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. David L. Rosenhan. On Being Sane in Insane Places. If sanity and insanity exist, how shall we know them? The question is neither capricious nor itself insane. Rosenhan was one of these critics. As a researcher and psychiatrist himself, he put together a team of eight perfectly healthy and sane “pseudo patients” (five.
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Conventional wisdom suggests that specially placss professionals have the ability to make reasonably accurate diagnoses. In this research, however, David Rosenhan provides evidence to challenge this assumption. If sanity and rosenban 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.
Thus, notions of normality and abnormality may not be quite as accurate as people believe they are. To raise questions regarding normality and abnormality is in no way to question the fact that some behaviors are deviant or odd.
So, too, are hallucinations. But normality and abnormality, sanity and insanity, and the diagnoses that flow from them may be less substantive than inxane believe them to be. At its heart, the question of whether the sane can be distinguished from the insane and whether degrees of insanity can be rosenyan from each other is a simple matter: D o the salient lpaces that lead to diagnoses reside in the patients themselves or in the environments and contexts in which observers find them?
More recently, gosenhan, this belief has been questioned. Based in part on theoretical and anthropological considerations, but also plaecs philosophical, legal, inszne therapeutic ones, the view has grown that psychological categorization of mental illness is useless at best and downright harmful, misleading, and pejorative at worst.
Psychiatric diagnoses, in this view, are in the minds of observers and are not valid summaries of characteristics displayed by the observed. Gains can be made in deciding which of these is more nearly accurate by getting normal people that is, people who do not have, and have never suffered, symptoms of serious psychiatric disorders admitted to psychiatric hospitals and then determining whether they were discovered to be sane and, if so, how.
If the sanity of such pseudopatients were always detected, there would be prima facie evidence that a sane individual can be distinguished from the insane context in rosenhaan he is found. Normality and presumably abnormality is distinct enough that it can be recognized wherever it occurs, for it is carried within the person.
If, on the other hand, the sanity of the pseudopatients were never discovered, serious difficulties would arise for those who support traditional modes of psychiatric diagnosis.
Given that the hospital staff was not incompetent, that the pseudopatient had been behaving as sanely as he had been out of the hospital, and that it had never been previously suggested that he belonged in a psychiatric hospital, such an unlikely outcome would support the view that psychiatric diagnosis betrays little about the patient but much about the environment in which an observer finds him.
This article describes such an experiment. Eight sane people gained secret admission to 12 different hospitals. Their diagnostic experiences constitute the data of the first part of this article; the remainder is devoted to a rosehan 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.
On Being Sane in Insane Places
They rarely talk about it with former patients, perhaps because they distrust information coming from the previously insane. Those who have worked in psychiatric hospitals are likely to have adapted so thoroughly to the benig that they are insensitive to the impact of that experience.
And while there have been occasional reports of researchers who submitted themselves to psychiatric hospitalization, these researchers have commonly remained in the hospitals for short periods of time, often with the knowledge of the hospital staff. It is difficult to know the extent to which they were treated like patients or like research colleagues. Nevertheless, their reports about the inside of the psychiatric hospital have been valuable. This article extends those efforts.
The eight pseudopatients were a varied group. Three pseudopatients were women, five were men. All of them employed pseudonyms, lest their alleged diagnoses embarrass them later. Those who were in mental health professions alleged another occupation in order to avoid the special attentions that might be accorded by staff, as a matter of courtesy or caution, to ailing colleagues.
The settings are similarly varied. In order to generalize the findings, admission into a variety of hospitals was sought. The 12 hospitals in the sample were located in five different states on the East and West coasts. Some were old and shabby, some were quite new.
Some had good staff-patient ratios, others were quite understaffed. Only one was a strict private hospital. All of the others were supported by state or federal funds or, in one instance, by university funds. After calling the hospital for an appointment, the pseudopatient arrived at the admissions office complaining that he had been xavid voices. The choice of these symptoms was occasioned by their apparent similarity to rosenuan symptoms.
Beyond alleging the symptoms and falsifying name, vocation, and employment, no further alterations of person, history, or circumstances were made. Relationships with parents and siblings, with spouse and bejng, with people at work and ppaces school, consistent with the aforementioned exceptions, were described as they were or had been. Frustrations and upsets were described along with joys and satisfactions. These facts are important to remember. If anything, they strongly biased the subsequent results in favor of detecting insanity, since none of their histories or current behaviors were seriously pathological in any way.
Immediately upon admission to the psychiatric ward, the pseudopatient ceased simulating any symptoms of abnormality. In some cases, there was a brief period of mild nervousness and anxiety, since none insxne the pseudopatients really believed that they would be admitted so easily. Indeed, their shared fear was that they would be immediately exposed as frauds and greatly embarrassed. Moreover, many of them had sne visited a psychiatric ward; even those who had, nevertheless rosenhn some genuine fears about what might happen to them.
Their nervousness, then, was quite appropriate to the novelty of the hospital setting, and it abated rapidly. The pseudopatient spoke to patients and staff as he might ordinarily. Because there is uncommonly little to do on a psychiatric ward, insanee attempted to engage others in conversation.
When asked by staff how he was feeling, he indicated that he was fine, that he dwvid longer experienced inasne.
He responded to instructions from attendants, to calls for medication which was not swallowedand to dining-hall instructions. Beyond such activities as were available to him on the admissions ward, he spent his time writing down his observations about the bein, its patients, and the staff.
No secret was made of these activities. The pseudopatient, very much as a true psychiatric patient, entered a hospital with no foreknowledge of when he would be discharged. Each was told that he would have to get out by his own devices, essentially by convincing the staff that he was sane.
Rosenhan Experiment: When Fake Mental Patients Fooled Doctors
The psychological stresses associated with hospitalization were considerable, and all but one of the pseudopatients desired to be discharged almost immediately after being admitted. Davis were, therefore, motivated not only to behave sanely, but to be paragons of cooperation.
That their behavior was in no way disruptive is confirmed by nursing reports, which have been obtained on most of the patients. Rather, the eane is strong that, once labeled schizophrenic, the pseudopatient was stuck with that label.
The uniform failure to recognize sanity cannot be attributed to the quality of the hospitals, for, although there were considerable variations among them, several are considered excellent. Nor can it be alleged that there was simply not enough time to observe the pseudopatients. Length of hospitalization ranged from 7 to 52 days, with an average of 19 days.
The pseudopatients were not, in fact, carefully observed, but this failure speaks more to traditions within psychiatric hospitals than to lack of opportunity. Finally, it cannot be said that the failure to recognize the pseudopatients’ sanity was due to the fact that they were not behaving sanely. While there was clearly some tension present in all of them, their daily visitors could detect no serious behavioral consequences—nor, indeed, could other patients. During the first three hospitalizations, when accurate counts were kept, 35 of a total of patients on the admissions ward voiced their suspicions, some vigorously.
The fact that the patients often recognized normality when staff did not raises important questions. Failure to detect sanity during the course of hospitalization may be due to the fact that physicians operate with a strong bias toward what statisticians call the Type 2 error. This is to say that physicians are more inclined to call a healthy person sick a false positive, Type 2 than a sick person healthy a false negative, Type 1.
The reasons for this are not hard to find: Better to err on the side of caution, to suspect illness even among the healthy. But what holds for medicine does not hold equally well for psychiatry. Medical illnesses, while unfortunate, are not commonly pejorative. Psychiatric diagnoses, on the contrary, carry with them personal, legal, and social stigmas. It was therefore important to see whether the tendency toward diagnosing the sane insane could be reversed.
The following experiment was arranged at a research and teaching hospital whose staff had heard these findings but doubted that such an error could occur in their hospital. The staff was informed that at some time during the following three months, one or more pseudopatients would attempt to be admitted into the psychiatric hospital. Each staff member was asked to rate each patient who presented himself at admissions or on the ward according to the likelihood that the patient was a pseudopatient.
A point scale was used, with a 1 and 2 reflecting high confidence that the patient was a pseudopatient. Judgments were obtained on patients who were admitted for psychiatric treatment.
All staff who had had sustained contact with or primary responsibility for the patient — attendants, nurses, psychiatrists, physicians, and psychologists — were asked to make judgments.
Forty-one patients were alleged, with high confidence, to be pseudopatients by at least one member of the staff. Twenty-three were considered suspect by at least one psychiatrist. Nineteen were suspected by one psychiatrist and one other staff member.
Actually, no genuine pseudopatient at bwing from my group presented himself during this period. The experiment is instructive. It indicates that the tendency to designate sane people as insane can be reversed when the stakes in this case, prestige and diagnostic acumen are high. There is no way bding knowing.
But one thing is certain: Beyond the tendency to call the healthy sick — a tendency that accounts better for diagnostic behavior on admission insaje it does for such behavior after a lengthy period bieng exposure — the data speak to the massive role of labeling in psychiatric assessment. Having once been labeled schizophrenic, there is nothing the pseudopatient can do to overcome the tag. 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.
Once a person is designated abnormal, all of his other behaviors and characteristics are colored by that label. Some rowenhan may clarify this issue.