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The number of people who are now maintained by the state as mental patients is probably no smaller than it used to be. They're in so-called transitional living quarters, in group homes, in nursing homes, in prisons, on the street, maintained on Social Security. In the old days, you didn't get money for being schizophrenic. Now you get a lot of money for it. They are now maintained like pets rather than being locked up in a zoo. -- Thomas S. Szasz
Selected quotes from D.L. Rosenhan's classic study, On Being Sane in Insane Places:
Eight sane people gained secret admission to 12 different hospitals... After calling the hospital for an appointment, the pseudopatient arrived at the admissions office complaining that he had been hearing voices. Asked what the voices said, he replied that they were often unclear, but as far as he could tell they said "empty," "hollow," and "thud." ...The pseudopatients were never detected... each was discharged with a diagnosis of schizophrenia "in remission."
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The evidence is strong that, once labeled schizophrenic, the pseudopatient was stuck with that label. If the pseudopatient was to be discharged, he must naturally be "in remission"; but he was not sane, nor, in the institution's view, had he ever been sane.
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Failure to detect sanity during the course of hospitalization may be due to the fact that physicians operate with a strong bias toward what statisticians call the Type 2 error. This is to say that physicians are more inclined to call a healthy person sick (a false positive, Type 2) than a sick person healthy (a false negative, Type 1). The reasons for this are not hard to find: it is clearly more dangerous to misdiagnose illness than health. Better to err on the side of caution, to suspect illness even among the healthy.
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Any diagnostic process that lends itself too readily to massive errors of this sort cannot be a very reliable one.
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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.
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Once a person is designated abnormal, all of his other behaviors and characteristics are colored by that label.
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One tacit characteristic of psychiatric diagnosis is that it locates the sources of aberration within the individual and only rarely within the complex of stimuli that surrounds him. Consequently, behaviors that are stimulated by the environment are commonly misattributed to the patient's disorder.
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A psychiatric label has a life and an influence of its own. Once the impression has been formed that the patient is schizophrenic, the expectation is that he will continue to be schizophrenic. When a sufficient amount of time has passed, during which the patient has done nothing bizarre, he is considered to be in remission and available for discharge. But the label endures beyond discharge, with the unconfirmed expectation that he will behave as a schizophrenic again. Such labels, conferred by mental health professionals, are as influential on the patient as they are on his relatives and friends, and it should not surprise anyone that the diagnosis acts on all of them as a self-fulfilling prophecy. Eventually, the patient himself accepts the diagnosis, with all of its surplus meanings and expectations, and behaves accordingly.
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The sane are not "sane" all of the time. We lose our tempers "for no good reason." We are occasionally depressed or anxious, again for no good reason. And we may find it difficult to get along with one or another person -- again for no reason that we can specify. Similarly, the insane are not always insane. Indeed, it was the impression of the pseudopatients while living with them that they were sane for long periods of time -- that the bizarre behaviors upon which their diagnoses were allegedly predicated constituted only a small fraction of their total behavior. If it makes no sense to label ourselves permanently depressed on the basis of an occasional depression, then it takes better evidence than is presently available to label all patients insane or schizophrenic on the basis of bizarre behaviors or cognitions. It seems more useful, as Mischel [Personality and Assessment, 1968] has pointed out, to limit our discussions to behaviors, the stimuli that provoke them, and their correlates.
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I may hallucinate because I am sleeping, or I may hallucinate because I have ingested a peculiar drug. These are termed sleep-induced hallucinations, or dreams, and drug-induced hallucinations, respectively. But when the stimuli to my hallucinations are unknown, that is called craziness, or schizophrenia -- as if that inference were somehow as illuminating as the others.
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The mentally ill are society's lepers.
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At times, depersonalization reached such proportions that pseudopatients had the sense that they were invisible, or at least unworthy of account.
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One illuminating instance of depersonalization and invisibility occurred with regard to medication. All told, the pseudopatients were administered nearly 2,100 pills, including Elavil, Stelazine, Compazine, and Thorazine, to name but a few. That such a variety of medications should have been administered to patients presenting identical symptoms is itself worthy of note.
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Heavy reliance upon psychotropic medication tacitly contributes to depersonalization by convincing staff that treatment is indeed being conducted and that further patient contact may not be necessary.
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A diagnosis of cancer that has been found to be in error is cause for celebration. But psychiatric diagnoses are rarely found to be in error. The label sticks, a mark of inadequacy forever.
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Finally, how many patients might be "sane" outside the psychiatric hospital but seem insane in it -- not because craziness resides in them, as it were, but because they are responding to a bizarre setting, one that may be unique to institutions which harbor nether people? Goffman [Asylums, 1961] calls the process of socialization to such institutions "mortification' -- an apt metaphor that includes the processes of depersonalization that have been described here.
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It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals. The hospital itself imposes a special environment in which the meaning of behavior can easily be misunderstood. The consequences to patients hospitalized in such an environment -- the powerlessness, depersonalization, segregation, mortification, and self-labeling -- seem undoubtedly counter-therapeutic.
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It could be a mistake, and a very unfortunate one, to consider that what happened to us derived from malice or stupidity on the part of the staff. Quite the contrary, our overwhelming impression of them was of people who really cared, who were committed and who were uncommonly intelligent. Where they failed, as they sometimes did painfully, it would be more accurate to attribute those failures to the environment in which they, too, found themselves than to personal callousness. Their perceptions and behaviors were controlled by the situation, rather than being motivated by a malicious disposition. In a more benign environment, one that was less attached to global diagnosis, their behaviors and judgments might have been more benign and effective.
On Being Sane in Insane Places by David L. Rosenhan.
Science, New Series, Vol. 179, No. 4070. (Jan. 19, 1973), pp. 250-258.
Copyright 1973 by the American Association for the Advancement of Science.
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