,s life as descri%ed %y him"
s far as & can determine diagnoses were in no way affected %y the relati$e
health of the circumstances of a pseudopatient,s life. Rather the re$erse
22
occurred; the perception of his circumstances was shaped entirely %y the
diagnosis.20 clear example of such translation is found in the case of a
pseudopatient who had had a close relationship with his mother %ut was
rather remote from his father during his early childhood. During adolescence
and %eyond howe$er his father %ecame a close friend while his relationship
with his mother cooled. His present relationship with his wife was
characteristically close and warm. part from occasional angry exchanges
friction was minimal. *he children had rarely %een spanked. 5urely there is
19fter & 8B: recei$ed my own la%el it was as if & had suddenly %ecome someone else. 5uddenly
e$erything & said felt or did was up for 'interpretation' %y others. *hey now see me though the filter of
their own %elief system.
20-eaning connected to context. Did you get that part J
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nothing especially pathological a%out such a history. &ndeed many readers
may see a similar pattern in their own experiences with no markedly
deleterious conse+uences. J%ser$e howe$er how such a history was
translated2in the psychopathological context this from the case summary
prepared after the patient was discharged.
*his white 09)year)old male . . . manifests a long history of considera%le
am%i$alence in close relationships which %egins in early childhood. warm
relationship with his mother cools during his adolescence. distant
relationship with his father is descri%ed as %ecoming $ery intense. ffecti$e
sta%ility is a%sent. His attempts to control emotionality with his wife and
children are punctuated %y angry out%ursts and in the case of the children
spankings. nd while he says that he has se$eral good friends one senses
considera%le am%i$alence em%edded in those relationships also . . .
*he facts of the case were unintentionally distorted %y the staff to achie$econsistency with a popular theory of the dynamics of a schiophrenic
reaction. 6othing of an am%i$alent nature had %een descri%ed in relations
with parents spouse or friends.2A*o the extent that am%i$alence could %einferred it was pro%a%ly not greater than is found in all human,s
relationships. &t is true the pseudopatient,s relationships with his parentschanged o$er time %ut in the ordinary context that would hardly %e
remarka%le I indeed it might $ery well %e expected. #learly the meaning
ascri%ed to his $er%aliations that is am%i$alence affecti$e insta%ility: wasdetermined %y the diagnosis; schiophrenia. n entirely different meaning2F
would ha$e %een ascri%ed if it were known that the man was normal.!
ll pseudopatients took extensi$e notes pu%licly. Mnder ordinary
circumstances such %eha$ior would ha$e raised +uestions in the minds ofo%ser$ers as in fact it did among patients. &ndeed it seemed so certain
that the notes would elicit suspicion that ela%orate precautions were taken toremo$e them from the ward each day. 4ut the precautions pro$ed needless.
*he closest any staff mem%er came to +uestioning those notes occurred
when one pseudopatient asked his physician what kind of medication he wasrecei$ing and %egan to write down the response. Eou needn,t write it! he
was told gently. &f you ha$e trou%le remem%ering =ust ask me again.!27
24L*ranslatedL as if the o%$ious truth were a foreign language. like the 'interpretations'
generated %y the est routine as well. 8B
25and e$en if am%i$alence 3(Sthere 3$*is the focus on oneperson and not the group
as a whole and why is am%i$alence experienced in all relationships defined as 'pathological'
in some%ut not in others"
26nd #$(#is a%out meaning connected to a "remiseisn't it" >ee...where ha$e we heard
that %efore"
27(riting %eha$iours 8B
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&f no +uestions were asked of the pseudopatients how was their writing
interpreted" 6ursing records for three patients indicate that the writing wasseen as an aspect of their pathological %eha$ior. 8atient engaged in writing
%eha$ior! was the daily nursing comment on one of the pseudopatients who
was ne$er +uestioned a%out his writing.2>i$en that the patient is in thehospital he must %e psychologically distur%ed. 29nd gi$en that he is
distur%ed continuous writing must %e %eha$ioral manifestation of thatdistur%ance perhaps a su%set of the compulsi$e %eha$iors that are
sometimes correlated with schiophrenia. 0G
Jne tacit characteristic of psychiatric diagnosis is that it locates the sourcesof a%erration within the indi$idual and only rarely within the complex of
stimuli that surrounds him. 01#onse+uently %eha$iors that are stimulated %ythe en$ironment are commonly misattri%uted to the patient,s disorder. 02/or
example one kindly nurse found a pseudopatient pacing the long hospital
corridors. 6er$ous -r. N"! she asked. 6o %ored! he said.
*he notes kept %y pseudopatients are full of patient %eha$iors that weremisinterpreted %y well)intentioned staff. Jften enough a patient would go
%erserk! %ecause he had wittingly or unwittingly %een mistreated %y sayan attendant. nurse coming upon the scene would rarely in+uire e$en
cursorily into the en$ironmental stimuli of the patient,s %eha$ior. Rather she
ass!med00that his upset deri$ed from his pathology not from his presentinteractions with other staff mem%ers. Jccasionally the staff might assume
that the patient,s family especially when they had recently $isited: or otherpatients had stimulated the out%urst. 4ut neverwere the staff found to
assume that one of themselves or the str!ct!re of the hos"italhadanything to do with a patient,s %eha$ior. Jne psychiatrist pointed to a groupof patients who were sitting outside the cafeteria entrance half an hour
%efore lunchtime. *o a group of young residents he indicated that such%eha$ior was characteristic of the oral)ac+uisiti$e nature of the syndrome.0&t seemed not to occur to him that there were $ery few things to anticipate
in a psychiatric hospital %esides eating.
286o one who %elie$es he or she already knows e$erything has any interest in asking or
listening. ?$erything has %een made meaningless the minute the 'patient' has %een defined
5 the patient. *he same thing occurs with know)it)alls in families. 8B29(riting is part of the attempt to sort out all the contradictions with which the patient is
%eing %om%arded %y others. ex cult mem%ers use this sorting method also. 8l
30&magine there is no such 'disease' and keep reading. &magine it is the dysfunctional con
=o% of 5J-? of those '%lameless others.
31Eoo hoo. experts..are you H?R&6> that J
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psychiatric la%el has a life and an influence of its own. Jnce the impressionhas %een formed that the patient is schiophrenic the expectation is that he
will continue to %e schiophrenic. (hen a sufficient amount of time haspassed during which the patient has done nothing %iarre he is considered
to %e in remission and a$aila%le for discharge. 4utthe lael end!res
eyond discharge,with the unconfirmed expectation that he will %eha$e asa schiophrenic again. 5uch la%els conferred %y mental health professionals
are as infl!ential on the "atient as they are on his relatives andfriends,0Aand it should not surprise anyone that the diagnosis acts on all
of them as a self;f!lfilling "ro"hecy.0F?$entually the patient himself
accepts the diagnosis with all of its surplus meanings and expectations and%eha$es accordingly. 07
*he inferences to %e made from these matters are +uite simple. -uch as
Oigler and 8hillips ha$e demonstrated that there is enormous o$erlap in the
symptoms presented %y patients who ha$e %een $ariously diagnosed sothere is enormous o$erlap in the %eha$iors of the sane and the insane. *he
sane are not sane! all of the time. (e lose our tempers for no goodreason.! (e are occasionally depressed or anxious again for no good
reason.0nd we may find it difficult to get along with one or another personI again for no reason that we can specify. 5imilarly the insane are not
always insane. &ndeed it was the impression of the pseudopatients while
li$ing with them that they were sane for long periods of time I that the%iarre %eha$iors upon which their diagnoses were allegedly predicated
constituted only a small fraction of their total %eha$ior. &f it makes no senseto la%el oursel$es permanently depressed on the %asis of an occasional
depression then it takes %etter e$idence than is presently a$aila%le to la%elall patients insane or schiophrenic on the %asis of %iarre %eha$iors orcognitions. &t seems more useful as -ischel has pointed out to limit our
discussions to %eha$iors the stimuli that pro$oke them and their correlates.
&t is not known why powerful impressions of personality traits such as
cray! or insane! arise. #oncei$a%ly when the origins of and stimuli thatgi$e rise to a %eha$ior are remote or unknown or when the %eha$ior strikes
us as immuta%le trait la%els regarding the %eha$ior arise. (hen on theother hand the origins and stimuli are known and a$aila%le discourse is
35(ho are then trained to treat us 'as if.L
36*hat's right. 8roduced with non stop pressure stress and the constant in$alidation of the
self righteous.
37-ost of us do %ut not all of us and those of us who don't are su%=ected to further
'treatment' and la%elled non compliant as & was. & told my reco$ery therapist that & was
escaping this fate %y the skin of my teeth and & knew it. (e get se$eral different la%els forthis same experience which seems to depend more on (HJ we get in the psychiatric crap
shoot and not on Lsymptoms.' *hat is how su%=ecti$e the diagnoses are.
38*his is also a $alue =udgement often %ased on &Opatient input at all.
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limited to to the %eha$ior itself.09*hus & may hallucinate %ecause & amsleeping or & may hallucinate %ecause & ha$e ingested a peculiar drug.
*hese are termed sleep)induced hallucinations or dreams and drug)inducedhallucinations respecti$ely. 4ut when the stimuli to my hallucinations are
unknownGthat is called crainess or schiophrenia Ias if that inference
were somehow as illuminating as the others.
#$% %
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professionals would insist that they are sympathetic toward the mentally illthat they are neither a$oidant nor hostile. 4ut it is more likely that an
ex+uisite am%i$alence characterises their relations with psychiatric patientssuch that their a$owed impulses are only part of their entire attitude.A
6egati$e attitudes are there too and can easily %e detected.F5uch attitudes
should not surprise us. *hey are the natural offspring of the la%els patientswear and the places in which they are found. 7
#onsider the structure of the typical psychiatric hospital. 5taff and patients
are strictly segregated. 5taff ha$e their own li$ing space including their
dining facilities %athrooms and assem%ly places. *he glassed +uarters thatcontain the professional staff which the pseudopatients came to call the
cage! sit out on e$ery dayroom. *he staff emerge primarily for care)takingpurposes I to gi$e medication to conduct therapy or group meeting to
instruct or reprimand a patient. Jtherwise staff keep to themsel$es almost
as if the disorder that afflicts their charges is somehow catching.
5o much is patient)staff segregation the rule that for four pu%lic hospitals inwhich 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 theoperational measure. (hile 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 tele$ision in the dayroom: it was the only wayin which one could gather relia%le data on time for measuring.
*he a$erage amount of time spent %y attendants outside of the cage was
11.0 percent range 0 to A2 percent:. *his figure does not represent onlytime spent mingling with patients %ut also includes time spent on suchchores as folding laundry super$ising patients while they sha$e directing
ward cleanup and sending patients to off)ward acti$ities. &t was therelati$ely rare attendant who spent time talking with patients or playing
games with them. &t pro$ed impossi%le to o%tain a percent mingling time!
for nurses since the amount of time they spent out of the cage was too
connections. 8B
45*hat definitely speaks to my personal experience as well. 8B
46(e who see them are used to %eing silenced for %eing a%le to do so. 8B
47*hese attitudes are then taken up %y the rest of society including family and friends who
then alter their own way of percei$ing the 'patient' so that it fits in with the la%elling and
diagnostics of the 'experts.' Jn the recei$ing end of this it /??B5 like %eing pushed out of
concrete reality and into the alternate one designed %y those who either cannot or will notface the truth. 8B
48&t does a fantastic =o% of creating a 'them and us' illusion. (hile 6J faults can usually %e
found in the staff no matter how glaringly o%$ious they may %e no end to the 'faults' are
found in the patients no matter how normally they may %e speaking or acting. *his makes
the experience as surreal as it gets. 8B
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%rief. Rather we counted instances of emergence from the cage. Jn thea$erage daytime nurses emerged from the cage 11.A times per shift
including instances when they left the ward entirely range to 09 times:.Bater afternoon and night nurses were e$en less a$aila%le emerging on the
a$erage 9. times per shift range to 1 times:. Data on early morning
nurses who arri$ed usually after midnight and departed at a.m. are nota$aila%le %ecause patients were asleep during most of this period.
8hysicians especially psychiatrists were e$en less a$aila%le. 9*hey were
rarely seen on the wards. Puite commonly they would %e seen only when
they arri$ed and departed with the remaining time %eing spend in theiroffices or in the cage. AGJn the a$erage physicians emerged on the ward F.7
times per day range 1 to 17 times:. &t pro$ed difficult to make an accurateestimate in this regard since physicians often maintained hours that allowed
them to come and go at different times.
*he hierarchical organiation of the psychiatric hospital has %een commented
on %efore %ut the latent meaning of that kind of organiation is worth notingagain. *hose with the most power ha$e the least to do with patients and
those with the least power are the most in$ol$ed with them. A1Recallhowe$er that the ac+uisition of role)appropriate %eha$iors occurs mainly
through the o%ser$ation of others with the most powerful ha$ing the most
influence. #onse+uently it is understanda%le that attendants not only spendmore time with patients than do any other mem%ers of the staff I that is
re+uired %y their station in the hierarchy I %ut also insofar as they learnfrom their superior,s %eha$ior spend as little time with patients as they can.
ttendants are seen mainly in the cage which is where the models theaction and the power are.A2
& turn now to a different set of studies these dealing with staff response topatient)initiated contact. &t has long %een known that the amount of time a
person spends with you can %e an index of your significance to him. &f he
49-y in hospital one %arely spoke to me though he seemed to %e en=oying himself when he
did. 8B
506urses often %latantly dysfunctional in their own relationships are $ery often the ones
who do the diagnosing %y looking for 'signs' as suggested to them %y the psychiatrists.
Ha$ing it suggested they seem to find what they are told to look for. *hey are also $erygood at closing ranks and keeping the institution's 'secrets.'8B
51& find this to %e as true today 2GG9:as it was when this was written. &t is also true that
& was one of the people who spent the most time with indi$idual patients when & was
working there as a LspecialL and was one of the people most openly scorned %y some of thestaff for my efforts. 8B
52& found 'dismissi$e' thinking and %eha$iour to represent the 'norm' among the hospital
staff from the top down. n extraordinary le$el of arrogance is %uilt into the system as a
whole and it now feeds upon itself. &t has %egun to attack it's own now whene$er a
professional dares to speak against the system itself. 8B
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initiates and maintains eye contact there is reason to %elie$e that he isconsidering your re+uests and needs. &f he pauses to chat or actually stops
and talks there is added reason to infer that he is indi$iduating you. &n fourhospitals the pseudopatients approached the staff mem%er with a re+uest
which took the following form; 8ardon me -r. Qor Dr. or -rs. N could you
tell me when & will %e eligi%le for grounds pri$ileges"! or . . . when & will%e presented at the staff meeting"! or . . . when & am likely to %e
discharged"!:. (hile the content of the +uestion $aried according to theappropriateness of the target and the pseudopatient,s apparent: current
needs the form was always a courteous and rele$ant re+uest for information.
#are was taken ne$er to approach a particular mem%er of the staff morethan once a day lest the staff mem%er %ecome suspicious or irritated . . .
QRemem%er that the %eha$ior of the pseudopatients was neither %iarre nordisrupti$e. A0 Jne could indeed engage in good con$ersation with them.
. . . -inor differences %etween these four institutions were o$erwhelmed %ythe degree to which staff a$oided continuing contacts that patients had
initiated. 4y far their most common response consisted of either a %rief
response to the +uestion offered while they were on the mo$e! and with
head a$erted or no response at all. *he encounter fre+uently took the
following %iarre form; pseudopatient: 8ardon me Dr. N. #ould you tell me
when & am eligi%le for grounds pri$ileges"! physician: >ood morning
Da$e. How are you today" -o$es off without waiting for a response.: . . .
PO3%RL%SS&%SS (&D D%P%RSO&(LI=(#IO&
?ye contact and $er%al contact reflect concern and indi$iduation@ their
a%sence a$oidance and depersonaliation.A*he data & ha$e presented do
not do =ustice to the rich daily encounters that grew up around matters of
depersonaliation and a$oidance. & ha$e records of patients who were
%eaten %y staff for the sin of ha$ing initiated $er%al contact.AADuring my
535ome psychiatrists and other physicians are now %eing diagnosed using this term as
e$idence of a psychiatric illness. *he system is now closing on itself tightening the noose
tautology: around the necks of it's own mem%ers.
54*he people who were assessing and e$aluating me and others don't seem to see a
person when they look at me %ut rather an 'o%=ect.' -y protagonist's $ersion of this ise$ident in the use of the word L&tem.L (e who are forced into this kind of position
fre+uently state we feel 'in$isi%le' which is then heard as a self contained 'symptom.L
55&n any other setting this would %e seen as %latant a%use %ut not when done to us
'attention seekers' who #J-8B&6 of a%use =ust to 'seek attention.L (atch for the e$er
present tautologies in this:
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own experience for example one patient was %eaten in the presence of
other patients for ha$ing approached an attendant and told him & like you.!
Jccasionally punishment meted out to patients for misdemeanors seemed
so excessi$e that it could not %e =ustified %y the most rational interpretations
of psychiatric cannon.AF6e$ertheless they appeared to go un+uestioned.
*empers were often short.A7 patient who had not heard a call for
medication would %e roundly excoriated and the morning attendants would
often wake patients with #ome on you mS S S S S f S S S S S s out of
%edK! A
6either anecdotal nor hard! data can con$ey the o$erwhelming sense of
powerlessness which in$ades the indi$idual as he is continually exposed to
the depersonaliation of the psychiatric hospital. &t hardly matters whichpsychiatric hospital A9I the excellent pu%lic ones and the $ery plush pri$ate
hospital were %etter than the rural and sha%%y ones in this regard %utagain the features that psychiatric hospitals had in common o$erwhelmed
%y far their apparent differences.
8owerlessness was e$ident e$erywhere. FG
*he patient is depri$ed of many of his legal rights %y dint of his psychiatric
commitment. He is shorn of credi%ility %y $irtue of his psychiatric la%el. F1Hisfreedom of mo$ement is restricted. He cannot initiate contact with the staff
%ut may only respond to such o$ertures as they make. F28ersonal pri$acy is
minimal. 8atient +uarters and possessions can %e entered and examined %yany staff mem%er for whate$er reason.F0His personal history and anguish is
56*he e$er present assumption is that all this is a%out the 'reason' of those not la%elled as
the 'sick' ones:. *he 'reason' is not logic@ it is group catharsis of suppressed emotion.
57Ees and if & +uestion this staff %eha$iour & am presumed to %e stupidTcray and seeing
things that are not there.
58*he patient howe$er is expected to smile and and ha$e perfect manners underscoring
the dou%le standard.
59&n$alidation %y design and %y constant pressure. Jften this is what %rought the patient
there in the first place.
60nd it still is e$ident to e$eryone except the staff. *hey are so used to doing it it feels
normal to them.
61Ees people stop hearing you or taking anything you say at face $alue =ust as they are
taught to do. Jf course they are all sure they are right to %eha$e this way too. (e are %eingtreated as less than human for our own good after all. *he psychological isolation is enough
in itself to %reak a person down. *hat is though of as 'good' too much of the time as thosewho are losing their sense of self are so much easier to reprogramme according to the
programmer's desires. Denying the humanity of the 'other' will excuse almost anything.
62-uch like sla$e owner and sla$e. Jr =ailer and prisoner.
63&f sThe complains he may well get told to stop %eing such a %a%y since the patient is not
as 'real' as the nurse who would not tolerate such treatment personally.
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a$aila%le to any staff mem%er often including the grey lady! and candystriper! $olunteer: who chooses to read his folder regardless of their
therapeutic relationship to him. His personal hygiene and waste e$acuationare often monitored. *he water closets ha$e no doors.
t times depersonaliation reached such proportions that pseudopatientshad the sense that they were in$isi%leFor at least unworthy of account.
Mpon %eing admitted & and other pseudopatients took the initial physicalexaminations in a semi)pu%lic room where staff mem%ers went a%out their
own %usiness as if we were not there.FA
Jn the ward attendants deli$ered $er%al and occasionally serious physical
a%use to patients in the presence of others the pseudopatients: who werewriting it all down. FF%usi$e %eha$ior on the other hand terminated +uite
a%ruptly when other staff mem%ers were known to %e coming. 5taff are
credi%le witnesses. 8atients are not.
nurse un%uttoned her uniform to ad=ust her %rassiere in the presence of anentire ward of $iewing men. Jne did not ha$e the sense that she was %eing
seducti$e. Rather she didn,t notice us. group of staff persons might pointto a patient in the dayroom and discuss him animatedly as if he were not
there.F7
Jne illuminating instance of depersonaliation and in$isi%ility occurred with
regard to medication. ll told the pseudopatients were administered nearly21GG pills including ?la$il 5telaine #ompaine and *horaine to name
%ut a few. *hat such a $ariety of medications should ha$e %eenadministered to patients presenting identical symptoms is itself worthy ofnote.: FJnly two were swallowed. *he rest were either pocketed or
deposited in the toilet. *he pseudopatients were not alone in this. lthough &ha$e no precise records on how many patients re=ected their medications
the pseudopatients fre+uently found the medications of other patients in the
toilet %efore they deposited their own. s long as they were cooperati$etheir %eha$ior and the pseudopatients, own in this matter as in other
645ay where ha$e we heard that %efore" Jf course it may well %e 'interpreted' %y others
as literal and then mocked from a few feet away.*he 'sane' BJU? mocking as part of their
group catharsis.65it sure doesn't seem the same as 'dia%etes' to us...
66(ell it is not like anyone who actually -**?R5 is complaining though is it" &t is only
some 'whack =o%' like me.
67*hey might do it on the streets or %uses as well and so do other mem%ers of the
community at large who tend to take their cues from the 'experts' and who don't +uestiontheir leaders or this group %eha$iour.
68Ees as it suggests that what you get 'diagnosed' with and what 'medication' is for you has
more to do with (HJ you get than (H* you Lha$e.L
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important matters went unnoticed throughout. F9
Reactions to such depersonaliation among pseudopatients were intense.lthough they had come to the hospital as participant o%ser$ers and were
fully aware that they did not %elong! they ne$ertheless found themsel$es
caught up in and fighting the process of depersonaliation. 7G5omeexamples; a graduate student in psychology asked his wife to %ring his
text%ooks to the hospital so he could catch up on his homework! I thisdespite the ela%orate precautions taken to conceal his professional
association. *he same student who had trained for +uite some time to get
into the hospital and who had looked forward to the experienceremem%ered! some drag races that he had wanted to see on the weekend
and insisted that he %e discharged %y that time.71 nother pseudopatientattempted a romance with a nurse. 5u%se+uently he informed the staff that
he was applying for admission to graduate school in psychology and was
$ery likely to %e admitted since a graduate professor was one of his regularhospital $isitors. *he same person %egan to engage in psychotherapy with
other patients I all of this as a way of %ecoming a person in an impersonalen$ironment.72
#$% SOUR)%S O D%P%RSO&(LI=(#IO&
(hat are the origins of depersonaliation" & ha$e already mentioned two.
/irst are attitudes held %y all of us toward the mentally ill I including those
who treat them I attitudes characteried %y fear distrust73and horri%le
expectations on the one hand7and %ene$olent intentions on the other.7A
Jur am%i$alence leads in this instance as in others to a$oidance.7F
69 4ecause it the illusions around the power and control issues that really matter in the
situation =ust like in the dysfunctional family..
70&magine trying to fight that from the position of %eing psychiatried when those you must
fight ha$e *J*B control o$er you.
71*he fear of the psychological trap he was in was starting to %e felt e$en though in H&5
case he knew he could get out with help. &magine when it is R?B and there is no escape
possi%le.72(hen 'real' patients or prisoners or a%used children do this same thing it is called
L5tockholm 5yndrome.!
73 Iwouldn't %e letting her into my apartment if & were you. ad$ice from one of my
smiling neigh%ours to another.:
74 & wouldn't %e doing this if you weren't making me do itK
75 (e're only trying to help you. Eou would think she would %e grateful...
76*he e$er popular dysfunctional 'no response at all' response...=ust ignore her. -ay%e
she will gi$e up...Lcome J6 lady...gi$e it up...L
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5econd and not entirely separate the hierarchical structure of the
psychiatric hospital facilitates depersonaliation. *hose who are at the top
ha$e least to do with patients77and their %eha$ior inspires the rest of the
staff.7$erage daily contact with psychiatrists psychologists residents and
physicians com%ined ranged form 0.9 to 2A.1 minutes with an o$erall mean
of F. six pseudopatients o$er a total of 129 days of hospitaliation:.79
&ncluded in this a$erage are time spent in the admissions inter$iew ward
meetings in the presence of a senior staff mem%er group and indi$idual
psychotherapy contacts case presentation conferences and discharge
meetings. #learly patients do not spend much time in interpersonal contact
with doctoral staff. nd doctoral staff ser$e as models for nurses and
attendants.G
*here are pro%a%ly other sources. 8sychiatric installations are presently in
serious financial straits. 5taff shortages are per$asi$e and that shortenspatient contact.1Eet while financial stresses are realities too much can %e
made of them. & ha$e the impression that the psychological forces that
result in depersonaliation are much stronger than the fiscal ones and that
the addition of more staff would not correspondingly impro$e patient care in
this regard. *he incidence of staff meetings and the enormous amount of
record)keeping on patients for example ha$e not %een as su%stantially
reduced as has patient contact.28riorities exist e$en during hard times.
8atient contact is not a significant priority in the traditional psychiatric
hospital and fiscal pressures do not account for this. $oidance and
depersonaliation may.
Hea$y reliance upon psychotropic medication tacitly contri%utes to
depersonaliation %y con$incing staff that treatment is indeed %eing
conducted and that further patient contact may not %e necessary.0 ?$en
here howe$er caution needs to %e exercised in understanding the role of
psychotropic drugs. &f patients were powerful rather than powerless if they
were $iewed as interesting indi$iduals rather than diagnostic entities if they
77Eoo hoo...is my doctor e$er going to talk directly to me""
78&t's called follow the authority for appro$al..79'I&U#%SK80nd nurses and attendants look for signs and sym%ols of madness e$erywhere as they
are instructed to do.
81*hey're late. *hey're late. /or a $ery important date. 6o time to say hello good%ye
they're late they're late they're late...
82J%=ectification allows for a %etter detachment from 'them.'
83?specially if 'treatment' reduces the awareness of the identified patient and keeps her
'managea%le.'
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were socially significant rather than social lepersif their anguish truly and
wholly compelled our sympathies and concerns would we not seek contact
with them despite the a$aila%ility of medications" 8erhaps for the pleasure
of it all"
(hat are the origins of depersonaliation" & ha$e already mentioned two.
/irst are attitudes held %y all of us toward the mentally ill I including those
who treat them I attitudes characteried %y fear distrustAand horri%le
expectations on the one handF and %ene$olent intentions on the other7.
Jur am%i$alence leads in this instance as in others to a$oidance .
5econd and not entirely separate the hierarchical structure of the
psychiatric hospital facilitates depersonaliation. *hose who are at the top
ha$e least to do with patients
9
and their %eha$ior inspires the rest of thestaff.9G$erage daily contact with psychiatrists psychologists residents and
physicians com%ined ranged from 0.9 to 2A.1 minutes with an o$erall mean
of F.91six pseudopatients o$er a total of 129 days of hospitaliation:.
&ncluded in this a$erage are time spent in the admissions inter$iew ward
meetings in the presence of a senior staff mem%er group and indi$idual
psychotherapy contacts case presentation conferences and discharge
meetings. #learly patients do not spend much time in interpersonal contact
with doctoral staff. nd doctoral staff ser$e as models for nurses and
attendants.92
*here are pro%a%ly other sources. 8sychiatric installations are presently inserious financial straits. 5taff shortages are per$asi$e and that shortens
patient contact. 90Eet while financial stresses are realities too much can %e
84&f they were people@ not disease processes...
85& wouldn't %e letting her into my apartment if & were you. ad$ice from one of my
smiling neigh%ours to another.:
86Eou ne$er know what one of 'them' is going to do. L*hey can turn on you in an instant for
no reason.L
87(e're only trying to help you. you would think she would %e grateful...:
.
88 *he e$er popular dysfunctional 'no response at all' response...=ust ignore her. -ay%e
she will gi$e up...Lcome J6 lady...gi$e it up...L &t is easier to achie$e 'detachment' if yousee no person there.
89Eoo hoo...is my doctor e$er going to talk directly to me""
90&t's called follow the authority for appro$al
91-&6M*?5K
92nd nurses and attendants look for signs and sym%ols of madness e$erywhere as they
are instructed to do.
93*hey're late. *hey're late. /or a $ery important date. 6o time to say hello good%ye
they're late they're late they're late...
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made of them. & ha$e the impression that the psychological forces that
result in depersonaliation are much stronger than the fiscal ones and that
the addition of more staff would not correspondingly impro$e patient care in
this regard. *he incidence of staff meetings and the enormous amount of
record)keeping on patients for example ha$e not %een as su%stantially
reduced as has patient contact. 98riorities exist e$en during hard times.
8atient contact is not a significant priority in the traditional psychiatric
hospital and fiscal pressures do not account for this. $oidance and
depersonaliation may.
Hea$y reliance upon psychotropic medication tacitly contri%utes to
depersonaliation %y con$incing staff that treatment is indeed %eing
conducted and that further patient contact may not %e necessary. 9A?$en
here howe$er caution needs to %e exercised in understanding the role of
psychotropic drugs. &f patients were powerful rather than powerless if they
were $iewed as interesting indi$iduals rather than diagnostic entities if theywere socially significant rather than social lepers9Fif their anguish truly and
wholly compelled our sympathies and concerns would we not seek contact
with them despite the a$aila%ility of medications" 8erhaps for the pleasure
of it all"
#$% )O&S%>U%&)%S O L(B%LI&8 (&D
D%P%RSO&(LI=(#IO&
(hene$er the ratio of what is known to what needs to %e known approaches
ero we tend to in$ent knowledge! and assume that we understand more
than we actually do.97(e seem una%le to acknowledge that we simply don,t
know.9*he needs for diagnosis and remediation of %eha$ioral and emotional
pro%lems are enormous.994ut rather than acknowledge that we are =ust
em%arking on understanding we continue to la%el patients schiophrenic!
manic)depressi$e! and insane! as if in those words we captured the
94J%=ectification allows for a %etter detachment from 'them.'95?specially if 'treatment' reduces the awareness of the identified patient and keeps her
'managea%le.'
96&f they were people not disease processes...
97 *he danger in that is in the defensi$e attitude of the 'knowledgea%le one' especially if he
or she has too much concrete power.
98 *hat has %een my own experience with psychiatry as well.
99 *here is also an assumption that the 'patient's pro%lems exist as defined %y others and
are self contained.
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essence of understanding.1GG*he facts of the matter are that we ha$e known
for a long time that diagnoses are often not useful or relia%le %ut we ha$e
ne$ertheless continued to use them.1G1(e now know that we cannot
distinguish sanity from insanity. &t is depressing to consider how that
information will %e used.
1G2
6ot merely depressing %ut frightening.1G0How many people one wondersare sane !t not recogni+ed as s!ch in our psychiatric institutions" 1GHow
many ha$e %een needlessly stripped of their pri$ileges of citienship from
the right to $ote and dri$e to that of handling their own accounts" Howmany ha$e feigned insanity in order to a$oid the criminal conse+uences of
their %eha$ior and con$ersely how many would rather stand trial than li$eintermina%ly in a psychiatric hospital I %ut are wrongly thought to %e
mentally ill" 1GAHow many ha$e %een stigmatied %y well)intentioned %ut
ne$ertheless erroneous diagnoses"1GFJn the last point recall again that a*ype 2 error! in psychiatric diagnosis does not ha$e the same
conse+uences it does in medical diagnosis. diagnosis of cancer that has%een found to %e in error is cause for cele%ration. 4ut psychiatric diagnoses
are rarely found to %e in error. 1G7*he la%el sticks a mark of inade+uacyfore$er.1G
/inally how many patients might %e sane! outside the psychiatric hospital
%ut seem insane in it I not %ecause crainess resides in them as it were
%ut %ecause they are responding to a %iarre setting1G9one that may %e
uni+ue to institutions which har%or nether people" >offman calls the processof socialiation to such institutions mortification! I an apt metaphor that
includes the processes of depersonaliation that ha$e %een descri%ed here.
nd while it is impossi%le to know whether the pseudopatients, responses to
these processes are characteristic of all inmates I they were after all not
real patients I it is difficult to %elie$e that these processes of socialiation to
100(hat they really do is reduce another person to managea%le sie and =ustify doing it.
101*he 'de$il' they know...
102&t seems to %e mostly ignored and denied
103*ell us a%out it. &t is like talking to the wall.
104& would say a lot more than most people think. -any could %e dri$en into psychosisunder pressure like a fulfilled prophecy.
105Right again on othcounts & would say
106 -y hand is raised on that one. Eou can't tell an employer that someone is cray and
without prospect of reco$ery and expect it is not going to ha$e a negati$e impact.
107 (ell no one wants to get %lamed for anything. 5o it is 'unrealistic' of me to expect an
admission or an apology is it not" *hat is what they tell me.
108 Hey..there she is...that whack =o%.!
109 *hat is putting it mildly. Don't worry she can't see us.!..ha ha ha
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a psychiatric hospital pro$ide useful attitudes or ha%its of response for li$ing
in the real world.!11G
SU''(R* (&D )O&)LUSIO&S
&t is clear that we cannot distinguish the sane from the insane in psychiatric
hospitals.111*he hospital itself imposes a special en$ironment in which the
meaning of %eha$ior can easily %e misunderstood.112*he conse+uences to
patients hospitalied in such an en$ironment I the powerlessness
depersonaliation segregation mortification and self)la%eling I seem
undou%tedly counter)therapeutic.110
& do not e$en now understand this pro%lem well enough to percei$e
solutions.114ut two matters seem to ha$e some promise. *he first concerns
the proliferation of community mental health facilities of crisis inter$ention
centers11Aof the human potential mo$ement11Fand of %eha$ior therapies
that for all of their own pro%lems tend to a$oid psychiatric la%els to focus
on specific pro%lems and %eha$iors and to retain the indi$idual in a
relati$ely non)pe=orati$e en$ironment. #learly to the extent that we refrain
from sending the distressed to insane places our impressions of them are
less likely to %e distorted.117*he risk of distorted perceptions it seems to
me is always present since we are much more sensiti$e to an indi$idual,s
%eha$iors and $er%aliations than we are to the su%tle contextual stimuli11
that often promote them. t issue here is a matter of magnitude. nd as &
1108sychiatrists don't li$e in the real world. *hey li$e in their own psychiatric fantasy. -ost
of 'us' learn how to nod and agree with authority though. &f only out of self preser$ation.
111*ry to keep thinking; this is a psychiatrist saying this.
112Ees. 4ecause it is gi$en a context %y those who see themsel$es as 'o%=ecti$e o%ser$ers'
who %elie$e they already .
113nd those of us who DJ6'* accept the 'diagnosis' and la%elling get defined as 'non
compliant' as & was.
114& %elie$e a solution is to stay self focused and percei$e e$eryone on earth as ha$ing aninherently e+ual $alue as a human %eing. 6o one as eitherinferior or superior.
115*hese also define the 'patient' %efore we walk in the door. ?specially in 2G1G when %io
psych is trying to rule the world.
1168otential to DJ and %elie$e (H*" /or some it means to control others not one's self.
117-ay%e we could stop calling the world them and us!...-ay%e we could say &! a lot
more.
118& too see a %ig #J6*?N* pro%lem and little or no communication a%out much of
anything.
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ha$e shown the magnitude of distortion is exceedingly high in the extreme
context that is a psychiatric hospital.119:
*he second matter that might pro$e promising speaks to the need to
increase the sensiti$ity of mental health workers and researchers to the
)atch 55 position of psychiatric patients.12G5imply reading materials in this
area will %e of help to some such workers and researchers. /or others
directly experiencing the impact of psychiatric hospitaliation will %e of
enormous use.121#learly further research into the social psychology122of
such total institutions will %oth facilitate treatment and deepen
understanding.
& and the other pseudopatients in the psychiatric setting had distinctlynegati$e reactions. (e do not pretend to descri%e the su%=ecti$e experiences
of true patients.120*heirs may %e different from ours particularly with the
passage of time and the necessary process of adaptation to one,s
en$ironment.124ut we can and do speak to the relati$ely more o%=ecti$e
indices of treatment within the hospital. &t could %e a mistake and a $ery
unfortunate one to consider that what happened to us deri$ed from malice
or stupidity on the part of the staff. Puite the contrary our o$erwhelming
impression of them was of people who really cared who were committed
and who were uncommonly intelligent.12A(here they failed as they
sometimes did painfully it would %e more accurate to attri%ute those failures
to the en$ironment in which they too found themsel$es than to personal
callousness. *heir perceptions and %eha$iors were controlled %y the
situation12Frather than %eing moti$ated %y a malicious disposition. &n a
more %enign en$ironment one that was less attached to glo%al diagnosis
119Ees the reality of the 5*// is e$ery %it as distorted as the 'patient.'
120Eou could %eat them o$er the head with it and most of them still won't get it.
121Ees nothing like 'experienced experience' is there"
1225J#&B psychology for BB mem%ers of the group. & am with you there. &t is a%outgroupthink and %eha$iour more than anything else.
123Eou are pretty close %ut add to that an original condition of extreme real distress for
wahte$er reason: and what you get is an ?N#?R4*?D condition and not 'help.'
124
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their %eha$iors and =udgments might ha$e %een more %enign and effecti$e.127
& thank (. -ischel ?. Jrne and -.5. Rosenhan for comments on an earlierdraft of this manuscript.
5JMR#?; Da$id B. Rosenhan Jn 4eing 5ane in &nsane 8laces! 5cience
Uol. 179 an. 1970: 2AG)2A.
#opyright 1970 %y the merican ssociation for the d$ancement of
5cience.
Q1 R. 4enedict .>en. 8sychol. 1G 190: A9.
Q2 4eyond the personal difficulties that the pseudo patient is likely to
experience in the hospital there are legal and social ones that com%ined
re+uire considera%le attention %efore entry. /or example once admitted to apsychiatric institution it is difficult if not impossi%le to %e discharged on
short notice state law to the contrary notwithstanding. & was not sensiti$e
to these difficulties at the outset of the pro=ect nor to the personal and
situational emergencies that can arise %ut later a writ of ha%eas corpus was
prepared for each of the entering pseudo patients and an attorney was kept
on call! during e$ery hospitaliation. 12& am grateful to ohn
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26/26
QA 5.?. sch . %norm. 5oc. 8sychol. 1 19F: 5ocial 8sychology
?nglewood #liffs 6/; 8renticeSHall 19A2:.
QF ?. Oigler and B. 8hillips . %norm. 5oc. 8sychol. F0 19F1: F9. 5ee also
R. offman sylums >arden #ity 6E@ Dou%leday 19F1: