In the early 1970s, eight sane people infiltrated 12 different mental hospitals with false symptoms. One was a psychology graduate student in his twenties, while the others were older and from varying professions (including a painter and a housewife). Three were women, five were men, and none had any prior history of psychological illness.
These “pseudopatients” complained of hearing voices and presented false names (and vocations, for those in psychological professions), but significant life events and relationships remained intact. Upon admittance, they stopped pretending to have abnormal symptoms. When asked, pseudopatients would claim to have no symptoms; they also acted friendly, took all directions, and pretended to take medication. They had no knowledge of when they would be released, since they would first have to convince staff that they were sane.
Psychiatry at Sixes and Sevens in the ’60s and ’70s
The architect of this experiment, David Rosenhan, is one among many in the ’60s and ’70s who composed the vanguard against the growing ambition and presumptions to power of the psychological profession epitomized in B.F. Skinner’s Walden Two. Michel Foucault’s Madness and Civilization, Erving Goffman’s Asylums, and Ken Kesey’s One Flew Over the Cuckoo’s Nest uncovered the spectre of limitless control, the perversion of human dignity, and the evil of unmitigated power.
The anti-psychiatric movement (at that time, before it was hijacked by the couch-jumping set) was a backlash against a vision of the human as clockwork behaviour; in the words of Anthony Burgess, “the application of Pavlovian or mechanical laws to an organism which, like a fruit, was capable of colour and sweetness.” (Hence, a clockwork orange.)
Rosenhan’s aim in his classic 1973 article “On being sane in insane places,” for which he planted his spies in the heart of the Hospital, was to learn whether or not characteristics that lead to mental health diagnoses reside in the patient or in the environmental context in which the observer finds him/her. Will a sane resident within a mental asylum be detected?
No. The pseudopatients, who acted normally and openly took notes on their experiences, were never detected by the psychiatric staff. While one case was diagnosed with schizophrenia, the rest were discharged with a diagnosis of schizophrenia “in remission.”
Were they in fact behaving sanely? Daily visitors and nurses’ reports indicate that they were, and in fact 25 in 118 patients on one ward voiced their suspicions that the pseudopatient was not crazy. The patients recognized normality when staff did not. But it gets better: a separate counter-experiment, in which Rosenhan told hospital administrators that one or more pseudopatients would be infiltrating their facilities, was revealing: dozens of suspected pseudopatients were highlighted by staff and psychiatrists, when in fact none had been dispatched!
The Persistence of Labels
Psychiatric labels are sticky and have the power to colour other impressions. In Rosenhan’s experiment, the psychiatrist’s perception of the patient’s circumstances was coloured by the diagnosis; normal life histories appeared rife with pathologies to suit the psychiatrist’s conclusions. Behaviours stimulated by the environment (such as boredom or anger) were interpreted to be symptoms of disease rather than natural responses. Note-taking by the pseudopatients aroused the suspicions of other patients, but not staff or psychiatrists. It merely seemed to be part of their pathological behaviour:
“Given that the patient is in the hospital, he must be psychologically disturbed. And given that he is disturbed, continuous writing must be a behavioral manifestation of that disturbance, perhaps a subset of the compulsive behaviors that are sometimes correlated with schizophrenia.”
All of this would not have been possible outside of an institution that stripped patients of their personhood, and these hospitals had all the trappings of depersonalization. Attempts by pseudopatients to initiate courteous exchanges were often met with aversion or silence; eye contact was avoided. To contrast, a similar study conducted at Stanford University, with a young questioner intercepting professors who were in a rush, found that all professors, without exception, responded; eye contact was maintained. Rosenhan even witnessed beatings of patients who initiated friendly verbal contact during his run as a pseudopatient.
Patients are stigmatized and depersonalized through their reduced legal status, restrictions on movement, lack of credibility, minimal privacy, and frequent surveillance. A nurse could unbutton her uniform and adjust her brassiere in the presence of an entire ward of men and not think twice. Pseudopatients often felt pressured to assert their status as persons. Rosenhan argues that cultural ambivalence about mental illness and the hierarchical nature of the hospital, in which lower orders imitate the upper orders’ avoidance of patients, are the root causes of depersonalization. He dismisses explanations that invoke fiscal shortcomings as wrongheaded.
Labels Beyond the Hospital
Sanity and insanity seem to overlap in a number of respects, since everyone occasionally feels depressed or loses their temper. Rosenhan argues that the label of schizophrenia, in remission or not, endures beyond the walls of the hospital. They influence the patient and his loved ones and friends; they can become self-fulfilling prophecies.
While doctors tend to err on the side of caution, psychiatry carries a number of potentially dangerous “personal, legal, and social stigmas” that should give us pause. The legal and social protections surrounding consent evaporate once a patient is seen to be unable to grant consent, and while in recent years courts have offered stronger affirmations of patients’ rights even in the absence of full consent capability, the forces of stigma and social control have hardly dissipated. Psychiatric labels, no matter how inaccurate, are remarkably tenacious once applied.
“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 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 counter-therapeutic.”
Needless to say, the mental hospital has undergone numerous permutations since the ’70s; the work of Rosenhan and others has become standard reading and there has been an ongoing shift towards community mental health facilities and greater autonomy for patients of residential care settings. The DSM has since been revised to ensure that diagnosis is more rigorous. Yet the spectre of those older institutions, some of which have become museums, remains with us today, and it is worth remembering how the impersonality and radical ambitions of these institutions — to make the crooked straight (often in more ways than one) — contributed to some of the greatest assaults on human dignity in the 20th century.
We are periodically surprised by stories of institutional abuse and neglect such as the recent story of an autistic man who was locked in a room for over 15 days. How can good people, well-meaning nurses and aides, do such horrible things? There are always serious dangers when authority and power dynamics are combined with routinized subjection and uniformity. The onus is upon all of us, individually and collectively, to be aware of the past and be on the lookout for our darker natures; to seek out and expunge disdain and indifference.
“The fault, dear Brutus, is not in our stars,
But in ourselves, that we are underlings.”