backtoiam » Sun Dec 06, 2015 10:56 pm wrote:Nevertheless, an honest account of my experience would doubtlessly garner the same qualification of "psychosis" should I reveal it to the wrong parties...
True that. Being honest can get you sucked into a mental healthcare systematic nightmare of epic proportion because the mental healthcare system is so corrupted.
There are a lot of really good and well meaning people working in the mental healthcare system that do not understand that they are perpetuating a system that might not be serving the best interest of people that really need quality mental healthcare.
Some of the questionaires being used in the mental health care system are downright devious.
"Do you ever worry about being able to pay your bills?"
"Well yes sometimes I do."
Diagnosis severe financial stress and blah blah etc....
Sometimes its better to keep your mouth shut...because if you get roped into the system you might be there a while. That was attempted on me.
If you think about it, it is attempted on everybody. All you have to do is be alive and breathing and the system will attempt to diagnose you with something and write you a prescription for the meds.
Should a person be unfortunate enough to have really serious problems they need help with quality help might be hard to find and possibly risky because the system will use that taxpayer money to keep you in the system.
ON 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. 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" (1). Finally, as early as 1934,
Benedict suggested that normality and 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 normahty and abnormality, sanity
and insanity, and the diagnoses that flow from them may be less
substantive than many 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 dis-
tinguished 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
Bleuler, through Kretchmer, 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--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 sanityof 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 beenoutside of the
hospital, and that it had never been previously suggested that he be
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 (6). 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.
Pseudopatients and Their Settings
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 psuedonyms, 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 was 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 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
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 unfamilar 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 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 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 re
ports 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 (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 7 to 52 days with an
average ofl9 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 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 (5). 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 rea
sons 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 3 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 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 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 so readily to massive errors of
this sort cannot be a very reliable one.
...
SUMMARY AND CONCLUSIONS
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 countertherapeutic.
I do not, even now, understand this problem well enough to perceive
solutions. But two matters seem to have some promise. The first
concerns the proliferation of community mental health facilities, of
crisis intervention centers, of the human potential movement, and of
behavior therapies that, for all of their own problems, tend to avoid
psychiatric labels, to focus on specific problems and behaviors, and
to retain the individual in a relatively nonpejorative environment.
Clearly, to the extent that we refrain from sending the distressed to
insane places, our impressions of them are less likely to be distorted.
(The risk of distorted perceptions, it seems to me, is always present,
since we are much more sensitive to an individual's behaviors and
verbalizations than we are to the subtle contextual stimuli that often
promote them. At issue here is a matter of magnitude. And, as I have
shown, the magnitude of distortion is exceedingly high in the extreme
context that is a psychiatric hospital.)
The second matter that might prove promising speaks to the need
to increase the sensitivity of mental health workers and researchers
to the Catch 22 position of psychiatric patients. Simply reading materials
in this area will be of help to some such workers and researchers.
For others, directly experiencing the impact of psychiatric hospitalization
will be of enormous use. Clearly, further research into the
social psychology of such total institutions will both facilitate treatment
and deepen understanding.
I and the other pseudopatients in the psychiatric setting had distinctly
negative reactions. We do not pretend to describe the subjective
experiences of true patients. Theirs may be different from ours,
particularly with the passage of time and the necessary process of
adaptation to one's environment. But we can and do speak to the
relatively more objective indices of treatment within the hospital. It
could be a mistake, and a very unfortunate one, to consider that what
happened to us derived from malice or stupidity on the part of the
staff. Quite the contrary, our overwhelming impression of them was
of people who really cared, who were committed and who were uncommonly
intelligent. Where they failed, as they sometimes did painfully,
it would be more accurate to attribute those failures to the
environment in which they, too, found themselves than to personal
callousness. Their perceptions and behavior were controlled by the
situation, rather than being motivated by a malicious disposition. In
a more benign environment, one that was less attached to global
diagnosis, their behaviors and judgments might have been more benign
and effective.
