'Dr.

Rosenhan personally had himself admitted as a ''mental patient'' in 1972

and wrote of his findings regarding the experience.
Please note: In this piece by David Rosenhan all the footnotes have
been added by me and speak of my own experience in relation to
Rosenhan's study which is based on his similar experience...
Patricia Lefave, Labelled, Delusional Disorder, (Paranoid)
On Being Sane In Insane Places
By 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 are
contradicted %y e+ually eminent psychiatrists for the prosecution on the
matter of the defendant,s sanity. -ore generally' there are a great deal of
conflicting data on the relia%ility' utility' and meaning of such terms as
sanity'! insanity'! mental illness'! and schi.ophrenia.!
/inally' as early as 1901' 2Ruth3 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$iant.
5o' too' are hallucinations. 6or does raising such +uestions deny the
existence of the personal anguish that is often associated with mental
illness.! 7nxiety and depression exist. 8sychological suffering exists. 4ut
normality and a%normality' sanity and insanity' and the diagnoses that flow
from them may %e less su%stanti$e than many %elie$e them to %e.
7t its heart' the +uestion of whether the sane can %e distinguished from the
insane 9and whether degrees of insanity can %e distinguished from each
other: is a simple matter; Do the salient characteristics that lead to
diagnoses reside in the patients themsel$es or in the en$ironments and
contexts in which o%ser$ers find them" /rom 4leuler' through <retchmer'
through the formulators of the recently re$ised Diagnostic and 5tatistical
-anual of the 7merican 8sychiatric 7ssociation' the %elief has %een strong
that patients present symptoms' that those symptoms can %e categori.ed'
and' implicitly' that the sane are distinguisha%le from the insane. -ore
recently' howe$er' this %elief has %een +uestioned. 4ased in part on
theoretical and anthropological considerations' %ut also on philosophical'
legal' and therapeutic ones' the $iew has grown that psychological
categori.ation of mental illness is useless at %est and downright harmful'
misleading' and pe=orati$e at worst. Psychiatric diagnoses, in this view,
are in the minds of oservers and are not valid s!mmaries of
characteristics dis"layed y the oserved.
1
>ains can %e made in deciding which of these is more nearly accurate %y
getting normal people 9that is' people who do not ha$e' and ha$e ne$er
suffered' symptoms of serious psychiatric disorders: admitted to psychiatric
hospitals and then determining whether they were disco$ered to %e sane
and' if so' how. &f the sanity of such pseudo patients were always detected'
there would %e prima facie e$idence that a sane indi$idual can %e
distinguished from the insane context in which he is found. 6ormality 9and
where$er it occurs' for it is carried within the person. &f' on the other hand'
the sanity of the pseudo patients were ne$er disco$ered' serious difficulties
would arise for those who support traditional modes of psychiatric diagnosis.
>i$en that the hospital staff was not incompetent' that the pseudo patient
had %een %eha$ing as sanely as he had %een out of the hospital' and that it
had ne$er %een pre$iously suggested that he %elonged in a psychiatric
hospital' such an unlikely outcome would support the $iew that psychiatric
diagnosis %etrays little a%out the patient %ut much a%out the en$ironment in
which an o%ser$er finds him.
2

*his article descri%es such an experiment. ?ight sane people gained secret
admission to 12 different hospitals. *heir diagnostic experiences constitute
the data of the first part of this article@ the remainder is de$oted to a
1 8erhaps this is the reason the o%ser$ed ones such as myself are told we are not 'allowed'
to speak of our point of $iew and of our own experiences might ruin the illusion which is
pri.ed so highly %y the o%ser$ers.
2 6ot so much a%out what we say %ut (H?R? we are when we say it.
description of their experiences in psychiatric institutions. *oo few
psychiatrists and psychologists' e$en those who ha$e worked in such
hospitals' know what the experience is like. *hey rarely talk a%out it with
former 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 the
impact of that experience. 7nd while there ha$e %een occasional reports of
researchers who su%mitted themsel$es to psychiatric hospitali.ation' these
researchers 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$er
detected. 7dmitted' except in one case' with a diagnosis of schi.ophrenia'
each was discharged with a diagnosis of schi.ophrenia in remission.! *he
la%el in remission! should in no way %e dismissed as a formality' for at no
time during any hospitali.ation had any +uestion %een raised a%out any
pseudo patient,s simulation. 6or are there any indications in the hospital
records that the pseudo patient,s status was suspect. Rather' the e$idence is
strong that' once la%eled schi.ophrenic' the pseudo patient was stuck with
that la%el. &f the pseudo patient was to %e discharged' he must naturally %e
in 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 sanity
0
cannot %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
hospitali.ation 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 recogni.e 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 $isitors could
3 ?mphasis mine 8B
detect no serious %eha$ioral conse+uencesCnor' indeed' could other
patients. It was ,!ite common for the "atients to -detect. the "se!do
"atient/s sanity.
1
During the first three hospitali.ations' when accurate
counts were kept' 0A of a total of 11D patients on the admissions ward
$oiced their suspicions' some $igorously. Eou,re not cra.y. Eou,re a
=ournalist' or a professor 9referring to the continual note)taking:. Eou,re
checking up on the hospital.! (hile most of the patients were reassured %y
the pseudo patient,s insistence that he had %een sick %efore he came in %ut
was fine now' some continued to %elie$e that the pseudo patient was sane
throughout his hospitali.ation. *he fact that the patients often recogni.ed
normality when staff did not raises important +uestions.
/ailure to detect sanity during the course of hospitali.ation may %e due to
the fact that physicians operate with a strong %ias toward what statisticians
call the *ype 2 error. *his is to say that physicians are more inclined to call a
healthy person sick 9a false positi$e' *ype 2: than a sick person healthy 9a
false negati$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$ersed. *he
following experiment was arranged at a research and teaching hospital
whose staff had heard these findings %ut dou%ted that such an error could
occur in their
F
hospital. *he staff was informed that at some time during the
following three months' one or more pseudo patients would attempt to %e
admitted into the psychiatric hospital. ?ach staff mem%er was asked to rate
each patient who presented himself at admissions or on the ward according
to the likelihood that the patient was a pseudo patient. 7 1G)point scale was
used' with a 1 and 2 reflecting high confidence that the patient was a
pseudo patient.
4 7gain emphasis mine 8B
5 *et for the identified patient to complain that one's life is %eing destroyed is to in$ite
further 'assessments' related to 'paranoia.'
6 it always seems to %e 'other' people perhaps' %ut certainly not #$%'.
Hudgements were o%tained on 190 patients who were admitted for
psychiatric treatment. 7ll staff who had had sustained contact with or
primary responsi%ility for the patient I attendants' nurses' psychiatrists'
physicians' and psychologists I were asked to make =udgments. /orty)one
patients were alleged' with high confidence' to %e pseudo patients %y at
least one mem%er of the staff. *wenty)three were considered suspect %y at
least one psychiatrist. 6ineteen were suspected %y one psychiatrist and one
other staff mem%er. 7ctually' no genuine pseudo patient 9at least from my
group: presented himself during this period.
*he experiment is instructi$e. &t indicates that the tendency to designate
sane people as insane can %e re$ersed when the stakes 9in this case'
prestige and diagnostic acumen: are high. B!t what can e said of the 01
"eo"le who were s!s"ected of eing -sane. y one "sychiatrist and
another staff memer2 3ere these "eo"le tr!ly 4sane4 or was it
rather the case that in the co!rse of avoiding the #y"e 5 error the
staff tended to ma6e more errors of the first sort 7 calling the cra+y
-sane.2
7
*here is no way of knowing. 4ut one thing is certain; any
diagnostic process that lends itself too readily to massi$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 $aried group. Jne was a psychology
graduate student in his 2G,s.
D
*he remaining se$en were older and
esta%lished.! 7mong them were three psychologists' a pediatrician' a
psychiatrist' a painter' and a housewife. *hree pseudo patients were women'
fi$e were men. 7ll 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 a
matter of courtesy or caution' to ailing colleagues.
(ith the exception myself 9& was the first pseudo patient and my presence
was known to the hospital administration and chief psychologist and' so far
7 Jr' is it =ust that this happens all the time to supposedly 'real' patients' who tell the
psychiatrists and staff they are 'not sick' %ut who can not %e heard %ecause of this $ery
pro%lem. 5aying one is not 'sick'' often meaning physically' is defined as one of the signs
that one IS sick' meaning physically' *he tautology is e$er present to =ustify all outcomes
and protect the system. 8B
8 I wonder if he said, "I know I could never get a psychiatric label cause I'm not sick."
9 Did they not understand it was just like having diabetes?
as & can tell' to them alone:' the presence of pseudo patients and the nature
of the research program was not known to the hospital staffs.
*he settings are similarly $aried. &n order to generali.e 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$ate
hospital. 7ll of the others were supported %y state or federal funds or' in one
instance' %y uni$ersity funds.
7fter calling the hospital for an appointment' the pseudo patient arri$ed at
the admissions office complaining that he had %een hearing $oices. 7sked
what the $oices said' he replied that they were often unclear' %ut as far as
he could tell they said empty'! hollow'! and thud.! *he $oices were
unfamiliar and were of the same sex as the pseudo patient. *he choice of
these symptoms was occasioned %y their apparent similarity to existential
symptoms. 5uch symptoms are alleged to arise from painful concerns a%out
the percei$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 these
symptoms was also determined %y the a%sence of a single report of
existential psychoses in the literature.
4eyond alleging the symptoms and falsifying name' $ocation' and
employment' no further alterations of person' history' or circumstances were
made. *he significant e$ents of the pseudo patient,s life history were
presented as they had actually occurred. Relationships with parents and
si%lings' with spouse and children' with people at work and in school'
consistent with the aforementioned exceptions' were descri%ed as they were
or had %een.
12
/rustrations and upsets were descri%ed along with =oys and
satisfactions. *hese facts are important to remem%er. &f anything' they
strongly %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 patient
ceased simulating any symptoms of a%normality. &n some cases' there was a
%rief period of mild ner$ousness and anxiety' since none of the pseudo
patients really %elie$ed that they would %e admitted so easily.
10
&ndeed' their
shared fear was that they would %e immediately exposed as frauds and
greatly em%arrassed. -oreo$er' many of them had ne$er $isited a
10 ell, they used to be. ith bio psych it is all pretty well defined as meaningless.
11 !ow we are not saying anything. e are just 'seeking attention"fame.'
12 #veryday reality in other words.
13 !one so blind as those who cannot see what's...right in front of them.
psychiatric ward@ e$en those who had' ne$ertheless had some genuine fears
a%out what might happen to them. *heir ner$ousness' then' was +uite
appropriate to the no$elty of the hospital setting' and it a%ated rapidly.
11
7part from that short)li$ed ner$ousness' the pseudo patient %eha$ed on the
ward as he normally! %eha$ed. *he pseudo patient spoke to patients and
staff as he might ordinarily. 4ecause there is uncommonly little to do on a
psychiatric ward' he attempted to engage others in con$ersation. (hen
asked %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 9which was not swallowed:' and to dining)
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$ations a%out the
ward' its patients' and the staff.
1A
&nitially these notes were written
secretly'! %ut as it soon %ecame clear that no one much cared' they were
su%se+uently written on standard ta%lets of paper in such pu%lic places as
the dayroom. 6o secret was made of these acti$ities.
*he pseudo patient' $ery much as a true psychiatric patient' entered a
hospital with no foreknowledge of when he would %e discharged. ?ach was
told that he would ha$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 hospitali.ation were considera%le' and all %ut one of the
pseudo 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$e %een o%tained on most of the
patients. *hese reports uniformly indicate that the patients were friendly'!
cooperati$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$e role of
la%eling in psychiatric assessment.
1D
Ha$ing once %een la%eled schi.ophrenic'
there is nothing the pseudo patient can do to o$ercome the tag. *he tag
14 *hey <6?( they were going to get out.
15 ?gadsK writing %eha$ioursK
16 ?ndless tautologies here we comeK
17 $nfortunately 'normality' has nothing to do with it.
18 Ees & agree. >etting the la%el placed as +uickly as possi%le seems to %e the most
important thing to the %io psychs. *he la%el gi$es the doctor control o$er the patient
profoundly colors others, perceptions of him and his %eha$ior.
19
/rom one $iewpoint' these data are hardly surprising' for it has long %een
known that elements are gi$en meaning %y the context
2G
in which they
occur. >estalt psychology made the point $igorously' and 7sch
demonstrated that there are central! personality traits 9such 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'! schi.ophrenic'! manic)depressi$e'! and cra.y! are pro%a%ly
among the most powerful of such central traits. Jnce a person is designated
a%normal' all of his other %eha$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 $eridical description of
personal history and circumstances was offered. *hose circumstances were
not psychotic. How were they made consonant with the diagnosis modified in
such a way as to %ring them into accord with the circumstances of the
pseudopatient,s life' as descri%ed %y him"
7s far as & can determine' diagnoses were in no way affected %y the relati$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
7 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$er' his father %ecame a close friend' while his relationship
with his mother cooled. His present relationship with his wife was
characteristically close and warm. 7part from occasional angry exchanges'
friction was minimal. *he children had rarely %een spanked. 5urely there is
19 7fter & 98B: recei$ed my own la%el it was as if & had suddenly %ecome someone else. 5uddenly
e$erything & said felt or did was up for 'interpretation' %y others. *hey now see me though the filter of
their own %elief system.
20 -eaning connected to context. Did you get that part J<" Do you get it %etter if another
'doctor' tells you rather than a 'whack =o%' like me"
21 & concur %ased on personal experience
22 *he Lexact oppositeL was the phrase & used. Remem%er" Lschi.ophrenia is the exact
opposite of what e$ery%ody %elie$es it is.L8B
23 47#<(7RD5. ?ffect defined as the cause. 8B L&t is a%out cause and effect. L(ho would
you rather %e"L asks the training.9as used %y my own antagonist:
nothing especially pathological a%out such a history. &ndeed' many readers
may see a similar pattern in their own experiences' with no markedly
deleterious conse+uences. J%ser$e' howe$er' how such a history was
translated
21
in the psychopathological context' this from the case summary
prepared after the patient was discharged.
*his white 09)year)old male . . . manifests a long history of considera%le
am%i$alence in close relationships' which %egins in early childhood. 7 warm
relationship with his mother cools during his adolescence. 7 distant
relationship with his father is descri%ed as %ecoming $ery intense. 7ffecti$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. 7nd 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$e
consistency with a popular theory of the dynamics of a schi.ophrenic
reaction. 6othing of an am%i$alent nature had %een descri%ed in relations
with parents' spouse' or friends.
2A
*o the extent that am%i$alence could %e
inferred' it was pro%a%ly not greater than is found in all human,s
relationships. &t is true the pseudopatient,s relationships with his parents
changed o$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 $er%ali.ations 9that is' am%i$alence' affecti$e insta%ility: was
determined %y the diagnosis; schi.ophrenia. 7n entirely different meaning
2F

would ha$e %een ascri%ed if it were known that the man was normal.!
7ll pseudopatients took extensi$e notes pu%licly. Mnder ordinary
circumstances' such %eha$ior would ha$e raised +uestions in the minds of
o%ser$ers' as' in fact' it did among patients. &ndeed' it seemed so certain
that the notes would elicit suspicion that ela%orate precautions were taken to
remo$e them from the ward each day. 4ut the precautions pro$ed needless.
*he closest any staff mem%er came to +uestioning those notes occurred
when one pseudopatient asked his physician what kind of medication he was
recei$ing and %egan to write down the response. Eou needn,t write it'! he
was told gently. &f you ha$e trou%le remem%ering' =ust ask me again.!
27
24 L*ranslatedL ' as if the o%$ious truth were a foreign language. like the 'interpretations'
generated %y the est routine as well. 8B
25 and e$en if am%i$alence 3(S there' 3$* is the focus on one person and not the group
as a whole' and why is am%i$alence experienced in all relationships defined as 'pathological'
in some %ut not in others"
26 7nd #$(# is a%out meaning connected to a "remise isn't it" >ee...where ha$e we heard
that %efore"
27 (riting %eha$iours 8B
&f no +uestions were asked of the pseudopatients' how was their writing
interpreted" 6ursing records for three patients indicate that the writing was
seen as an aspect of their pathological %eha$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.
2D
>i$en that the patient is in the
hospital' he must %e psychologically distur%ed.
29
7nd gi$en that he is
distur%ed' continuous writing must %e %eha$ioral manifestation of that
distur%ance' perhaps a su%set of the compulsi$e %eha$iors that are
sometimes correlated with schi.ophrenia.
0G
Jne tacit characteristic of psychiatric diagnosis is that it locates the sources
of a%erration within the indi$idual and only rarely within the complex of
stimuli that surrounds him.
01
#onse+uently' %eha$iors that are stimulated %y
the en$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 were
misinterpreted %y well)intentioned staff. Jften enough' a patient would go
%erserk! %ecause he had' wittingly or unwittingly' %een mistreated %y' say'
an attendant. 7 nurse coming upon the scene would rarely in+uire e$en
cursorily into the en$ironmental stimuli of the patient,s %eha$ior. Rather' she
ass!med
00
that his upset deri$ed from his pathology' not from his present
interactions with other staff mem%ers. Jccasionally' the staff might assume
that the patient,s family 9especially when they had recently $isited: or other
patients had stimulated the out%urst. 4ut never were the staff found to
assume that one of themselves or the str!ct!re of the hos"ital had
anything to do with a patient,s %eha$ior. Jne psychiatrist pointed to a group
of 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.
01
&t seemed not to occur to him that there were $ery few things to anticipate
in a psychiatric hospital %esides eating.
28 6o one who %elie$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
75 the patient. *he same thing occurs with know)it)alls in families. 8B
29 (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.
31 Eoo hoo. experts..are you H?7R&6> that J<" the est hole understands it. 8B
32 5u%=ecti$e >RJM8 pro=ection. 7 defence mechanism. &t's a%out responsi%ility. 8B
33 7nd what happens when we 'assume"L
34 /ormerly known 'as waiting for lunch.'
7 psychiatric la%el has a life and an influence of its own. Jnce the impression
has %een formed that the patient is schi.ophrenic' the expectation is that he
will continue to %e schi.ophrenic. (hen a sufficient amount of time has
passed' during which the patient has done nothing %i.arre' he is considered
to %e in remission and a$aila%le for discharge. 4ut the lael end!res
eyond discharge, with the unconfirmed expectation that he will %eha$e as
a schi.ophrenic again. 5uch la%els' conferred %y mental health professionals'
are as infl!ential on the "atient as they are on his relatives and
friends,
0A
and it should not surprise anyone that the diagnosis acts on all
of them as a self;f!lfilling "ro"hecy.
0F
?$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 $ariously diagnosed' so
there is enormous o$erlap in the %eha$iors of the sane and the insane. *he
sane are not sane! all of the time. (e lose our tempers for no good
reason.! (e are occasionally depressed or anxious' again for no good
reason.
0D
7nd we may find it difficult to get along with one or another person
I again for no reason that we can specify. 5imilarly' the insane are not
always insane. &ndeed' it was the impression of the pseudopatients while
li$ing with them that they were sane for long periods of time I that the
%i.arre %eha$iors upon which their diagnoses were allegedly predicated
constituted only a small fraction of their total %eha$ior. &f it makes no sense
to la%el oursel$es permanently depressed on the %asis of an occasional
depression' then it takes %etter e$idence than is presently a$aila%le to la%el
all patients insane or schi.ophrenic on the %asis of %i.arre %eha$iors or
cognitions. &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
cra.y! or insane'! arise. #oncei$a%ly' when the origins of and stimuli that
gi$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$ior arise. (hen' on the
other hand' the origins and stimuli are known and a$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$eral different la%els for
this same experience which seems to depend more on (HJ we get in the psychiatric crap
shoot and not on Lsymptoms.' *hat is how su%=ecti$e the diagnoses are.
38 *his is also a $alue =udgement often %ased on &O patient input at all.
limited to to the %eha$ior itself.
09
*hus' & may hallucinate %ecause & am
sleeping' or & may hallucinate %ecause & ha$e ingested a peculiar drug.
*hese are termed sleep)induced hallucinations' or dreams' and drug)induced
hallucinations' respecti$ely. 4ut when the stimuli to my hallucinations are
unknown'
1G
that is called cra.iness' or schi.ophrenia Ias if that inference
were somehow as illuminating as the others.
#$% %<P%RI%&)% O: PS*)$I(#RI) $OSPI#(LI=(#IO&
*he term mental illness! is of recent origin. &t was coined %y people who
were humane in their inclinations and who wanted $ery much to raise the
station of 9and the pu%lic,s sympathies toward: the psychologically distur%ed
from that of witches and cra.ies! to one that was akin to the physically ill.
11

7nd they were at least partially successful' for the treatment of the mentally
ill has impro$ed considera%ly o$er the years. 4ut while treatment has
impro$ed' it is dou%tful that people really regard the mentally ill in the same
way that they $iew the physically ill. 7 %roken leg is something one reco$ers
from' %ut mental illness allegedly endures fore$er.
12
7 %roken leg does not
threaten the o%ser$er' %ut a cra.y schi.ophrenic" *here is %y now a host of
e$idence that attitudes toward the mentally ill are characteri.ed %y fear'
hostility' aloofness' suspicion' and dread.
10
*he mentally ill are society,s
lepers.
*hat such attitudes infect the general population is perhaps not surprising'
only upsetting. 4ut that they affect the professionals I attendants' nurses'
physicians' psychologists and social workers I who treat and deal with the
mentally ill is more disconcerting' %oth %ecause such attitudes are self)
e$idently pernicious and %ecause they are unwitting.
11
-ost mental health
39 7s if external reality and other people were irrele$ant
40 Jr known %y me yet in$alidated %y the psychiatrist
41 *hat may well ha$e %een the intention %ut in' my experience +uite the opposite has
happened. *he witch hunt remains and the insults like %eing called Lthe whack =o%L from a
few feet away remains the reality. 8B
42 7t least' that is what psychiatry promotes isn't it"8B
43 *his is true for me for the last 1F years though there is always the pretence of
acceptance and a facade of manners is $ery common from most. PL
44 &t is a lot more than =ust 'upsetting' to the psychiatri.ed one. &n fact' this group
%eha$iour is often the $ery thing that triggers psychosis. *he lack of conscious awareness in
the participants is what makes it an inescapa%le 'snare' for in speaking a%out this as reality'
the psychiatri.ed one is not seen or heard as she really is. *his largely %ecause the group is
%lind to itself@ well 'hidden' %ehind their group delusion which & ha$e named 5.7.#.5. *he
same sort of phenomenon occurs in dysfunctional families and cults which & why & see the
professionals would insist that they are sympathetic toward the mentally ill'
that they are neither a$oidant nor hostile. 4ut it is more likely that an
ex+uisite am%i$alence characterises their relations with psychiatric patients'
such that their a$owed impulses are only part of their entire attitude.
1A

6egati$e attitudes are there too and can easily %e detected.
1F
5uch attitudes
should not surprise us. *hey are the natural offspring of the la%els patients
wear and the places in which they are found.
17
#onsider the structure of the typical psychiatric hospital. 5taff and patients
are strictly segregated. 5taff ha$e their own li$ing space' including their
dining facilities' %athrooms' and assem%ly places. *he glassed +uarters that
contain the professional staff' which the pseudopatients came to call the
cage'! sit out on e$ery dayroom. *he staff emerge primarily for care)taking
purposes 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.
1D

5o much is patient)staff segregation the rule that' for four pu%lic hospitals in
which an attempt was made to measure the degree to which staff and
patients mingle' it was necessary to use time out of the staff cage! as the
operational measure. (hile it was not the case that all time spent out of the
cage was spent mingling with patients 9attendants' for example' would
occasionally emerge to watch tele$ision in the dayroom:' it was the only way
in which one could gather relia%le data on time for measuring.
*he a$erage amount of time spent %y attendants outside of the cage was
11.0 percent 9range' 0 to A2 percent:. *his figure does not represent only
time spent mingling with patients' %ut also includes time spent on such
chores as folding laundry' super$ising patients while they sha$e' directing
ward cleanup' and sending patients to off)ward acti$ities. &t was the
relati$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$ing end of this it /??B5 like %eing pushed out of
concrete reality and into the alternate one designed %y those who either cannot' or will not'
face the truth. 8B
48 &t does a fantastic =o% of creating a 'them and us' illusion. (hile 6J faults can usually %e
found in the staff' no matter how glaringly o%$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
%rief. Rather' we counted instances of emergence from the cage. Jn the
a$erage' daytime nurses emerged from the cage 11.A times per shift'
including instances when they left the ward entirely 9range' 1 to 09 times:.
Bater afternoon and night nurses were e$en less a$aila%le' emerging on the
a$erage 9.1 times per shift 9range' 1 to 11 times:. Data on early morning
nurses' who arri$ed usually after midnight and departed at D a.m.' are not
a$aila%le %ecause patients were asleep during most of this period.
8hysicians' especially psychiatrists' were e$en less a$aila%le.
19
*hey were
rarely seen on the wards. Puite commonly' they would %e seen only when
they arri$ed and departed' with the remaining time %eing spend in their
offices or in the cage.
AG
Jn the a$erage' physicians emerged on the ward F.7
times per day 9range' 1 to 17 times:. &t pro$ed difficult to make an accurate
estimate in this regard' since physicians often maintained hours that allowed
them to come and go at different times.
*he hierarchical organi.ation of the psychiatric hospital has %een commented
on %efore' %ut the latent meaning of that kind of organi.ation is worth noting
again. *hose with the most power ha$e the least to do with patients' and
those with the least power are the most in$ol$ed with them.
A1
Recall'
howe$er' that the ac+uisition of role)appropriate %eha$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 spend
more 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 learn
from their superior,s %eha$ior' spend as little time with patients as they can.
7ttendants are seen mainly in the cage' which is where the models' the
action' and the power are.
A2

& turn now to a different set of studies' these dealing with staff response to
patient)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
50 6urses' 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 $ery
good at closing ranks and keeping the institution's 'secrets.'8B
51 & find this to %e as true today'9 2GG9:as it was when this was written. &t is also true that
& was one of the people who spent the most time with indi$idual patients when & was
working there as a LspecialL and was one of the people most openly scorned %y some of the
staff for my efforts. 8B
52 & found 'dismissi$e' thinking and %eha$iour to represent the 'norm' among the hospital
staff from the top down. 7n 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
initiates and maintains eye contact' there is reason to %elie$e that he is
considering your re+uests and needs. &f he pauses to chat or actually stops
and talks' there is added reason to infer that he is indi$iduating you. &n four
hospitals' the pseudopatients approached the staff mem%er with a re+uest
which took the following form; 8ardon me' -r. Qor Dr. or -rs.R N' could you
tell me when & will %e eligi%le for grounds pri$ileges"! 9or . . . when & will
%e presented at the staff meeting"! or . . . when & am likely to %e
discharged"!:. (hile the content of the +uestion $aried according to the
appropriateness of the target and the pseudopatient,s 9apparent: current
needs the form was always a courteous and rele$ant re+uest for information.
#are was taken ne$er to approach a particular mem%er of the staff more
than once a day' lest the staff mem%er %ecome suspicious or irritated . . .
QRRemem%er that the %eha$ior of the pseudopatients was neither %i.arre nor
disrupti$e.
A0
Jne could indeed engage in good con$ersation with them.
. . . -inor differences %etween these four institutions were o$erwhelmed %y
the degree to which staff a$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 %i.arre form; 9pseudopatient: 8ardon me' Dr. N. #ould you tell me
when & am eligi%le for grounds pri$ileges"! 9physician: >ood morning'
Da$e. How are you today" 9-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$oidance and depersonali.ation.
A1
*he data & ha$e presented do
not do =ustice to the rich daily encounters that grew up around matters of
depersonali.ation and a$oidance. & ha$e records of patients who were
%eaten %y staff for the sin of ha$ing initiated $er%al contact.
AA
During my
53 5ome psychiatrists and other physicians are now %eing diagnosed using this term as
e$idence of a psychiatric illness. *he system is now closing on itself tightening the noose
9tautology: 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 $ersion of this is
e$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$isi%le' which is then heard as a self contained 'symptom.L
55 &n any other setting this would %e seen as %latant a%use %ut not when done to us
'attention seekers' who #J-8B7&6 of a%use =ust to 'seek attention.L 9(atch for the e$er
present tautologies in this:
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.
AF
6e$ertheless' they appeared to go un+uestioned.
*empers were often short.
A7
7 patient who had not heard a call for
medication would %e roundly excoriated' and the morning attendants would
often wake patients with' #ome on' you mS S S S S f S S S S S s' out of
%edK!
AD
6either anecdotal nor hard! data can con$ey the o$erwhelming sense of
powerlessness which in$ades the indi$idual as he is continually exposed to
the depersonali.ation of the psychiatric hospital. &t hardly matters which
psychiatric hospital
A9
I the excellent pu%lic ones and the $ery plush pri$ate
hospital were %etter than the rural and sha%%y ones in this regard' %ut'
again' 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 $irtue of his psychiatric la%el.
F1
His
freedom of mo$ement is restricted. He cannot initiate contact with the staff'
%ut may only respond to such o$ertures as they make.
F2
8ersonal pri$acy is
minimal. 8atient +uarters and possessions can %e entered and examined %y
any staff mem%er' for whate$er reason.
F0
His personal history and anguish is
56 *he e$er present assumption is that all this is a%out the 'reason' of those not la%elled as
the 'sick' one9s:. *he 'reason' is not logic@ it is group catharsis of suppressed emotion.
57 Ees and if & +uestion this staff %eha$iour' & am presumed to %e stupidTcra.y and seeing
things that are not there.
58 *he patient howe$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.
60 7nd it still is e$ident to e$eryone except the staff. *hey are so used to doing it it feels
normal to them.
61 Ees' 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 %eing
treated 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 those
who 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.
a$aila%le to any staff mem%er 9often including the grey lady! and candy
striper! $olunteer: who chooses to read his folder' regardless of their
therapeutic relationship to him. His personal hygiene and waste e$acuation
are often monitored. *he water closets ha$e no doors.
7t times' depersonali.ation reached such proportions that pseudopatients
had the sense that they were in$isi%le'
F1
or at least unworthy of account.
Mpon %eing admitted' & and other pseudopatients took the initial physical
examinations 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 $er%al and occasionally serious physical
a%use to patients in the presence of others 9the pseudopatients: who were
writing it all down.
FF
7%usi$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.
7 nurse un%uttoned her uniform to ad=ust her %rassiere in the presence of an
entire ward of $iewing men. Jne did not ha$e the sense that she was %eing
seducti$e. Rather' she didn,t notice us. 7 group of staff persons might point
to a patient in the dayroom and discuss him animatedly' as if he were not
there.
F7
Jne illuminating instance of depersonali.ation and in$isi%ility occurred with
regard to medication. 7ll told' the pseudopatients were administered nearly
21GG pills' including ?la$il' 5tela.ine' #ompa.ine' and *hora.ine' to name
%ut a few. 9*hat such a $ariety of medications should ha$e %een
administered to patients presenting identical symptoms is itself worthy of
note.:
FD
Jnly two were swallowed. *he rest were either pocketed or
deposited in the toilet. *he pseudopatients were not alone in this. 7lthough &
ha$e no precise records on how many patients re=ected their medications'
the pseudopatients fre+uently found the medications of other patients in the
toilet %efore they deposited their own. 7s long as they were cooperati$e'
their %eha$ior and the pseudopatients, own in this matter' as in other
64 5ay' where ha$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.
65 it sure doesn't seem the same as 'dia%etes' to us...
66 (ell it is not like anyone who actually -7**?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 +uestion
their leaders or this group %eha$iour.
68 Ees as it suggests that what you get 'diagnosed' with and what 'medication' is for you has
more to do with (HJ you get than (H7* you Lha$e.L
important matters' went unnoticed throughout.
F9
Reactions to such depersonali.ation among pseudopatients were intense.
7lthough 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 depersonali.ation.
7G
5ome
examples; 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 this
despite 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 experience'
remem%ered! some drag races that he had wanted to see on the weekend
and insisted that he %e discharged %y that time.
71
7nother pseudopatient
attempted 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 regular
hospital $isitors. *he same person %egan to engage in psychotherapy with
other patients I all of this as a way of %ecoming a person in an impersonal
en$ironment.
72
#$% SOUR)%S O: D%P%RSO&(LI=(#IO&
(hat are the origins of depersonali.ation" & ha$e already mentioned two.
/irst are attitudes held %y all of us toward the mentally ill I including those
who treat them I attitudes characteri.ed %y fear' distrust'
73
and horri%le
expectations on the one hand'
71
and %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 psychiatri.ed when those you must
fight ha$e *J*7B control o$er you.
71 *he fear of the psychological trap he was in was starting to %e felt e$en though in H&5
case he knew he could get out with help. &magine when it is R?7B and there is no escape
possi%le.
72 (hen 'real' patients or prisoners or a%used children do this same thing it is called
L5tockholm 5yndrome.!
73 I wouldn't %e letting her into my apartment if & were you. 9ad$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$e it up...L
5econd' and not entirely separate' the hierarchical structure of the
psychiatric hospital facilitates depersonali.ation. *hose who are at the top
ha$e least to do with patients'
77
and their %eha$ior inspires the rest of the
staff.
7D
7$erage daily contact with psychiatrists' psychologists' residents' and
physicians com%ined ranged form 0.9 to 2A.1 minutes' with an o$erall mean
of F.D 9six pseudopatients o$er a total of 129 days of hospitali.ation:.
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$idual
psychotherapy contacts' case presentation conferences and discharge
meetings. #learly' patients do not spend much time in interpersonal contact
with doctoral staff. 7nd doctoral staff ser$e as models for nurses and
attendants.
DG

*here are pro%a%ly other sources. 8sychiatric installations are presently in
serious financial straits. 5taff shortages are per$asi$e' and that shortens
patient contact.
D1
Eet' while financial stresses are realities' too much can %e
made of them. & ha$e the impression that the psychological forces that
result in depersonali.ation are much stronger than the fiscal ones and that
the addition of more staff would not correspondingly impro$e patient care in
this regard. *he incidence of staff meetings and the enormous amount of
record)keeping on patients' for example' ha$e not %een as su%stantially
reduced as has patient contact.
D2
8riorities exist' e$en during hard times.
8atient contact is not a significant priority in the traditional psychiatric
hospital' and fiscal pressures do not account for this. 7$oidance and
depersonali.ation may.
Hea$y reliance upon psychotropic medication tacitly contri%utes to
depersonali.ation %y con$incing staff that treatment is indeed %eing
conducted and that further patient contact may not %e necessary.
D0
?$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
77 Eoo 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#%SK
80 7nd 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 $ery important date. 6o time to say hello good%ye'
they're late they're late' they're late...
82 J%=ectification allows for a %etter detachment from 'them.'
83 ?specially if 'treatment' reduces the awareness of the identified patient and keeps her
'managea%le.'
were socially significant rather than social lepers'
D1
if their anguish truly and
wholly compelled our sympathies and concerns' would we not seek contact
with them' despite the a$aila%ility of medications" 8erhaps for the pleasure
of it all"
(hat are the origins of depersonali.ation" & ha$e already mentioned two.
/irst are attitudes held %y all of us toward the mentally ill I including those
who treat them I attitudes characteri.ed %y fear' distrust'
DA
and horri%le
expectations on the one hand
DF
' and %ene$olent intentions on the other
D7
.
Jur am%i$alence leads' in this instance as in others' to a$oidance
.DD
5econd' and not entirely separate' the hierarchical structure of the
psychiatric hospital facilitates depersonali.ation. *hose who are at the top
ha$e least to do with patients
D9
' and their %eha$ior inspires the rest of the
staff.
9G
7$erage daily contact with psychiatrists' psychologists' residents' and
physicians com%ined ranged from 0.9 to 2A.1 minutes' with an o$erall mean
of F.D
91
9six pseudopatients o$er a total of 129 days of hospitali.ation:.
&ncluded in this a$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. 7nd doctoral staff ser$e as models for nurses and
attendants.
92

*here are pro%a%ly other sources. 8sychiatric installations are presently in
serious financial straits. 5taff shortages are per$asi$e' and that shortens
patient contact.
90
Eet' 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. 9ad$ice from one of my
smiling neigh%ours to another.:
86 Eou ne$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. 9you 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 you
see no person there.
89 Eoo 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
92 7nd 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 $ery important date. 6o time to say hello good%ye'
they're late they're late' they're late...
made of them. & ha$e the impression that the psychological forces that
result in depersonali.ation 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.
91
8riorities exist' e$en during hard times.
8atient contact is not a significant priority in the traditional psychiatric
hospital' and fiscal pressures do not account for this. 7$oidance and
depersonali.ation may.
Hea$y reliance upon psychotropic medication tacitly contri%utes to
depersonali.ation %y con$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 they
were socially significant rather than social lepers'
9F
if 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.
9D
*he needs for diagnosis and remediation of %eha$ioral and emotional
pro%lems are enormous.
99
4ut rather than acknowledge that we are =ust
em%arking on understanding' we continue to la%el patients schi.ophrenic'!
manic)depressi$e'! and insane'! as if in those words we captured the
94 J%=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$e attitude of the 'knowledgea%le one' especially if he
or she has too much concrete power.
98 *hat has %een my own experience with psychiatry as well.
99 *here is also an assumption that the 'patient's pro%lems exist as defined %y others and
are self contained.
essence of understanding.
1GG
*he facts of the matter are that we ha$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.
1G0
How many people' one wonders'
are sane !t not recogni+ed as s!ch in our psychiatric institutions"
1G1
How
many ha$e %een needlessly stripped of their pri$ileges of citi.enship' from
the right to $ote and dri$e to that of handling their own accounts" How
many 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$e
intermina%ly in a psychiatric hospital I %ut are wrongly thought to %e
mentally ill"
1GA
How many ha$e %een stigmati.ed %y well)intentioned' %ut
ne$ertheless erroneous' diagnoses"
1GF
Jn the last point' recall again that a
*ype 2 error! in psychiatric diagnosis does not ha$e the same
conse+uences it does in medical diagnosis. 7 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+uacy
fore$er.
1GD
/inally' how many patients might %e sane! outside the psychiatric hospital
%ut seem insane in it I not %ecause cra.iness resides in them' as it were'
%ut %ecause they are responding to a %i.arre setting'
1G9
one that may %e
uni+ue to institutions which har%or nether people" >offman calls the process
of sociali.ation to such institutions mortification! I an apt metaphor that
includes the processes of depersonali.ation that ha$e %een descri%ed here.
7nd 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$e that these processes of sociali.ation to
100 (hat they really do is reduce another person to managea%le si.e and =ustify doing it.
101 *he 'de$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$en into psychosis
under pressure like a fulfilled prophecy.
105 Right again on oth counts & would say
106 -y hand is raised on that one. Eou can't tell an employer that someone is cra.y and
without prospect of reco$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
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 hospitali.ed in such an en$ironment I the powerlessness'
depersonali.ation' segregation' mortification' and self)la%eling I seem
undou%tedly counter)therapeutic.
110
& do not' e$en now' understand this pro%lem well enough to percei$e
solutions.
111
4ut two matters seem to ha$e some promise. *he first concerns
the proliferation of community mental health facilities' of crisis inter$ention
centers'
11A
of the human potential mo$ement'
11F
and 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$ironment. #learly' to the extent that we refrain
from sending the distressed to insane places' our impressions of them are
less likely to %e distorted.
117
9*he risk of distorted perceptions' it seems to
me' is always present' since we are much more sensiti$e to an indi$idual,s
%eha$iors and $er%ali.ations than we are to the su%tle contextual stimuli
11D
that often promote them. 7t issue here is a matter of magnitude. 7nd' as &
110 8sychiatrists don't li$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.
112 Ees. 4ecause it is gi$en a context %y those who see themsel$es as 'o%=ecti$e o%ser$ers'
who %elie$e they already <6J( the 'patient' %y 'what they say' and they are not. *hey
ha$e %een trained 4?/JR? the patient arri$es to hear a particular -?76&6>.
113 7nd those of us who DJ6'* accept the 'diagnosis' and la%elling get defined as 'non
compliant' as & was.
114 & %elie$e a solution is to stay self focused and percei$e e$eryone on earth as ha$ing an
inherently e+ual $alue as a human %eing. 6o one as either inferior or superior.
115 *hese also define the 'patient' %efore we walk in the door. ?specially in 2G1G when %io
psych is trying to rule the world.
116 8otential to DJ and %elie$e (H7*" /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.
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$ity of mental health workers and researchers to the
)atch 55 position of psychiatric patients.
12G
5imply reading materials in this
area will %e of help to some such workers and researchers. /or others'
directly experiencing the impact of psychiatric hospitali.ation will %e of
enormous use.
121
#learly' further research into the social psychology
122
of
such total institutions will %oth facilitate treatment and deepen
understanding.
& and the other pseudopatients in the psychiatric setting had distinctly
negati$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.
121
4ut 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
situation'
12F
rather than %eing moti$ated %y a malicious disposition. &n a
more %enign en$ironment' one that was less attached to glo%al diagnosis'
119 Ees the reality of the 5*7// is e$ery %it as distorted as the 'patient.'
120 Eou could %eat them o$er the head with it and most of them still won't get it.
121 Ees nothing like 'experienced experience' is there"
122 5J#&7B psychology for 7BB mem%ers of the group. & am with you there. &t is a%out
groupthink and %eha$iour more than anything else.
123 Eou are pretty close %ut add to that an original condition of extreme real distress 9 for
wahte$er reason: and what you get is an ?N7#?R47*?D condition and not 'help.'
124 7<7 5tockholm 5yndrome
125 Ees and that is what makes it so terrifying. &f the well intentioned will do this' what
would the maliciously intentioned agree to do"
126 7s are the patient's when we recogni.e we are caught in an escape proof trap with no
way out.
their %eha$iors and =udgments might ha$e %een more %enign and effecti$e.
127
& thank (. -ischel' ?. Jrne' and -.5. Rosenhan for comments on an earlier
draft of this manuscript.
5JMR#?; Da$id B. Rosenhan' Jn 4eing 5ane in &nsane 8laces'! 5cience'
Uol. 179 9Han. 1970:' 2AG)2AD.
#opyright 1970 %y the 7merican 7ssociation for the 7d$ancement of
5cience.
Q1R R. 4enedict' H.>en. 8sychol.' 1G 91901:' A9.
Q2R 4eyond the personal difficulties that the pseudo patient is likely to
experience in the hospital' there are legal and social ones that' com%ined'
re+uire considera%le attention %efore entry. /or example' once admitted to a
psychiatric institution' it is difficult' if not impossi%le' to %e discharged on
short notice' state law to the contrary notwithstanding. & was not sensiti$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$ery hospitali.ation.
12D
& am grateful to Hohn <aplan and
Ro%ert 4artels for legal ad$ice and assistance in these matters.
Q0R Howe$er distasteful such concealment is' it was a necessary first step to
examining these +uestions. (ithout concealment' there would ha$e %een no
way to know how $alid these experiences were@ nor was there any way of
knowing whether whate$er detections occurred were a tri%ute to the
diagnostic acumen of the hospital,s rumour network. J%$iously' since my
concerns are general ones that cut across indi$idual hospitals and staffs' &
ha$e respected their anonymity and ha$e eliminated clues that might lead to
their identification.
Q1R &nterestingly' of the 12 admissions' 11 were diagnosed as schi.ophrenic
and one' with the identical symptomatology' as manic)depressi$e psychosis.
129
*his diagnosis has more fa$ora%le prognosis' and it was gi$en %y the
pri$ate hospital in our sample. Jne the relations %etween social class and
psychiatric diagnosis' see 7. de4. Hollingshead and /.#. Redlich' 5ocial #lass
and -ental &llness; 7 #ommunity 5tudy 96ew Eork; Hohn (iley' 19AD:.
127 4eing human %eings talking to e+ual human %eings might do wonders.
128 8atients do not ha$e lawyers standing %y on retainer though do they"
129 *his one and 'personality disorders' are more popular in 2G1G
QAR 5.?. 7sch' H. 7%norm. 5oc. 8sychol.' 11 9191F:' 5ocial 8sychology
9?nglewood #liffs' 6/; 8renticeSHall' 19A2:.
QFR ?. Oigler and B. 8hillips' H. 7%norm. 5oc. 8sychol. F0' 919F1: F9. 5ee also
R. <. /reuden%erg and H. 8. Ro%ertson' 7.-.7. 7rch. 6eurol. 8sychiatr.' 7F'
919AF:' 11
Q7R (. -ischel' 8ersonality and 7ssessment 96ew Eork@ Hohn (iley' 19FD:.
QDR ?. >offman' 7sylums 9>arden #ity' 6E@ Dou%leday' 19F1: