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1. Zimbardo says that assigning labels to people and putting them into a situation where those labels acquire validity and meaning is sufficient to elicit pathological behavior. Discuss what he means with regards to the social structure of the prison.

2. When the personnel of one hospital found out about this experiment, they said nothing like that could ever happen in their hospital. Rosenhan said he would have a pesudopatient admitted to the hospital within the next three months. What happened? How could that happen?

Each of your answers should be around 300 words for a total of approximately 600 words.

The first four screenshots is the article for question number 1. I will send the article for question number 2 after

27 The Pathology of Imprisonment
think I will be a thief when I am released. No, I’m not rehabilitated. It’s just that I no
longer think of becoming wealthy by stealing. I now only think of killing-killing those
who have beaten me and treated me as if I were a dog. I hope and pray for the sake of
my own soul and future life of freedom that I am able to overcome the bitterness and
hatred which eats daily at my soul, but I know to overcome it will not be easy.
PHILIP G. ZIMBARDO
Why are our prisons such powder kegs? To most people, the answer is obvious—because of
the kind of people who are locked up in prisons: They are criminals, antisocial, and disposed
to violence. If not that, then they hate the guards, the food, or the restrictions of prison life
(which is what they deserved in the first place!). Similarly, people have little difficulty
explaining why prison guards are brutal: It is either the type of people with whom the guards
must deal (“animals”) or the type of people who are attracted to being prison guards in the
first place (“sadistic types”). Such reasons are commonly cited to explain prison violence. It
turns out, however, that more fundamental social processes are involved. As Zimbardo’s
remarkable experiment uncovered, the structuring of relationships within the prison lays the
foundation for prison brutality and violence.
While reading this fascinating account, you may begin to think about how prisons could
be improved in order to minimize violence. To reach such a goal, what changes would you
suggest that we make in the social structure of prisons?
THIS ELOQUENT PLEA FOR PRISON REFORM—for humane treatment of
human beings, for the basic dignity that is the right of every American-came to me
secretly in a letter from a prisoner who cannot be identified because he is still in a
state correctional institution. He sent it to me because he read of an experiment I
recently conducted at Stanford University. In an attempt to understand just what it
means psychologically to be a prisoner or a prison guard, Craig Haney, Curt Banks,
Dave Jaffe, and I created our own prison. We carefully screened over 70 volunteers
who answered an ad in a Palo Alto city newspaper and ended up with about two
dozen young men who were selected to be part of this study. They were mature,
emotionally stable, normal, intelligent college students from middle-class homes
throughout the United States and Canada. They appeared to represent the cream of
the crop of this generation. None had any criminal record and all were relatively
homogeneous on many dimensions initially.
Half were arbitrarily designated as prisoners by a flip of a coin, the others as
guards. These were the roles they were to play in our simulated prison. The guards
were made aware of the potential seriousness and danger of the situation and their
own vulnerability. They made up their own formal rules for maintaining law, order,
and respect, and were generally free to improvise new ones during their eight-hour,
three-man shifts. The prisoners were unexpectedly picked up at their homes by a city
policeman in a squad car, searched, handcuffed, fingerprinted, booked at the Palo
Alto station house, and taken blindfolded to our jail. There they were stripped,
deloused, put into a uniform, given a number, and put into a cell with two other
prisoners where they expected to live for the next two weeks. The pay was good
($15 a day), and their motivation was to make money.
We observed and recorded on videotape the events that occurred in the prison,
I was recently released from solitary confinement after being held therein for 37 months
[months!). A silent system was imposed upon me and to even whisper to the man in the
next cell resulted in being beaten by guards, sprayed with chemical mace, blackjacked,
stomped and thrown into a strip-cell naked to sleep on a concrete floor without bedding,
covering, wash basin or even a toilet. The floor served as toilet and bed, and even there
the silent system was enforced. To let a moan escape your lips because of the pain and
discomfort … resulted in another beating. I spent not days, but months there during my
37 months in solitary…. I have filed every writ possible against the administrative acts
of brutality. The state courts have all denied the petitions. Because of my refusal to let
the things die down and forget all that happened during my 37 months in solitary … I
am the most hated prisoner in [this] penitentiary, and called a “hard-core incorrigible.”
Maybe I am an incorrigible, but if true, it’s because I would rather die than to accept
being treated as less than a human being. I have never complained of my prison
sentence as being unjustified except through legal means of appeals. I have never put a
knife on a guard’s throat and demanded my release. I know that thieves must be
punished and I don’t justify stealing, even though I am a thief myself. but now I don’t
and to abandon their brother.
and we interviewed and tested the prisoners and guards at various points throughout
the study. Some of the videotapes of the actual encounters between the prisoners and
guards were seen on the NBC News feature “Chronolog” on November 26, 1971.
At the end of only six days we had to close down our mock prison because what
we saw was frightening. It was no longer apparent to most of the subjects (or to us)
where reality ended and their roles began. The majority had indeed become
prisoners or guards, no longer able to clearly differentiate between role playing and
self. There were dramatic changes in virtually every aspect of their behavior,
thinking, and feeling. In less than a week the experience of imprisonment undid
(temporarily) a lifetime of learning; human values were suspended, self-concepts
were challenged, and the ugliest, most base, pathological side of human nature
surfaced. We were horrified because we saw some boys (guards) treat others as if
they were despicable animals, taking pleasure in cruelty, while other boys
(prisoners) became servile, dehumanized robots who thought only of escape, of their
own individual survival, and of their mounting hatred for the guards.
We had to release three prisoners in the first four days because they had such
acute situational traumatic reactions as hysterical crying, confusion in thinking, and
severe depression. Others begged to be paroled, and all but three were willing to
forfeit all the money they had earned if they could be paroled. By then (the fifth day)
they had been so programmed to think of themselves as prisoners that when their
request for parole was denied, they returned docilely to their cells. Now, had they
been thinking as college students acting in an oppressive experiment, they would
have quit once they no longer wanted the $15 a day we used as our only incentive.
However, the reality was not quitting an experiment but “being paroled by the parole
board from the Stanford County Jail.” By the last days, the earlier solidarity among
the prisoners (systematically broken by the guards) dissolved into “each man for
himself.” Finally, when one of their fellows was put into solitary confinement (a
small closet) for refusing to eat, the prisoners were given a choice by one of the
guards: give up their blankets and the incorrigible prisoner would be let out, or keep
their blankets and he would be kept in all night. They voted to keep their blankets
About a third of the guards became tyrannical in their arbitrary use of power, in
enjoying their control over other people. They were corrupted by the power of their
roles and became quite inventive in their techniques of breaking the spirit of the
prisoners and making them feel they were worthless. Some of the guards merely did
their jobs as tough but fair correctional officers, and several were good guards from
the prisoners’ point of view since they did them small favors and were friendly.
However, no good guards ever interfered with a command by any of the bad guards;
they never intervened on the side of the prisoners, they never told the others to ease
off because it was only an experiment, and they never even came to me as prison
superintendent or experimenter in charge to complain. In part, they were good
because the others were bad; they needed the others to help establish their own egos
in a positive light. In a sense, the good guards perpetuated the prison more than the
other guards because their own need to be liked prevented them from disobeying or
violating the implicit guards’ code. At the same time, the act of befriending the
prisoners created a social reality which made the prisoners less likely to rebel.
By the end of the week the experiment had become a reality, as if it were a
Pirandello play directed by Kafka that just keeps going after the audience has left.
The consultant for our prison, Carlo Prescott, an exconvict with 16 years of
imprisonment in California’s jails, would get so depressed and furious each time he
visited our prison, because of its psychological similarity to his experiences, that he
would have to leave. A Catholic priest who was a former prison chaplain in
Washington, D.C., talked to our prisoners after four days and said they were just like
the other first-timers he had seen.
But in the end, I called off the experiment not because of the horror I saw out
there in the prison yard, but because of the horror of realizing that I could have
easily traded places with the most brutal guard or become the weakest prisoner full
of hatred at being so powerless that I could not eat, sleep, or go to the toilet without
permission of the authorities. I could have become Calley at My Lai, George
Jackson at San Quentin, one of the men at Attica, or the prisoner quoted at the
beginning of this article.
Individual behavior is largely under the control of social forces and
environmental contingencies rather than personality traits, character, will power, or
other empirically unvalidated constructs. Thus we create an illusion of freedom by
attributing more internal control to ourselves, to the individual, than actually exists.
We thus underestimate the power and pervasiveness of situational controls over
behavior because: (a) they are often nonobvious and subtle, (b) we can often avoid
entering situations where we might be so controlled, (c) we label as “weak” or
“deviant” people in those situations who do behave differently from how we
believed we would.
Each of us carries around in our heads a favorable self-image in which we are
essentially just, fair, humane, and understanding. For example, we could not imagine
inflicting pain on others without much provocation or hurting people who had done
nothing to us, who in fact were even liked by us. However, there is a growing body
of social psychological research which underscores the conclusion derived from this
prison study. Many people, perhaps the majority, can be made to do almost anything
when put into psychologically compelling situations-regardless of their morals,
ethics, values, attitudes, beliefs, or personal convictions. My colleague, Stanley
Milgram, has shown that more than 60 percent of the population will deliver what
they think is a series of painful electric shocks to another person even after the
victim cries for mercy, begs them to stop, and then apparently passes out. The
subjects complained that they did not want to inflict more pain but blindly obeyed
the command of the authority figure (the experimenter) who said that they must go
on. In my own research on violence, I have seen mild-mannered co-eds repeatedly
give shocks (which they thought were causing pain) to another girl, a stranger whom
they had rated very favorably, simply by being made to feel anonymous and put in a
situation where they were expected to engage in this activity.
Observers of these and similar experimental situations never predict their
outcomes and estimate that it is unlikely that they themselves would behave
similarly. They can be so confident only when they are outside the situation.
However, since the majority of people in these studies do act in nonrational,
nonobvious ways, it follows that the majority of observers would also succumb to
the social psychological forces in the situation.
With regard to prisons, we can state that the mere act of assigning labels to
people and putting them into a situation where those labels acquire validity and
meaning is sufficient to elicit pathological behavior. This pathology is not
predictable from any available diagnostic indicators we have in the social sciences,
and is extreme enough to modify in very significant ways fundamental attitudes and
behavior. The prison situation, as presently arranged, is guaranteed to generate
severe enough pathological reactions in both guards and prisoners as to debase their
humanity, lower their feelings of self-worth, and make it difficult for them to be part
of a society outside of their prison.
For years our national leaders have been pointing to the enemies of freedom, to
the fascist or communist threat to the American way of life. In so doing they have
overlooked the threat of social anarchy that is building within our own country
without any outside agitation. As soon as a person comes to the realization that he is
being imprisoned by his society or individuals in it, then, in the best American
tradition, he demands liberty and rebels, accepting death as an alternative. The third
alternative, however, is to allow oneself to become a good prisoner-docile,
cooperative, uncomplaining, conforming in thought, and complying in deed.
Our prison authorities now point to the militant agitators who are still vaguely
referred to as part of some communist plot, as the irresponsible, incorrigible
troublemakers. They imply that there would be no trouble, riots, hostages, or deaths
if it weren’t for this small band of bad prisoners. In other words, then, everything
would return to “normal” again in the life of our nation’s prisons if they could break
these men.
The riots in prison are coming from within—from within every man and woman
who refuses to let the system turn them into an object, a number, a thing, or a no-
thing. It is not communist-inspired, but inspired by the spirit of American freedom.
No man wants to be enslaved. To be powerless, to be subject to the arbitrary exercise
of power, to not be recognized as a human being is to be a slave.
To be a militant prisoner is to become aware that the physical jails are but more
blatant extensions of the forms of social and psychological oppression experienced
daily in the nation’s ghettos. They are trying to awaken the conscience of the nation
to the ways in which the American ideals are being perverted, apparently in the
name of justice but actually under the banner of apathy, fear, and hatred. If we do
not listen to the pleas of the prisoners at Attica to be treated like human beings, then
we have all become brutalized by our priorities for property rights over human
rights. The consequence will not only be more prison riots but a loss of all those
ideals on which this country was founded.
The public should be aware that they own the prisons and that their business is
failing. The 70 percent recidivism rate and the escalation in severity of crimes
committed by graduates of our prisons are evidence that current prisons fail to
rehabilitate the inmates in any positive way. Rather, they are breeding grounds for
hatred of the establishment, a hatred that makes every citizen a target of violent
assault. Prisons a bad investment for us taxpayers. Until now we have not cared;
we have turned over to wardens and prison authorities the unpleasant job of keeping
people who threaten us out of our sight. Now we are shocked to learn that their
management practices have failed to improve the product and instead turn petty
thieves into murderers. We must insist upon new management or improved
operating procedures.
The cloak of secrecy should be removed from the prisons. Prisoners claim they
are brutalized by the guards; guards say it is a lie. Where is the impartial test of the
truth in such a situation? Prison officials have forgotten that they work for us, that
they are only public servants whose salaries are paid by our taxes. They act as if it is
their prison, like a child with a toy he won’t share. Neither lawyers, judges, the
legislature, nor the public is allowed into prisons to ascertain the truth unless the
visit is sanctioned by authorities and until all is prepared for their visit. I was
shocked to learn that my request to join a congressional investigating committee’s
tour of San Quentin and Soledad was refused, as was that of the news media.
There should be an ombudsman in every prison, not under the pay or control of
the prison authority, and responsible only to the courts, the state legislature, and the
public. Such a person could report on violations of constitutional and human rights.
Guards must be given better training than they now receive for the difficult job
society imposes upon them. To be a prison guard as now constituted is to be put in a
situation of constant threat from within the prison, with no social recognition from
the society at large. As was shown graphically at Attica, prison guards are also
prisoners of the system who can be sacrificed to the demands of the public to be
punitive and the needs of politicians to preserve an image. Social scientists and
business administrators should be called upon to design and help carry out this
training.
The relationship between the individual (who is sentenced by the courts to a
prison term) and his community must be maintained. How can a prisoner return to a
dynamically changing society that most of us cannot cope with after being out of it
for a number of years? There should be more community involvement in these
rehabilitation centers, more ties encouraged and promoted between the trainees and
family and friends, more educational opportunities to prepare them for returning to
their communities as more valuable members of it than they were before they left.
Finally, the main ingredient necessary to effect any change at all in prison reform,
in the rehabilitation of a single prisoner, or even in the optimal development of a
child is caring. Reform must start with people-especially people with power-
caring about the well-being of others. Underneath the toughest, society-hating
convict, rebel, or anarchist is a human being who wants his existence to be
recognized by his fellows and who wants someone else to care about whether he
lives or dies and to grieve if he lives imprisoned rather than lives free.
28 On Being Sane in Insane Places
DAVID L. ROSENHAN
abnormality are not universal.2 What is viewed as normal in one culture may be
seen as quite aberrant in another. 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. Murder is deviant. So, too, are
hallucinations. Nor does raising such questions deny the existence of the personal
anguish that is often associated with “mental illness.” Anxiety and depression exist.
Psychological suffering exists. But normality and abnormality, sanity and insanity,
and the diagnoses that flow from them may be less substantive than many believe
them to be.
On the one hand, it is not uncommon for people who violate explicit rules written into law to
find themselves enmeshed in a formal system that involves passing judgment on their fitness
to remain in society. As we saw in the preceding selection, removing people’s freedom can
thrust them into volatile situations. On the other hand, people who violate implicit rules (the
assumptions about what characterizes “normal” people) also can find themselves caught up
in a formal system that involves passing judgment on their fitness to remain in society. If
found “guilty of insanity,” they, too, are institutionalized-placed in the care of keepers who
oversee almost all aspects of their lives.
The taken-for-granted assumption in institutionalizing people who violate implicit rules is
that we are able to tell the sane from the insane. If we cannot do so, the practice itself would
be insane! In that case, we would have to question psychiatry as a mechanism of social
control. But what kind of question is this? Even most of us non-psychiatrists can tel he
difference between who is sane and who is not, can’t we? In a fascinating experiment,
Rosenhan put to the test whether or not even psychiatrists can differentiate between the sane
and the insane. As detailed in this account, the results contain a few surprises.
At its heart, the question of whether the sane can be distinguished from the insane
(and whether degrees of insanity can be distinguished from each other) is a simple
matter: Do the salient characteristics that lead to diagnoses reside in the patients
themselves or in the environments and contexts in which observers find them? From
IF SANITY AND INSANITY 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. It is commonplace, for example, to read about murder trials wherein
eminent psychiatrists for the defense are contradicted by equally eminent
psychiatrists for the prosecution on the matter of the defendant’s sanity. More
generally, there are a great deal of conflicting data on the reliability, utility, and
meaning of such terms as “sanity,” “insanity,” “mental illness,” and
“schizophrenia.”l Finally, as early as 1934, Benedict suggested that normality and
Bleuler, through Kretschmer, through the formulators of the recently revised
Diagnostic and Statistical Manual of the American Psychiatric Association, the
belief has been strong that patients present symptoms, that those symptoms can be
categorized, and, implicitly, that the sane are distinguishable from the insane. More
recently, however, this belief has been questioned. Based in part on theoretical and
anthropological considerations, but also on philosophical, legal, and 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 the observers and are not
valid summaries of characteristics displayed by the observed.3,4,5
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 which 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 outside 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 twelve different hospitals. Their diagnostic experiences constitute the
data of the first part of this article; the remainder is devoted to a description 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. 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 settings 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,7 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.
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. 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.8 With the exception of myself (I was the first pseudopatient and
my presence was known to the hospital administrator and chief psychologist and, so
far as I can tell, to them alone), the presence of pseudopatients and the nature of the
research program were not known to the hospital staffs.9
The settings were similarly varied. In order to generalize the findings, admission
into a variety of hospitals was sought. The twelve 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 were research-oriented, others not. Some had
good staff-patient ratios; others were quite understaffed. Only one was a strictly
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 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 voices were unfamiliar and were of the
same sex as the pseudopatient. The choice of these symptoms was occasioned by
their apparent similarity to existential symptoms. Such symptoms are alleged to arise
from painful concerns about the perceived meaninglessness of one’s life. It is as if
the hallucinating person were saying, “My life is empty and hollow.” The choice of
these symptoms was also determined by the absence of a single report of existential
psychoses in the literature.
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
Pseudopatients and Their Settings
The eight pseudopatients were a varied group. One was a psychology graduate
student in his twenties. The remaining seven were older and “established.” Among
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
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 sanity, 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. Indeed, their shared fear was that they would be
immediately exposed as frauds and greatly embarrassed. Moreover, many of them
had never visited a psychiatric ward; even those who had, nevertheless had 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.
Apart from that short-lived nervousness, the pseudopatient behaved on the ward
as he “normally” behaved. The pseudopatient spoke to patients and staff as he might
ordinarily. Because there is uncommonly little to do on a psychiatric ward, he
attempted to engage others in conversation. When asked by 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 (which was not
swallowed), and 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 ward, its patients, and the staff. Initially these notes were written
“secretly,” but as it soon became clear that no one much cared, they were
subsequently written on standard tablets of paper in such public places as the
dayroom. 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. The psychological stresses associated with hospitalization were
considerable, and all but one of the pseudopatients desired to be discharged almost
Despite their public “show” of sanity, the pseudopatients were never detected.
Admitted, except in one case, with a diagnosis of schizophrenia,10 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 seven to fifty-two
days, with an average of nineteen days. The pseudopatients were not, in fact,
carefully observed, but this failure clearly 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
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 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 nineteen 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 so readily to massive errors of this sort cannot be a very reliable one.
patients to “detect” the pseudopatients’ 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.11 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.12 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 10-point scale was used, with a 1 and 2 reflecting
high confidence that the patient was a pseudopatient.
Judgments were obtained on 193 patients who were admitted for psychiatric
treatment. All staff who had had sustained contact with or primary responsibility for
The Stickiness of Psychodiagnostic Labels
Beyond the tendency to call the healthy sick-a tendency that accounts better for
diagnostic behavior on admission than it does for such behavior after a lengthy
period of 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. The tag profoundly colors others’
perceptions of him and his behavior.
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. Gestalt
psychology made this point vigorously, and Asch13 demonstrated that there are
“central” personality traits (such as “warm” versus “cold”) which are so powerful
that they markedly color the meaning of other information in forming an impression
of a given personality.14 “Insane,” “schizophrenic,” “manic-depressive,” and
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 schizophrenic reaction.15
Nothing of an ambivalent nature had been described in relations with parents,
spouse, or friends. To the extent that ambivalence could be inferred, it was probably
not greater than is found in all human relationships. It is true the pseudopatient’s
relationships with his parents changed over time, but in the ordinary context that
would hardly be remarkable— indeed, it might very well be expected. 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.”
“crazy” are probably among the most powerful of such central traits. Once a person
is designated abnormal, all of his other behaviors and characteristics are colored by
that label. Indeed, that label is so powerful that many of the pseudopatients’ normal
behaviors were overlooked entirely or profoundly misinterpreted. Some examples
may clarify this issue.
Earlier I indicated that there were no changes in the pseudopatient’s personal
history and current status behond those of name, employment, and, where necessary,
vocation. Otherwise, a veridical description of personal history and circumstances
was offered. Those circumstances were not psychotic. How were they made
consonant with the diagnosis of psychosis? Or were those diagnoses modified in
such a way as to bring them into accord with the circumstances of the
pseudopatient’s life, as described by him?
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.
All pseudopatients took extensive notes publicly. Under ordinary circumstances,
such behavior would have raised questions in the minds of observers, as, in fact, it
did among patients. Indeed, it seemed so certain that the notes would elicit suspicion
that elaborate precautions were taken to remove them from the ward each day. But
the precautions proved needless. The closest any staff member came to questioning
these notes occurred when one pseudopatient asked his physician what kind of
medication he was receiving and began to write down the response. “You needn’t
write it,” he was told gently. “If you have trouble remembering, just ask me again.”
If no questions were asked of the pseudopatients, how was their writing
interpreted? Nursing records for three patients indicate that the writing was seen as
an aspect of their pathological behavior. “Patient engages in writing behavior” was
the daily nursing comment on one of the pseudopatients who was never questioned
about his writing. 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.
One tacit characteristic of psychiatric diagnosis is that it locates the sources of
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
adolescence. A distant relationship to 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
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. For example, one kindly nurse
found a pseudopatient pacing the long hospital corridors. “Nervous, Mr. X?” she
asked. “No, bored,” he said.
The notes kept by pseudopatients are full of patient behaviors that were
misinterpreted by well-intentioned staff. Often enough, a patient would go “berserk”
because he had, wittingly or unwittingly, been mistreated by, say, an attendant. A
nurse coming upon the scene would rarely inquire even cursorily into the
environmental stimuli of the patient’s behavior. Rather, she assumed that his upset
derived from his pathology, not from his present interactions with other staff
members. Occasionally, the staff might assume that the patient’s family (especially
when they had recently visited) or other patients had stimulated the outburst. But
never were the staff found to assume that one of themselves or the structure of the
hospital had anything to do with a patient’s behavior. One psychiatrist pointed to a
group of patients who were sitting outside the cafeteria entrance half an hour before
lunchtime. To a group of young residents, he indicated that such behavior was
characteristic of the oral-acquisitive nature of the syndrome. It seemed not to occur
to him that there were very few things to anticipate in the psychiatric hospital
besides eating
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 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.15
The inferences to be made from these matters are quite simple. Much as Zigler
and Phillips have demonstrated that there is enormous overlap in the symptoms
presented by patients who have been variously diagnosed,16 so there is enormous
overlap in the behaviors of the sane and the insane. 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 Mischel17 has pointed out,
to limit our discussions to behaviors, the stimuli that provoke them, and their
correlates.
It is not known why powerful impressions of personality traits, such as “crazy” or
“insane,” arise. Conceivably, when the origins of and stimuli that give rise to a
behavior are remote or unknown, or when the behavior strikes us as immutable, trait
labels regarding the behavior arise. When, on the other hand, the origins and stimuli
are known and available, discourse is limited to the behavior itself. Thus, 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….
The
Consequences
of
Labeling
and
Depersonalization
Whenever the ratio of what is known to what needs to be known approaches zero,
we tend to invent “knowledge” and assume that we understand more than we
actually do. We seem unable to acknowledge that we simply don’t know. The needs
for diagnosis and remediation of behavioral and emotional problems are enormous.
But rather than acknowledge that we are just embarking on understanding, we
continue to label patients “schizophrenic,” “manic-depressive,” and “insane,” as if in
those words we had captured the essence of understanding. 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 insanity from sanity. 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? How many have feigned insanity in order to
avoid the criminal consequences of their behavior, and, conversely, how many
would rather stand trial than live interminably in a psychiatric hospital — but are
wrongly thought to be mentally ill? How many have been stigmatized by well-
intentioned, but nevertheless erroneous, diagnoses? On the last point, recall again
that a “type 2 error” in psychiatric diagnosis does not have the same consequences it
does in medical diagnosis. 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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