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The Role of Environment in Diagnosing Sanity: Insights from Psychiatric Hospitals, Lecture notes of Psychology

University of NorthamptonPsychology

The debate on whether the characteristics of insanity reside in patients themselves or in their environments. It discusses the experiences of pseudopatients in psychiatric hospitals and the implications of patient-staff segregation and depersonalization on patient care. The document also touches upon the subjective experiences of true patients and the potential countertherapeutic consequences of hospitalization.

Typology: Lecture notes

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bg1
The
Geographical
Ditribution
of
Animas
(Wiley,
New
York,
1957);
B.
Rensch,
Evolu-
tion
Above
the
Specie
Level
(Methuen,
London,
1959);
V.
Grant,
The
Origin
of
Adaptations
(Columbia
Univ.
Press,
New
York,
1963).
5.
S.
Wright,
Genetics
16,
97
(1931).
6.-
,
Ibid.
28,
114
(1943);
Ibid.
31.
39
(1946);
Evolution
and
the
Genetics
ot
Popu-
lations,
vol.
2,
The
Theory
of
Gene
Fre-
quencies
(Univ.
of
Chicago
Press,
Chicago,
1969);
F.
3.
Rohlf
and
0.
D.
Schnell,
Amer.
Natur.
105,
295
(1971).
7.
3.
B.
S.
Haldane,
J.
Genet.
48,
277
(1948).
8.
R.
A.
Fisher,
Biometrics
6,
353
(1950);
M.
Kimura,
Annu.
Rep.
Nat.
Inst.
Genet.
Mishima-City,
Japan
9,
84
(1958).
9.
M.
Kimura
and
G.
H.
Weiss,
Genetics
49,
561
(1964);
M.
Kimura
and
T.
Maruyama,
Genet.
Res.
18,
125
(1971).
10.
P.
R.
Ehrlich
and
P.
H.
Raven,
Science
165,
1228
(1969).
11.
For
example,
J.
Maynard-Smith,
Amer.
Natur.
100,
637
(1966).
12.
J.
M.
Thoday,
Nature
181,
1124
(1958);
and
T.
B.
Boam,
Heredity
13,
204
(1959);
E.
Millicent
and
J.
M.
Thoday,
Ibid.
16,
219
(1961);
M.
Thoday
and
J.
B.
Gibson,
Amer.
Natur.
105,
86
(1971).
.13.
F.
A.
Streams
and
D.
Pimentel,
Ibid.
9S,
201
(1961);
Th.
Dobzhansky
and
B.
Spassky,
Proc.
Roy.
Soc.
London
Ser.
B.
168,
27
(1967);
,
J.
Sved,
Ibid.
173,
191
(1969);
Th.
Dobzhansky,
H.
Levene,
B.
Spassky,
ibid.
18W,
21
(1972).
14.
M.
Slatkin,
thesis,
Harvard
University
(1971).
15.
S.
K.
Jain
and
A.
D.
Bradshaw,
Heredity
21,
407
(1966).
16.
Parapatric
divergence
is
divergence
between
adjacent
but
genetically
continuous
popula-
tions.
See
H.
M.
Smith,
Syst.
Zool.
14,
57
(1965);
ibid.
18,
254
(1969);
M.
3.
D.
White,
R.
E.
Blacidth,
R.
M.
Blaclidth,
J.
Cheney,
Aust.
J.
Zool.
15,
263
(1967);
M.
J.
D.
White,
Science
159,
1065
(1968);
K.
H.
L.
Key,
Syst.
Zool.
17,
14
(1968).
17.
J.
S.
Huxley,
Nature
142,
219
(1938);
BlJdr.
Dierk.
Leiden
27,
491
(1939).
18.
F.
B.
Sumner,
BIbliogr.
Genet.
9,
1
(1932).
19.
F.
Salomonsen,
Dan.
Blol.
Medd.
22,
1
(1955).
20.
E.
B.
Ford,
Blol.
Rev.
Cambridge
Phil.
Soc.
20,
73
(1945).
21.
Examples
of
morph-ratio
clines
include:
H.
B.
D.
Kettlewell
and
R.
J.
Berry,
Heredity
16,
403
(1961);
Ibid.
24,
1
(1969);
H.
B.
D.
Kettlewell,
R.
J.
Berry.
C.
J.
Cadbury,
G.
C.
Phillips,
Ibid.,
p.
15;
H.
N.
Southern,
J.
Zool.
London
Ser.
A
138,
455
(1966);
A.
J.
Cain
and
3.
D.
Currey.
Phil.
Trans.
Roy.
Soc.
London
Ser.
D.
246,
1
(1962);
A.
P.
Plant
and
L
P.
Brower,
Evolu-
tion
t2,
699
(1968);
0.
Halkka
and
E.
Mikkola,
Ierditas
54,
140
(1965);
B.
C.
Clarke,
in
Evolution
and
Environment,
E.
T.
Drake,
Ed.
(Yale
Univ.
Press,
New
Haven,
1968),
p.
351;
B.
C.
Clarke
and
J.
J.
Murray,
in
Ecological
Genetics
and
Evolution,
R.
Greed,
Ed.
(Blackwells,
Oxford,
1971),
p.
51;
J.
A.
Bishop
and
P.
S.
Harper,
Heredity
25,
449
(1969);
J.
A.
Bishop,
J.
Anim.
Ecol.
41,
209
(1972);
G. Hewitt
and
F.
M.
Brown,
Heredity
25,
365
(1970);
G.
Hewitt
and
C.
Ruscoe,
1.
Anim.
Ecol.
48,
753
(1971);
H.
Wolda,
Ibid.
38,
623
(1969);
F.
B.
LIving-
stone,
Amer.
J.
Phys.
Anthropol.
31,
1
(1969).
22.
C.
P.
Hasklns,
E.
F.
Haskins,
J.
J.
A.
McLaughlan,
R.
E.
Hewitt,
in
Vertebrate
Speclatlon,
W.
F.
Blair,
Ed.
(Univ.
of
Texas
Press,
Austin,
1961),
p.
320.
23.
A.
3.
Bateman,
Heredity
1,
234,
303
(1947);
Ibid.
4,
353
(1950);
R.
N.
Colwell,
Amer.
I.
Bot.
38,
511
(1951);
M.
R.
Roberts
and
H.
Lewis,
Evolution
9,
445
(1955);
C.
P.
Haskins,
personal
commnunication;
K.
P.
Lamb,
E.
Hassan,
D.
P.
Sooter,
Ecology
52,
178
(1971).
For
localized
distribution
and
problem
of
establishment
see
also:
W.
F.
Blair,
Ann.
N.Y.
Acad.
Sc.
44,
179
(1943);
Evolution
4,
253
(1950);
Lf
R.
Dice,
Amer.
Natut.
74,
289
(1940);
P.
Labine,
Evolution
20,
580
(1966);
H.
Lewis,
Ibid.
7,
1
(1953);
W.
Z.
Lidicker,
personal
communication;
J.
T.
Marshall,
Jr.,
Condor
50,
193,
233
(1948);
R.
K.
Sealander,
Amer.
Zool.
10,
53
(1970);
P.
Voiplo,
Ann.
Zool.
Fenn.
15,
1
(1952);
P.
K.
Anderson,
Science
145,
177
(1964).
24.
N.
W.
rumofeeff-Ressovsky,
In
The
New
Systematics,
3.
S.
Huxley,
Ed.
(Oxford
Univ.
Press,
Oxford,
1940),
p.
73.
25.
The
null
point
is
the
position
at
which
selection
changes
over
from
favoring
one
type
to
favoring
another.
26.
3.
A.
Endler,
in
preparation.
27.
L.
M.
Cook,
Coefficients
of
Natural
Selection
(Hutchinson
Univ.
Library,
Biological
Sci-
ences
No.
153,
London,
1971);
P.
B.
Lving-
stone,
Amer.
J.
Phys.
Anthropol.
31,
1
(1969).
28.
W.
C.
Allee,
A.
E.
Emerson,
0.
Park,
T.
Park,
K.
P.
Schmidt,
Prncdpks
of
Animal
Ecology
(Saunders,
Philadelphia,
1949);
H.
C.
Andrewartha
and
L.
C.
Birch,
The
Distrib-
tion
and
Abundance
of
Animal
(Univ.
of
Chicago
Press,
Chicago,
1954);
G.
L.
Clarke,
Elements
of
Ecology
(Wiley,
New
York,
1954);
R.
Geiger,
The
Climate
Near
the
Ground
(transation,
Harvard
Univ.
Press,
Cambridge,
1966).
29.
Results
for
autosomal
and
sex-lnked
systenu
do
not
differ
for
the
models
to
be
discussed,
except
that,
for
a
given
amount
of
selection,
the
sex-linked
system
is
l
sensitive
to
the
effect
of
gene
flow.
'This
Is
because
the
effective
selection
on
males
In
sex-inked
lod
makes
the
net
selection
sronger,
com-
pared
to
autosomal
loci,
for
the
population
as
a
whole.
See
C.
C.
Li,
Populion
Genedes
(Univ.
of
Chicago
Press,
Chicago,
1955)
for
a
good
dion
of
sex-linkage
and
selection.
30.
The
equilibrium
configurations
are
not
sig-
nificandy
altered
if
the
emigrants
from
the
end
demes
-do
not
retur,
unless
the
number
of
demes
(d)
very
small
(3.
A.
Endler,
unpublished
data).
31.
See,
for
example,
the
models
of
B.
C.
Clarke
[Amer.
Natr.
1W1,
389
(1966)1
and
those
in
(14).
32.
This
model
incorporates
Clarke's
model
of
frequency-dependence;
see
B.
C.
Clarke,
Evolution
18,
364
(1964).
33.
R.
A.
Fisher
and
F.
Yates,
Statsteal
Tables
for
Biologkia,
Agricultural,
ad
Medical
Re-
search
(Oliver
&
Boyd,
Edinburgh,
1948);
R.
R.
Sokcal
and
F.
J.
Rohlf,
Biometry
(Freeman,
San
Francisco,
1969).
34.
See,
for
example,
C.
G.
Johnson,
Migration
ad
Dispersal
of
Inects
by
FUght
(Methuen,
London,
1969);
3.
Antonovics,
Amer.
Sd.
99,
593
(1971).
35.
E.
C.
Pielou,
An
Introduction
to
Mathematical
Ecology
(Wiey-Interscience,
New
York,
1969).
36.
W.
F.
Blair,
Contrtb.
Lab.
Vertebrate
Btol.
Univ.
Mich.
No.
36,
1
(1947).
37.
P.
A.
Parsons,
Genetica
33,
184
(1963).
38.
G.
Hewitt
and
B.
John.
Chromosome
21,
140
(1967);
Evolution
24,
169
(1970);
G.
Hewitt,
personal
communication;
H.
Wolda,
J.
Anim.
Ecol.
38,
305,
623
(1969).
39.
L.
R.
Dice,
Contrib.
Lab.
Vertebrate
Genet.
Univ.
Mich.
No.
8
(1939),
p.
1;
ibid.
No.
15
(1941),
p.
1.
40.
1.
C.
J.
Galbraith,
Bull.
Brit.
Mus.
Natur.
Hist.
Zoolk
4,
133
(1956).
41.
I
am
grateful
to
the
National
Science
Founda-
tion
for
a
graduate
fellowship
In
support
of
this
study.
I
thank
Prof.
Alan
Robertson
and
the
Institute
of
Animal
Genetics,
Uni-
versity
of
Edinburgh,
for
the
Drosophila,
and
for
klindly
providing
me
with
fresh
medium
throughout
the
study.
Criticism
of
the
manu-
script
by
Professors
John
Bonner
and
Jane
Potter,
Dr.
Philip
Ashmole,
Peter
Tuft,
Dr.
David
Noakes,
Dr.
John
Godfrey,
Dr.
Caryl
P.
Haskins,
and
M.
C.
Bathgate
was
very
welcome.
In
particular,
I
thank
my
supervisor,
Professor
Bryan
C.
Clarke,
for
help
and
criti-
cism
throughout
this
study.
Any
errors
or
omissions
are
entirely
my
own.
I
thank
the
Edinburgh
Regional
Computing
Center
and
the
Edinburgh
University
Zoology
Department
for
generous
computer
tiWm
allowanoes.
I
will
supply
the
specially
wrtten
IMP
language
program
upon
request.
On
Being
Sane
in
Insane
Places
D.
L.
Rosenhan
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
con-
250
tradicted
by
equally
eminent
psychia-
trists
for
the
prosecution
on
the
matter
of
the
defendant's
sanity.
More
gen-
erally,
there
are
a
great
deal
of
conflict-
ing
data
on
the
reliability,
utility,
and
meaning
of
such
terms
as
"sanity,"
"in-
sanity,"
"mental
illness,"
and
"schizo-
phrenia"
(1).
Finally,
as
early
as
1934,
Benedict
suggested
that
normality
and
abnormality
are
not
universal
(2).
What
is
viewed
as
normal
in
one
cul-
ture
may
be
seen
as
quite
aberrant
in
another.
Thus,
notions
of
normality
and
abnormality
may
not
be
quite-as
accu-
rate
as
people
believe
they
are.
To
raise
questions
regarding
normal-
ity
and
abnormality
is
in
no
way
to
question
the
fact
that
some
behaviors
are
deviant
or
odd.
Murder
is
deviant.
So,
too,
are
hallucinatio,ns.
Nor
does
raising
such
questions
deny
the
exis-
tence
of
the
personal
anguish
that
is
often
associated
with
"mental
illness."
Anxiety
and
depression
exist.
Psycho-
logical
sufferng'
exists.
But
normality
and
abnormality,
sanity
and
insanity,
and
the
diagnoses
that
flow
from
them
Th
author
is
professor
of
psychoWgy
and
law
at
Stanford
University,
Stanford,
Caifornis
9430S.
Portions
of
thee
data
were
presented
to
collo-
quiums
of
the
psychology
departents
at
the
University
of
Cafomra
at
Berkeley
and
at
Santa
Barbar;
University
of
Arizona,
Tucson;
and
Harvard
Univwrsity,
Cambridge,
Massachusetts.
SCIENCE6
VOL.
179
on March 13, 2014www.sciencemag.orgDownloaded from on March 13, 2014www.sciencemag.orgDownloaded from on March 13, 2014www.sciencemag.orgDownloaded from on March 13, 2014www.sciencemag.orgDownloaded from on March 13, 2014www.sciencemag.orgDownloaded from on March 13, 2014www.sciencemag.orgDownloaded from on March 13, 2014www.sciencemag.orgDownloaded from on March 13, 2014www.sciencemag.orgDownloaded from on March 13, 2014www.sciencemag.orgDownloaded from
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The Geographical Ditribution of Animas (Wiley, New York, 1957); B. Rensch, Evolu- tion Above the Specie Level (Methuen, London, 1959); V. Grant, The Origin of Adaptations (Columbia Univ. Press, New York, 1963).

  1. S. Wright, Genetics 16, 97 (1931). 6.- , Ibid. 28, 114 (1943); Ibid. 31. 39 (1946); Evolution and the Genetics ot Popu- lations, vol. 2, The Theory of Gene Fre- quencies (Univ. of Chicago Press, Chicago, 1969); F. 3. Rohlf and 0. D. Schnell, Amer. Natur. 105, 295 (1971).
    1. B. S. Haldane, J. Genet. 48, 277 (1948).
  3. R. A. Fisher, Biometrics 6, 353 (1950); M. Kimura, Annu. Rep. Nat. Inst. Genet. Mishima-City, Japan 9, 84 (1958).
  4. M. Kimura and G. H. (^) Weiss, Genetics (^) 49, 561 (1964); M. Kimura and T. Maruyama, Genet. Res. 18, 125 (1971).
  5. P. R. Ehrlich and P. H. Raven, Science 165, 1228 (1969).
  6. For example, J. Maynard-Smith, Amer. Natur. 100, 637 (1966).
  7. J. M. Thoday, Nature 181, 1124 (1958); and T. B. Boam, Heredity 13, 204 (1959); E. Millicent and J. M. Thoday, Ibid. 16, 219 (1961); M. Thoday and J. B. Gibson, Amer. Natur. 105, 86 (1971). .13. F. A. Streams and D. Pimentel, Ibid. 9S, 201 (1961); Th. Dobzhansky and B. Spassky, Proc. Roy. Soc. London Ser. B. 168, 27 (1967); , J. Sved, Ibid. 173, 191 (1969); Th. Dobzhansky, H. (^) Levene, B. (^) Spassky, ibid. (^) 18W, 21 (1972).
  8. M. Slatkin, thesis, Harvard University (1971).
  9. (^) S. K. (^) Jain and A. (^) D. Bradshaw, Heredity 21, 407 (1966).
  10. Parapatric divergence is divergence between adjacent but genetically continuous popula- tions. See H. M. Smith, Syst. Zool. 14, 57 (1965); ibid. 18, 254 (1969); M. 3. D. White, R. E. Blacidth, R. M. Blaclidth, J. Cheney, Aust. J. Zool. 15, 263 (1967); M. J. D. White, Science 159, 1065 (1968); K. H. L. Key, Syst. Zool. 17, 14 (1968).
  11. J. S. Huxley, Nature 142, 219 (1938); BlJdr. Dierk. Leiden 27, 491 (1939).
  12. (^) F. B. (^) Sumner, BIbliogr. Genet. (^) 9, 1 (1932).
  13. F.^ Salomonsen, Dan.^ Blol.^ Medd. 22, 1 (1955).
  14. E. B. Ford, Blol. Rev. Cambridge Phil. Soc. 20, 73 (1945).
  15. Examples of morph-ratio clines include: H. B. D. Kettlewell and R. J. Berry, Heredity 16, 403 (1961); Ibid. 24, 1 (1969); H. B. D. Kettlewell, R. J. Berry. C. J. Cadbury, G. C. Phillips, Ibid., p. 15; H. N. Southern, J. Zool. London Ser. A 138, 455 (1966); A. J. Cain and 3. D. Currey. Phil. Trans. Roy. Soc. London Ser. D. 246, 1 (1962);

A. P. Plant and L P. Brower, Evolu- tion t2, 699 (1968); 0. Halkka and E. Mikkola, Ierditas 54, 140 (1965); B. C. Clarke, in Evolution and Environment, E. T. Drake, Ed. (Yale Univ. Press, New Haven, 1968), p. 351; B. C. Clarke and J. J. Murray, in Ecological Genetics and Evolution, R. Greed, Ed. (Blackwells, Oxford, 1971), p. 51; J. A. Bishop and P. S. Harper, Heredity 25, 449 (1969); J. A. Bishop, J. Anim. Ecol. 41, 209 (1972); G. Hewitt and F. M. Brown, Heredity 25, 365 (1970); G. Hewitt and C. Ruscoe, 1. Anim. Ecol. 48, 753 (1971); H. Wolda, Ibid. 38, 623 (1969); F. B. LIving- stone, Amer. J. Phys. Anthropol. 31, 1 (1969).

  1. C. P. Hasklns, E. F. Haskins, J. J. A. McLaughlan, R. E. Hewitt, in Vertebrate Speclatlon, W. F. Blair, Ed. (Univ. of Texas Press, Austin, 1961), p. 320.
  2. A. 3. Bateman, Heredity 1, 234, 303 (1947); Ibid. 4, 353 (1950); (^) R. N. Colwell, Amer. I. Bot. 38, 511 (1951); M. (^) R. Roberts and H. Lewis, Evolution 9, 445 (1955); C. P. Haskins, personal commnunication; K. P. Lamb, E. Hassan, D. P. Sooter, Ecology 52, 178 (1971). For localized distribution and problem of establishment see also: W. F. Blair, Ann. N.Y. Acad. Sc. 44, 179 (1943); Evolution 4, 253 (1950); LfR. Dice, Amer. Natut. 74, 289 (1940); P. Labine, Evolution 20, 580 (1966); H. (^) Lewis, Ibid. 7, 1 (1953); W. Z. Lidicker, personal communication; J. T. Marshall, Jr., Condor 50, 193, 233 (1948); R. K. Sealander, Amer. Zool. 10, 53 (1970); P. Voiplo, Ann. Zool. Fenn. 15, 1 (1952); P. K. Anderson, Science 145, 177 (1964).
  3. N. W. (^) rumofeeff-Ressovsky, In The New Systematics, 3. S. Huxley, Ed. (Oxford Univ. Press, Oxford, 1940), p. 73.
  4. The^ null point is the position at which selection changes over from favoring one type to favoring another.
    1. A. Endler, in preparation.
  6. L. M. Cook, Coefficients of Natural Selection (Hutchinson Univ. Library, Biological Sci- ences No. 153, London, 1971); P. B. (^) Lving- stone, Amer. J. Phys. Anthropol. 31, 1 (1969).
  7. W. C. Allee, A. E. Emerson, 0. Park, T. Park, K. P. Schmidt, Prncdpks of Animal Ecology (Saunders, Philadelphia, 1949); H. C. Andrewartha and (^) L. C. Birch, The Distrib- tion and Abundance of Animal (Univ. of Chicago Press, Chicago, 1954); G. L. Clarke, Elements (^) of Ecology (Wiley, New York, 1954); R. Geiger, The Climate Near^ the Ground (^) (transation, Harvard Univ. Press, Cambridge, 1966).
  8. Results for autosomal and sex-lnked systenu do not differ for the models to be discussed, except that, for a given amount of selection, the sex-linked system is l sensitive to

the effect of gene flow. 'This Is because the effective selection on males In sex-inked lod makes the net selection sronger, com- pared to autosomal loci, for the (^) population as a whole. See C. C. Li, Populion Genedes (Univ. of^ Chicago Press, Chicago, 1955) for a good dion of (^) sex-linkage and selection.

  1. The equilibrium configurations are not sig- nificandy altered if the emigrants from the end demes -do not retur, unless the number of demes (d) very small (3. A. (^) Endler, unpublished data).
  2. See, for example, the models of B. C. Clarke (^) [Amer. Natr. 1W1, 389 (1966)1 and those in (14).
  3. This model incorporates Clarke's model of frequency-dependence; (^) see B. C. Clarke, Evolution 18, 364 (1964).
  4. R. A. Fisher and F. Yates, Statsteal Tables for Biologkia, Agricultural, ad Medical Re- search (Oliver & Boyd, Edinburgh, 1948); R. R. Sokcal and F. J. Rohlf, Biometry (Freeman, San Francisco, 1969).
  5. See, for example, C. G. Johnson, (^) Migration ad Dispersal of Inects by FUght (^) (Methuen, London, 1969); 3. Antonovics, Amer. Sd. 99, 593 (1971).
  6. E. C. Pielou, An Introduction to Mathematical Ecology (Wiey-Interscience, New York, 1969).
  7. W.^ F.^ Blair, Contrtb. Lab. Vertebrate Btol. Univ. Mich. No. 36, 1 (1947).
  8. P. A. Parsons, Genetica 33, 184 (1963).
  9. G. Hewitt and B. John. Chromosome 21, (^140) (1967); Evolution (^) 24, 169 (1970); G. Hewitt, personal communication; H. Wolda, J. Anim. Ecol. 38, 305, 623 (1969).
  10. L. R. (^) Dice, Contrib. Lab. Vertebrate Genet. Univ. Mich. No. 8 (1939), p. 1; ibid. No. 15 (1941), p. 1.
    1. C. J. Galbraith, Bull. Brit. Mus. Natur. Hist. Zoolk 4, 133 (1956).
  12. I am grateful to the National Science Founda- tion for a graduate fellowship In support of this study. I thank Prof. Alan Robertson and the Institute of Animal Genetics, Uni- versity of Edinburgh, for the Drosophila, and for klindly providing me with fresh (^) medium throughout the study. Criticism of the manu- script by Professors^ John Bonner and Jane Potter, Dr. Philip Ashmole, Peter Tuft, Dr. David Noakes, Dr. John Godfrey, Dr. Caryl P. Haskins, and M. C. Bathgate was very welcome. In particular, I thank my supervisor, Professor Bryan C. Clarke, for help and criti- cism (^) throughout this study. Any errors or omissions (^) are entirely my own. I thank the Edinburgh Regional Computing Center and the (^) Edinburgh University Zoology Department for generous computer tiWm allowanoes. I will supply the specially wrtten IMP language program upon request.

On Being Sane in Insane Places

D. L. Rosenhan

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^ con- 250

tradicted by equally eminent psychia- trists for the prosecution on the matter of (^) the defendant's sanity. More gen- erally, there^ are^ a^ great deal of conflict- ing data on the reliability, utility, and meaning of such terms as "sanity," "in- sanity," "mental illness," and "schizo- phrenia" (1). Finally, as early as 1934, Benedict suggested that normality and abnormality are not universal (2).

What is viewed as normal in one cul-

ture may be seen as quite aberrant in

another. Thus, notions of normality and

abnormality may not be quite-as accu-

rate as people believe they are.

To raise questions regarding normal-

ity and abnormality is in no way to

question the^ fact that^ some^ behaviors

are deviant or odd. Murder is deviant. So, too, are^ hallucinatio,ns. Nor does

raising such questions deny the exis-

tence of the (^) personal anguish that is

often associated with "mental illness."

Anxiety and depression exist. Psycho-

logical sufferng' exists. But normality and (^) abnormality, sanity and (^) insanity,

and the diagnoses that flow from them

Th author is professor of psychoWgy and law at Stanford (^) University, Stanford, Caifornis 9430S. Portions of thee data were presented to collo- quiums of the^ psychology departents at the University of^ Cafomra at^ Berkeley and at Santa Barbar; University of Arizona, Tucson; and Harvard Univwrsity, Cambridge, Massachusetts. SCIENCE6 VOL.^179

may be less substantive than many be-,

lieve 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 char- acteristics that lead to diagnoses reside in the patients themselves or in the en- vironments and contexts in which ob- servers find them? From Bleuler, through Kretchmer, through the formu- lators of the recently revised Diagnostic and Statistical Manual of the American Psychiatric Association, the belief has been strong that patients present (^) symp- toms, that those symptoms can be cate- gorized, and, (^) implicitly, that the sane are distinguishable from the insane. More (^) recently, however, this belief has been (^) questioned. Based in (^) part on (^) theo- retical and (^) anthropological considera-

tions, 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 diag- noses, in this view, are in the minds of the observers and are not valid^ sum- maries of characteristics displayed by the observed (3-5). 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 suf- fered, symptoms of serious (^) psychiatric disorders) admitted to (^) psychiatric hos- pitals and then (^) determining whether they were discovered to be sane (^) and, if so, how. If the sanity of such pseudo- patients were always (^) detected, there wAlNd be prima facie evidence that a sane individual can be (^) distinguished from the insane context in which he is found. (^) Normality (and presumably ab- normality) 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 (^) psy- chiatric (^) diagnosis. Given that the (^) hospi- tal staff was not (^) incompetent, that the pseudopatient had been (^) behaving as sanely as he had been outside of (^) the hospital, and that it had never been previously suggested that he belonged in a psychiatric hospital, such an un- likely outcome would (^) support the view that psychiatric diagnosis (^) betrays little about the patient but much about the environment in which an observer finds him.

19 JANUARY 1973

This article describes such an experi-

ment. Eight sane people gained secret

admission to 12 different hospitals (6).

Their (^) diagnostic experiences constitute

the data of the first part of this article;

the remainder is devoted to a descrip-

tion 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 com-

ing from the previously insane. Those

who have worked in psychiatric hospi-

tals are likely to have adapted so thor-

oughly to the settings that they are

insensitive to the impact of that expe-

rience. And while there have been oc-

casional reports of researchers who

submitted themselves to psychiatric hos-

pitalization (7), 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 psychi-

atric 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 re-

maining seven were older and "estab-

lished." Among them were three psy-

chologists, a pediatrician, a psychiatrist,

a painter, and a housewife. Three

pseudopatients were women, five were

men. All of them employed pseudo-

nyms, lest their alleged diagnoses (^) em-

barrass them later. Those who were in

mental health professions alleged an-

other occupation in order to avoid the

special attentions (^) that might be ac-

corded by staff, as a matter of courtesy

or caution, to ailing colleagues (8).

With the exception of myself (I was the

first pseudopatient and (^) my presence was

known to the hospital administrator and

chief psychologist and, so far as I can

tell, to them alone), the presence of

pseudopatients and the nature of the re-

search program was not known to the

hospital staffs (9).

The settings were similarly varied. In

order to generalize the findings, admis-

sion 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 were research-oriented, others

not. Some had (^) good staff-patient ratios, others were' (^) quite understaffed. (^) Only one was a (^) strictly private hospital. All of the others were (^) supported (^) by state or federal funds (^) or, in one (^) instance, by university funds. After (^) calling the (^) hospital for an (^) ap- pointment, 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 pseudo-

patient. The choice of these symptoms

was occasioned by their apparent sim-

ilarity 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 de-

termined by the absence of a single

report of existential psychoses in the

literature.

Beyond alleging the symptoms and

falsifying name, vocation, and employ-

ment, no further alterations of (^) person,

history, or circumstances were made.

The significant events of the pseudo-

patient's life history were presented as

they had^ actually occurred.^ Relation-

ships with^ parents and^ siblings, with

spouse and children, with people at

work and in school, consistent with the

aforementioned exceptions, were de-

scribed as they were or had been. Frus-

trations and upsets were described

along with joys and satisfactions. These

facts are important to remember. If

anything, they strongly biased the sub-

sequent results in favor of detecting

sanity, since none of their histories or

current behaviors were seriously patho-

logical in any way.

Immediately upon admission to the

psychiatric ward, the pseudopatient

ceased simulating any symptoms of ab-

normality. In some cases, there was a

brief period of mild nervousness and

anxiety, since none of the pseudopa-

tients really believed that they would be

admitted so (^) easily. Indeed, their shared fear was that they would be immedi-

ately 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 nov-

251

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 this point

vigorously, and^ Asch (13) demon- strated that there are "central" (^) person-

ality 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 (14). "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 character- istics 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 per-

sonal history and^ current^ status^ beyond

those of (^) name, employment, and, where necessary, vocation.^ Otherwise, a^ veridi-

cal description of^ personal history and

circumstances was offered. Those cir-

cumstances were not psychotic. How

were they made^ consonant^ with^ the

diagnosis of^ psychosis? Or^ were^ those

diagnoses modified^ in such^ a^ way as^ to bring them into accord with the cir-

cumstances 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 pseudo-

patient's life. Rather, the^ reverse^ oc-

curred: the (^) perception of his cir-

cumstances 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 re- lationship with his mother but was rather remote from his father during his (^) early childhool. During adolescence and beyond, however, his father be- came a close friend, while his relation- ship with his mother cooled. His present relationship with his wife was charac- teristically 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 l

history. Indeed, many readers may see

a similar pattern in their own experi-

(^19) JANUARY 1973

ences, with no markedly. deleterious

consequences. Observe, however, (^) how

such a history was translated in thei

psychopathological (^) context, this from

the case summary prepared after the

patient was^ discharged. This white (^) 39-year-old male... (^) mani- fests a long history of considerable ambiv- alence in close relationships, which (^) begins in (^) early childhood. A warm relationship with his mother cools during his adoles- cence. A distant (^) relationship to 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 out- bursts and, in the case of the children, spankings. And (^) while he says that he has several good friends, one senses consider- able (^) ambivalence embedded in those rela- tionships also.... The facts of the case were uninten- tionally distorted by the staff to achieve consistency with a popular theory of the dynamics of a schizophrenic reac- tion (^) (15). Nothing of an ambivalent nature had been described in (^) relations with parents, spouse, or friends. To the extent (^) that ambivalence could be in- ferred, it was probably not greater (^) than is found in all human 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 instabil- ity) 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 circum- stances, such (^) behavior would have raised questions in the minds of ob- servers, as, in^ fact, it did among pa- tients. Indeed, it seemed so (^) certain that the notes would elicit suspicion that elaborate (^) precautions were taken to re- move them from the ward each day. But the precautions proved (^) needless. The closest any staff member came to questioning these (^) notes occurred when one pseudopatient asked his physician what kind of (^) medication he was receiv- ing and began to write down the re- sponse. "You needn't write (^) it," he was told (^) gently. "If you have trouble re- membering, 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 engages in writing behavior" was the daily nursing com-

ment 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, continu-

ous (^) writing must be a behavioral mani-

festation of that disturbance, perhaps a

subset of the compulsive behaviors that

are sometimes (^) correlated with (^) schizo-

phrenia.

One tacit characteristic (^) of psychiatric

diagnosis is that it locates the sources

of aberration (^) within the individual and

only rarely within^ the^ complex of stim-

uli that surrounds him. Consequently, behaviors that (^) are stimulated by the environment are (^) commonly misattrib-

uted to the patient's disorder. For ex-

ample, 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 mis- interpreted by well-intentioned staff. Often (^) enough, a (^) patient would go "ber- serk" because he had, wittingly or un- wittingly, been mistreated by, say, an attendant. A nurse coming (^) upon the scene would rarely inquire even cursor- ily into the environmental stimuli of the patient's behavior. Rather, she as- sumed that (^) his upset derived from his pathology, not from his present inter- actions with other staff members. Oc- casionally, the staff might assume (^) that the patient's family (especially when they had^ recently visited) or other pa- tients 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 pature of the syndrome. It seemed not to (^) occur to him that there were very few things to anticipate in a psychiatric (^) hospital be- sides eating. A (^) psychiatric label has a life and an influence of its own. Once the impres- sion 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 dis- charge. But the label endures beyond discharge, with the unconfirmed (^) expec- tation that he will behave as a schizo- phrenic again. Such labels, conferred 253

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^ him-

self accepts the^ diagnosis, with all^ of

its surplus meanings and expectations, and behaves accordingly (5). The inferences to be made from

these matters are quite simple. Much

as Zigler and^ Phillips^ have^ demon- strated that there is enormous overlap

in the symptoms presented^ by^ patients

who have been variously diagnosed (16), so there is^ enormous^ overlap in the behaviors of the^ sane^ and the in- sane. The s.- ne are not "sane" all of the time. We lose^ our^ tempers^ "for^ no good reason."^ We^ are^ occasionally^ de- pressed 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^ in- sane. Indeed, it was the impression of

the pseudopatients while^ living^ with

them that they were sane^ for^ long pe-

riods of^ time-that the bizarre behav- iors 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 avail- able to label all patients insane or schizophrenic on^ the basis of bizarre

behaviors or cognitions. It^ seems^ more

useful, as^ Mischel^ (17) has^ pointed

out, to limit our discussions^ to^ behav-

iors, the stimuli^ that^ provoke them,^ and

their correlates. It is not^ known^ why powerful^ impres- sions 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 behaver arise. When, on^ the^ other hand, the origins and stimuli are known and (^) available, discourse is limited to the behavior itself.^ Thus, I may hallu- cinate 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, respective-

ly. But when^ the stimuli^ to^ my hallu-

cinations are unknown, that^ is called

craziness, or^ schizophrenia-as if^ that

inference were somehow^ as^ illuminating

as the others.

Te Experience of

Psychiatric Hospitaization

The term 'mental^ illness"^ is of re-

cent 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 success- ful, for the treatment of^ the mentally ill has improved considerably over the years. But while treatment has^ im- proved, 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 en- dures forever (18).^ 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 (19). 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,^ phy-

sicians, psychologists, and social work-

ers-who treat and^ deal with the^ men- tally ill is more disconcerting, both because such attitudes are^ self-evidently

pernicious and^ because^ they^ are^ unwit-

ting. 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 ambiv-

alence 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^ con- tain the professional staff,^ which^ the

pseudopatients came to call "the cage,"

sit out on every dayroom. The staff emerge primarily for caretaking pur- poses-to give medication, to conduct a

therapy or group meeting, to instruct or

reprimand a patient. Otherwise,^ staff

keep to themselves, almost^ as if^ the^ dis-

order that afflicts their charges is some- how catching. So much is patient-staff^ segregation the rule that, for four public hospitals in which^ an^ attempt was^ made to^ mea- sure the degree to which staff^ and pa- tients 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 occa- sionally 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 clean- up, and sending patients to off-ward activities. It was the relatively rare at- tendant 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).

Late 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 mid- night 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 com- monly, they would be seen only^ when they arrived and departed, with the re-

maining time being spent^ in^ their^ offices

or in the cage. On the average, physi-

cians 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^ com- mented on before (20), but the latent meaning of that kind of organization i worth noting again. Those with the'" 254 SCIENCE, VOL. 179*

bal contact. During my own^ experience, for example, one^ patient^ was^ beaten^ in the presence of other patients^ for^ hav- ing approached an attendant and told him, "I like you." Occasionally,^ punish- ment meted out to patients for misde- meanors seemed so^ excessive^ that^ it could not^ be^ justified^ by^ the^ most^ radi- cal interpretations of^ psychiatric canon. Nevertheless, they appeared to go^ un- questioned. Tempers were^ often short. A patient who^ had^ not^ heard^ a^ call^ for medication would be roundly excori- ated, 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 indi- vidual as he is continually exposed^ to the depersonalization of^ the^ psychiatric hospital. It^ hardly^ matters^ which^ psy- ,fiiatric hospital-the excellent^ public ,*s 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^ every- where. The patient is deprived of many of his legal rights by dint of his^ psy- chiatric commitment^ (21).^ He^ is^ shorn of credibility by virtue of his psychiatric label. His freedom of^ movement^ is^ re- stricted. He cannot initiate contact with the staff, but may only^ respond^ to^ such overtures as they make. Personal^ pri- vacy is^ ininimal. Patient^ quarters^ and possessions can^ be^ entered^ and^ ex- amined by any staff^ member,^ for^ what-

ever 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^ per- sonal hygiene and waste evacuation^ are often monitored. The^ water^ closets may 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^ pseudo-

patients took the initial^ physical exami-

nations 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

other observing patients, some^ of whom

(the pseudopatients) 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 presence 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 disctiss

him animatedly, as if he were not there.

One illuminating instance^ of^ deper- sonalization and invisibility occurred with regard to medications. 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 ad- ministered to patients presenting identi- cal 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^ pre-

cise records on^ how^ many^ patients

rejected their^ medications,^ the^ pseudo-

patients frequently found^ the^ medica- tions 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.^ Al-

though 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^ de- personalization. Some examples: a^ grad- uate student^ in^ psychology asked^ his wife to bring his textbooks^ to^ the^ hos- pital so^ he^ could^ "catch^ up^ on^ his

homework"-this despite the^ elaborate

precautions taken^ to^ conceal^ his^ profes-

sional association. The^ same^ student,

who had trained^ for^ quite some^ time

to get into the hospital, and^ who^ had

looked forward^ to^ the^ experience,^ "re- membered" 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 ap-

plying 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^ depersonali- zation? I have already mentioned two. First are attitudes held by all of us toward the mentally ill-including those who treat them-attitudes character- ized by fear, distrust,^ and^ horrible^ ex- pectations on the one hand, and benev- olent intentions on^ the^ other.^ Our ambivalence leads, in this instance as in others, to avoidance. Second, and not entircly separate, the hierarchical structure^ of^ the psy- chiatric hospital^ facilitates depersonali- zation. Those who are at^ the^ top^ have least to do with patients, and their be- havior inspires the rest of^ the^ staff. Average daily contact with psychia- trists, psychologists, residents,^ and physicians combined ranged from 3.

to 25.1 minutes, with^ an^ overall mean

of 6.8 (six pseudopatients over a total of 129 days of hospitalization). In- cluded in this average are time spent in the admissions interview, ward meet- ings in the presence^ of^ a^ senior^ staff member, group and individual psycho-

therapy contacts, case presentation con-

ferences, and^ discharge^ meetings. Clearly, patients do not spend much time in interpersonal contact with doc- toral 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, staff time at a premium. Something has to give, and that some- thing is^ patient^ contact.^ Yet,^ while financial stresses are realities,^ too^ much can be made of them. I have the im- pression 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 sub- stantially reduced as^ has^ patient^ con- tact Priorities exist, even during hard times. Patient contact is -not a signifi- cant priority in the traditional^ psychia-

tric hospital, and fiscal pressures do^ not

account for^ this.^ Avoidance^ and^ de- personalization may. Heavy reliance upon psychotroP;'.

256 SCLENC-E.^ VOL.^ 179,i

mnedication tacitly contributes to deper-

sonalization 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 under-

standing the role of psychotropic drugs.

If (^) patients were^ powerful rather than powerless, if they were viewed as inter- esting individuals rather than (^) diagnostic entities, if they were socially significant rather than social lepers, if their an-

guish 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 emo-

tional problems are enormous. But

rather than acknowledge that we are

just embarking on understanding, we

continue to label patients "schizo-

phrenic," "manic-depressive," and "in-

sane," as if in those words we had

captured the essence of understanding.

The facts of the matter^ are^ that^ we

have known for a long time that diag-

noses are often not useful or reliable, but we have nevertheless continued to use (^) them. We now know that we (^) can-I not distinguish insanity from sanity. It is depressing to (^) consider how that in- formation will be used. Not merely depressing, but frighten- ing. 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 behav- ior, 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 erro-

neous, diagnoses? On the last point,

recall again that a "type 2 error" in Psychiatric diagnosis does not have the (^19) JANUARY 1973

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 (^) diag- noses 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 te a bizarre setting, one that may be (^) unique to institutions which harbor (^) nether people? Goffman (4) calls the (^) process of (^) socialization to such institutions "mortification"-an apt (^) metaphor that includes the processes of depersonali- zation that (^) have been described nere. 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 liv- ing 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 mean- ings of behavior can easily be misunder- stood. 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 solu- tions. 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 move- ment, 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 impres- sions of (^) them are less likely to be dis- torted. (The risk of distorted percep- tions, it seems to me, is (^) always present, since we are much more sensitive to an individual's behaviors and- verbaliza- tions than we (^) are to the subtle con-

textual stimuli that (^) often promote them.

At issue here is a matter of magnitude.

And, as^ I^ have^ shown, the^ magnitude

of distortion is exceedingly high in the

extreme context that is a psychiatric

hospital.)

The second matter that might prove

promising speaks to the need to in-

crease 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

experiezicing 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 nega-

tive reactions. We do not (^) pretend to describe the subjective experiences of

true patients. Theirs may be different

from ours, particularly with the pas-

sage 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 mis-

take, and^ a^ very unfortunate one, to consider that what (^) happened to us de- rived 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 (^) uncom- monly 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 percep-

tions and (^) behavior were controlled by the situation, rather than being moti- vated 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.

References (^) and Notes

  1. (^) P. Ash, J. Abnorm. Soc. PsychoL 44, (^272) (1949); A. T. (^) Beck. Amer. J. Psychiat. 119, 210 (1962); A. T. Boisen, (^) Psychlairy 2, (^233) (1938); N. Kreitman, J. Ment. Sci. 107, 976 (1961); N. Kreitmsn, P. (^) Salnsbury, J. (^) Morrisey, J. (^) Towers. J. Scrivener, (^) Ibid., p. (^) 887; H. (^) 0. Schmitt and C. P. Fonda, J. (^) Abnorn. Soc. Psychol. 52, 262 (^) (1956); W. Seeman, J. Nerv. Ment. DIs. 118, 541 (1953). For an (^) analysis of these artifacts and (^) sunumarles of (^) the dis- putes, see 3. Zubin, Annu. Rev. Psycho. (^) i18, (^373) (1967); L. Phillips and J. G. (^) Dragms, Ibid. 22, 447 (1971).
  2. R. (^) Benedict, J. Gen. Psychol. (^) 10. 59 (1934).
  3. See in this regard H. (^) Becker, Outsiders: Studies In the Sociology of (^) Deviance (Free

Press, New York, 1963); B. M. Brginsky.

257