On Being Sane
In Insane Places
David L. Rosenhan
Science 19 January 1973: Vol. 179 no. 4070 pp. 250-258
DOI: 10.1126/science.179.4070.250
Abstract (and Conclusion): It
is clear that we cannot distinguish the sane from the insane in psychiatric
hospitals (精神科の病院で正常者と精神異常者を見分けるのは不可能であることは、明らかである）. The hospital itself imposes
a special environment in which the meanings 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 countertherapeutic.
PSEUDOPATIENTS AND THEIR
SETTINGS
(Eight sane people gained
secret admission to 12 different hospitals.)
The eight pseudopatients were a varied group. One was a
psychology graduate student in his 20’s. The remaining seven were older and
“established.” Among them were three psychologists, a pediatrician, a
psychiatrist, a painter, and a housewife. Three pseudopatients were women, five
were men. All of them employed pseudonyms, lest their alleged diagnoses
embarrass them later.
After calling the hospital
for an appointment, the pseudopatient arrived at the admissions office
complaining that he had been hearing voices…
Beyond alleging the
symptoms and falsifying name, vocation, and employment, no further alterations
of person, history, or circumstances were made. The significant
events of the pseudopatient’s life history were presented as they had actually
occurred. Relationships with parents and siblings, with spouse and
children, with people at work and in 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 of the pseudopatients really believed that they would be
admitted so easily.
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. The
psychological stresses associated with hospitalization were considerable, and
all but one of the pseudopatients desired to be discharged almost immediately
after being admitted. They 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. These reports uniformly indicate that the patients were
“friendly,” “cooperative,” and “exhibited no abnormal indications.”
THE NORMAL ARE NOT
DETECTABLY SANE
Despite their public “show”
of sanity, the pseudopatients were never detected. Admitted, except in one
case, with a diagnosis of schizophrenia,[4] each was discharged with a diagnosis of
schizophrenia “in remission.” The label “in remission” should in no way be
dismissed as a formality, for at no time during any hospitalization had any
question been raised about any pseudopatient’s simulation. Nor are there any
indications in the hospital records that the pseudopatient’s status was suspect.
Rather, 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.
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. It was quite
common for the patients to “detect” the pseudopatient’s sanity. During
the first three hospitalizations, when accurate counts were kept, 35 of a
total of 118 patients on the admissions ward voiced their suspicions, some
vigorously. “You’re not crazy. You’re a journalist, or a professor
(referring to the continual note-taking). You’re checking up on the hospital.”
While most of the patients were reassured by the pseudopatient’s insistence
that he had been sick before he came in but was fine now, some continued to
believe that the pseudopatient was sane throughout his hospitalization. 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: 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.
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…
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 least 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. But what can be said of the 19 people who were suspected
of being “sane” by one psychiatrist and another staff member? Were these people
truly "sane" or was it rather the case that in the course of
avoiding the Type 2 error the staff tended to make more errors of the first
sort – calling the crazy “sane”? There is no way of knowing. But one
thing is certain: any diagnostic process that lends itself too readily to
massive errors of this sort cannot be a very reliable one.
THE STICKINESS OF
PSYCHODIAGNOSTIC LABELS
As far as I can determine, diagnoses
were in no way affected by the relative health of the circumstances of a
pseudopatient’s life. Rather, the reverse occurred: the perception of
his circumstances 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
relationship with his mother but was rather remote from his father during his
early childhood. During adolescence and beyond, however, his father became a
close friend, while his relationship with his mother cooled. His present
relationship with his wife was characteristically 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 history.
Indeed, many readers may see a similar pattern in their own experiences, with
no markedly deleterious consequences. Observe, however, how such a history was
translated in the psychopathological context, this from the case summary
prepared after the patient was discharged.
This white 39-year-old male
. . . manifests a long history of considerable ambivalence in close relationships,
which begins in early childhood. A warm relationship with his mother cools
during his adolescence. A distant relationship with 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 outbursts and,
in the case of the children, spankings. And while he says that he has several
good friends, one senses considerable ambivalence embedded in those
relationships also . . .
The facts of the case were
unintentionally distorted by the staff to achieve consistency with a popular
theory of the dynamics of a schizophrenic reaction… Clearly, the meaning
ascribed to his verbalizations (that is, ambivalence, affective instability)
was determined by the diagnosis: schizophrenia. An entirely
different meaning would have been ascribed if it were known that the man was
“normal.”
THE CONSEQUENCES OF
LABELING AND DEPERSONALIZATION
…The facts of the matter
are that we have known for a long time that diagnoses are often not useful or
reliable, but we have nevertheless continued to use them. We now know that we
cannot distinguish sanity from insanity. It is depressing to consider how that
information will be used.
Not merely depressing, but frightening. 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?
Rosehan,
D. L. (1973). On being sane in insane places.
