On Being Sane in Insane Places
Introduction
The central question is whether sanity and insanity are distinguishable, and if degrees of insanity can be differentiated. "If sanity and insanity exist, how shall we know them?"
The core issue: do the characteristics leading to psychiatric diagnoses reside within the patients themselves or in the environments in which they are observed? "Do the attributes that are said to be associated with diagnosis reside in the patients themselves or in the environments in which observers find them?"
Traditional belief: patients exhibit symptoms that can be categorized, allowing the sane to be distinguished from the insane. Those with "manifestsymptoms, that is, that the symptomatic behavior of the disturbed is considered qualitatively different from the behavior of the sane."
A growing view questions the validity of psychological categorization of mental illness, suggesting it may be useless or harmful. "The view is growing that psychological categorization of mental illness is useless at best and downright harmful, misleading, and pejorative at worst."
Experiment: Normal individuals (pseudopatients) were admitted to psychiatric hospitals to determine if their sanity would be detected.
Pseudopatients and Their Settings
Eight sane individuals (graduate student, psychologists, pediatrician, psychiatrist, painter, and housewife) gained admission to 12 different hospitals. "Eight relatively normal people gained secret admission to 12 different psychiatric hospitals."
Settings varied: old, new, research-oriented, understaffed, state-funded, and private hospitals across five states. "The hospitals represented a wide range of ages, sizes, types, and degrees of staffing. Some were old and shabby, some new and plush. Some were research-oriented, others not."
Pseudopatients reported hearing voices saying "empty," "hollow," and "thud," chosen for their similarity to existential symptoms. "The single symptom manifested by all of the pseudopatients was that of hearing voices. When asked what the voices said, they were told that the voices were unclear, but that they seemed to be saying 'empty,' 'hollow,' and 'thud.'"
Beyond symptoms and falsified personal information, the pseudopatients presented their life histories accurately. "Beyond alleging the symptoms and falsifying name, vocation, and employment, no further alterations of person, history, or circumstances were made."
Upon admission, pseudopatients ceased simulating any symptoms and behaved normally. "Immediately upon admission to the psychiatric ward, the pseudopatient ceased simulating any symptoms of abnormality."
They engaged in conversations, responded to instructions, and documented their observations in writing. "In short, the pseudopatient behaved on the ward as he behaved prior to admission, with the one exception of writing notes."
Pseudopatients were instructed to secure their release by convincing the staff of their sanity. "The main point was to convince the staff that they were sane."
Nursing reports described the pseudopatients as "friendly," "cooperative," and exhibiting "no abnormal indications."
The Normal Are Not Detectably Sane
Despite behaving sanely, pseudopatients were not detected. Most were admitted with a diagnosis of schizophrenia and discharged with the same diagnosis "in remission." "[A]ny diagnostic process that lends itself too readily to massive errors of this sort cannot be a very reliable one."
The failure to recognize sanity was not attributed to hospital quality or lack of observation time (hospitalization ranged from 7 to 52 days, averaging 19 days). "The length of hospitalization varied from 7 to 52 days, with an average of 19 days."
Patients often recognized the pseudopatients' sanity, while staff did not. "The pseudopatients sometimes elicited suspicion from some of the other patients—'You're not crazy. You're a journalist, or a professor [referring to the continual note-taking].'"
Physicians are more inclined to diagnose a healthy person as sick (type 2 error) due to the potential dangers of misdiagnosing illness. "It is clearly more dangerous to misdiagnose illness than health."
Psychiatric diagnoses carry personal, legal, and social stigmas, making the tendency to diagnose the sane as insane particularly problematic. "The social consequences of receiving the diagnosis of mental illness are grave."
Experiment at a research and teaching hospital: Staff were informed that pseudopatients would attempt admission, and they were asked to rate patients on the likelihood of being a pseudopatient. "Each staff member was asked to judge each patient as to the likelihood that the patient was a pseudopatient."
Forty-one patients were suspected of being pseudopatients by at least one staff member with high confidence. However, no actual pseudopatients were sent during this period. "Judgments were obtained on 193 patients who were admitted for psychiatric treatment. All staff members had been told that some—time during the 3 months would be pseudopatients. Forty-one patients were alleged to be pseudopatients by at least one staff member."
The Stickiness of Psychodiagnostic Labels
Once labeled schizophrenic, the pseudopatients' behaviors were interpreted through the lens of that label. "The tendency to designate sane people as insane can be reversed when the stakes (in terms of consequences) are high."
Normal behaviors were either overlooked or misinterpreted to align with the diagnosis. "[M]any of their behaviors were secondary to living in an environment that demanded conformity to an alien and incomprehensible set of norms."
Example: A pseudopatient's history of relationships was distorted to fit a popular theory of schizophrenic dynamics. "[A] record of amicable relationships with women was described as promiscuous. Almost any activity that the pseudopatient engaged in could then be tied to the diagnosis of schizophrenia."
Note-taking, a normal activity, was viewed as pathological behavior. "The note-taking was now described as 'writing behavior' and was related directly to the diagnosis of schizophrenia."
The study highlights the tendency to attribute behavior to the individual's disorder rather than environmental factors. "[I]n the context of a psychiatric hospital, actions that would normally be viewed as unremarkable were seen as evidence of mental illness."
The Experience of Psychiatric Hospitalization
Attitudes toward the mentally ill are characterized by fear, hostility, and dread. "[M]ental patients are likely to be avoided by ordinary citizens."
Staff and patients are strictly segregated in psychiatric hospitals. "They rarely approached the attendants, and the attendants in turn spent most of their time talking to each other, rather than to patients."
The average time attendants spent outside the "cage" was 11.3 percent, including chores. "The attendants spent an average of 11.3 percent of their time out of the cage, 9.4 percent of the time during the day and late afternoon, and 6.7 percent of the time at night."
Nurses emerged from the cage 11.5 times per shift during the day and 9.4 times during the late afternoon and night. "On the average, nurses emerged from the cage 11.5 times during the day shift, and 9.4 times during the late afternoon and night shifts."
Physicians emerged on the ward 6.7 times per day on average. "Physicians emerged from the ward on the average of 6.7 times per day."
Staff avoided patient-initiated contact. "The attendants spent most of their time talking to each other, rather than to patients."
Patients experienced powerlessness and depersonalization, including instances of abuse. "Powerlessness was evident everywhere. The patients were deprived of many of their legal rights by dint of their psychiatric hospitalization."
Personal privacy was minimal, and hygiene was often monitored. "The patients were often exposed to the view of others on the ward. Hygiene was often monitored."
Pseudopatients were administered nearly 2100 pills, most of which were discarded unnoticed. "[T]he pseudopatients were given approximately 2100 pills. Only two were swallowed by the group."
Sources of Depersonalization
Attitudes toward the mentally ill, hierarchical structure, financial strains, and reliance on medication contribute to depersonalization. "Several sources of depersonalization can be identified."
Average daily contact with doctoral staff ranged from 3.9 to 25.1 minutes. "Time spent by staff on the ward was limited. Contact with the doctoral staff averaged 3.9 minutes per day."
Consequences of Labeling and Depersonalization
Reliance on diagnostic labels without sufficient understanding leads to misused labels. "The heavy reliance upon psychodiagnostic labels carries with it the unfortunate consequence of misuse. Labels tend to 'stick,' and are often applied reflexively."
The study raises concerns about the number of sane individuals unrecognized in psychiatric institutions and the consequences of erroneous diagnoses. "How many people are sane but not recognized as such in our psychiatric institutions? How many have been needlessly stripped of their privileges and rights, and how long must they endure?".
The hospital environment can induce insane behaviors that are a product of depersonalization instead of the patient's illness. "[I]n general, the stress of the hospital environment may lead patients to behave in ways that perpetuate the label of sickness."
Goffman refers to the process of socialization to these institutions as mortification
Summary and Conclusions
The study concludes that psychiatric hospitals cannot distinguish the sane from the insane. "It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals."
The hospital environment contributes to powerlessness, depersonalization, and self-labeling. "The hospital itself induces behavior that is suggestive of mental illness."
Community mental health facilities and behavior therapies offer a more promising approach. "If treatment is to be effective, it must not reside in the institution alone."
Increasing the sensitivity of mental health workers through direct experience and further research is essential. "[T]hese results have implications for the kind of training that should be given to mental health workers, particularly those who work in institutions."
The authors stress the staff's commitment and intelligence, attributing failures to the environment rather than malice. "It is important to emphasize that we do not assume malice on the part of the staff. Quite the contrary, their dedication to what they conceive to be their jobs is considerable."
Key Concepts
Type 1 Error: False negative; classifying a sick person as healthy.
Type 2 Error: False positive; classifying a healthy person as sick. "It is clearly more dangerous to misdiagnose illness than health."
Mortification: Goffman's term for the socialization process in total institutions like psychiatric hospitals, involving depersonalization and loss of identity.