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On Being Sane in Insane Places Article Review

The article On Being Sane in Insane Places, by David Rosenhan discusses the results and

implications of a study that followed pseudopatients experiences within a psychiatric facility.

The implications of the study are then applied to society, with some frightening realizations.

The article first discusses how we, as a society, differentiate the sane from the insane.

Depending on the culture, different social norms define normality, however there are some

behaviors that are always deemed, as Rosenhan expressed, deviant, such as murder or

hallucinations. Depression and anxiety are widely observed and believed however defining

insanity is more subjective and non-substantive. The other then poses a question to the reader

whether what defines insanity is within a patient or in the environment and context in which the

observer finds them. The DSM defines insanity as markedly different than sanity, however the

author capitulates that it is more difficult to define either of those terms.

By using sane people as a control in institutions, this would give clear data that would

lead to the detection of either a true definition of sanity/insanity (if the pseudopatient was

discovered) or determine that is not easy to define these terms. The experiment was set up such

that there were 8 pseudopatients that admitted themselves, each with the same set of existential

symptoms that were never indicated as markers in any literature for diagnosis, all at different

facilities. After admission, all the symptoms of the pseudopatients ceased, and all the

pseudopatients were as cooperative and normal as possible. However, they were all either

labeled schizophrenic in remission or, in one case, just schizophrenic. And once labeled insane

they were treated as if they were not, nor have never been sane.
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In these cases, diagnosis was not made after careful observation or long term symptoms;

the diagnoses were made from the initial interview and then every future observation was

colored to fit in that diagnosis. The author postulates that this may be due to the inherent bias

within medical professionals that it is better to diagnose someone who is not sick than to not treat

someone when they are indeed, unhealthy. Another smaller experiment was performed that

demonstrated that when told there would be fake patients trying to be admitted, 19 real patients

were labeled by both a psychiatrist and another staff member that they were confident the patient

was a sane person trying to be admitted. However, no such pseudopatients tried to enter the

institution. This came from the professionals feeling that if they were wrong they would lose

prestige or that they had to prove their diagnostic acumen. Therefore, it was shown that there

are issues with the current practices in psychiatric facilities, and in defining insanity.

After diagnosed all the patients behaviors were looked at through a lens that they were

insane, rather than objective observation. For example, one patient related to a staff member that

he had a close relationship with his mother growing up and then it cooled down and he had a

distance relationship with his father as a child and they became much closer as an adult. This is a

common situation some men find themselves in, as a child the mother is normally the primary

caregiver and therefore a child is closer with his mother. However, as he grows up, he develops

more in common with his father and therefore their relationship becomes closer and he loses

similarities with his mother. This situation was changed to fit his diagnosis as schizophrenic, by

the staff, and stated that this situation displayed an ambivalence toward relationships due to

inconsistent emotional relationships.

Once labeled with a diagnosis, patients are treated and almost encouraged to act within

the parameters of the diagnosis. All behaviors are confirmation of the diagnosis, which cause a
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self-fulfilling prophecy such that even if a patient is not insane to begin with, even normal

things he or she does, cause him or her to think that what they are doing is insane, thereby

become insane. The pseudopatients noticed that the staff attributed all their behaviors to the

disease whereas the other patients in the facility could identify the pseudopatients as not crazy.

For example, the staff attributed the pseudopatients writing down notes as writing behavior,

bored pacing as anxiety and even eating as oral acquisitive behavior. This has me believe that

the more interaction with the patient, the more likely it would have been that the psychiatrist

would have noticed the pseudopatient was in fact sane.

After diagnosis, treatment and interactions changed. The pseudopatients were no longer

treated as people, rather, they were frequently ignored. The author said that at one point it felt

like the staff treated the patients as if they were contagious; very limited contact and when there

was contact, it was dismissive. For example, when a pseudopatient would ask the staff a

question, the staff would either give a curt, non-committal response or they would ignore the

question entirely. This kind of dismissive behavior depersonalizes the patients and that feeling of

being invisible causes them to become even more invisible to the staff in a cycle that severely

damages the patient. Some pseudopatients even witnessed a staff member beating an actual

patient. The staff would only hit the patients if another staff member was not present. A feeling

of powerlessness pervaded throughout the pseudopatients stay, and is summed up by the

authors take on the staff beatings, Staff are credible witnesses. Patients are not. Staff would

clearly point and talk about patients behind their glass viewing cages.

Another practice in these facilities that I found interesting was that for the 8

pseudopatients, over 2100 pills were given out, with varying medications, showing the

nonuniform treatment of the patients over different facilities when they all presented with the
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same symptoms. Another interesting anecdote concerned the pseudopatients throwing away their

pills; when they flushed them down the toilet, other patients pills were also there but there was

never a concern in testing whether the patient was actually taking their pills so long as the patient

was behaving.

Near the end of what the pseudopatients could endure, the subjects began trying to re-

individualize themselves. At the onset of the experiment, patients with psychology backgrounds

were given different backgrounds as to not arouse suspicion. However, by the end of the

experiment, the psuedopatients would talk about how they were going to go to psychology

graduate school when they got out.

The author gives four theories of why the depersonalization arises in these facilities.

First, there is an inherent bias against the mentally ill. Second, there is a hierarchical structure

within these facilities in which the most powerful person spends the least amount of time with

the patients thereby teaching his or her subordinates to interact with the patients less. Third, with

a smaller staff, there is less time for individual contact, however there is the same amount of

record keeping regardless of how long was spent with a patient. And finally, that there is a high

reliance on psychotropic drugs. Psychiatric professionals may believe that the drugs work so that

contact is redundant or unnecessary. Regardless of the reason, depersonalization is an issue in

psychiatric facilities across the world, and this study illuminated the issues in our current mental

health system.

In summation, 8 pseudopatients were admitted into various mental health facilities and all

diagnosed based upon their first interview. They were subsequently viewed with a lens that

confirmed the diagnoses and they were treated as if they were not human, or not there at all.
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Rosenhan brought to light a large issue with our current mental health system and hopefully,

changes in practice will be brought about by his observations.

Personally, this experiment reminded me of the Stanford Prison Experiment, in that many

of the patients assumed the role of an insane person after being told that all their experience

aligned with their diagnosis. In the Stanford Prison Experiment, people were either assigned the

role as inmate or guard and after a few weeks, the subjects assumed the prototype of their

position, the guards became brutal and depersonalized the inmates and the inmates, much like the

pseudopatients became depersonalized. I am curious as to whether the similarities stem from the

fact that the mentally ill were first treated (contained) in prisons. This also raises alarm from

me in that we should not be treating our prisoners and mentally ill the same and furthermore

neither should be subjected to depersonalization as it does not help anyone.