Professional Documents
Culture Documents
Author(s): D. L. Rosenhan
Source: Science , Jan. 19, 1973, New Series, Vol. 179, No. 4070 (Jan. 19, 1973), pp. 250-
258
Published by: American Association for the Advancement of Science
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diagnosis of schizophrenia (10), each healthy (a false negative, type 1). The
was discharged with a diagnosis of reasons for this are not hard to find:
schizophrenia "in remission." The label it is clearly more dangerous to mis- The Stickiness of
"in remission" should in no way be diagnose illness than health. Better to
Psychodiagnostic Labels
dismissed as a formality, for at no timeerr on the side of caution, to suspect
during any hospitalization had any illness even among the healthy. Beyond the tendency to call the
question been raised about any pseudo- But what holds for medicine does healthy sick-a tendency that accounts
patient's simulation. Nor are there any not hold equally well for psychiatry. better for diagnostic behavior on admis-
indications in the hospital records thatMedical illnesses, while unfortunate, sion are
than it does for such behavior after
the pseudopatient's status was suspect. not commonly pejorative. Psychiatric a lengthy period of exposure-the data
Rather, the evidence is strong that, oncediagnoses, on the contrary, carryspeak withto the massive role of labeling in
252 SCIENCE, VOL. 179
Psychiatric
Psychiatric hospitals
hospitals University campus University medical center
(nonmedical)
-__ _______ _____ (nonmedical) Physicians
Contact (2) (4) (5)
(1) Nurses (3) (4) (5) (6)
()Psychiatrs aNurses (3)l "Looking
Psycaattendants Fapsychiatri
attendants
Responses
Moves on, head averted (%) 71 88 0 0 0 0
Makes eye contact (%) 23 10 0 11 0 0
Pauses and chats (%) 2 2 0 11 0 10
Stops and talks (%) 4 0.5 100 78 100 90
Mean number of questions
answered (out of 6) * * 6 3.8 4.8 4.5
Respondents (No.) 13 47 14 18 15 10
Attempts (No.) 185 1283 14 18 15 10
* Not applicable.
most power have least to do with pa- ritated. In examining these data, re- ". .. to the medical school?").
school:
tients, and those with the least power member that the behavior of the 5) "Is it difficult to get in?"
are most involved with them. Recall, pseudopatients was neither bizarre nor 6) "Is there financial aid?"
however, that the acquisition of role- disruptive. One could indeed engage Without
in exception, as can be seen in
appropriate behaviors occurs mainly good conversation with them. Table 1 (column 3), all of the questions
through the observation of others, with The data for these experiments are were answered. No matter how rushed
the most powerful having the most in- shown in Table 1, separately for physi- they were, all respondents not only
fluence. Consequently, it is understand- cians (column 1) and for nurses and maintained eye contact, but stopped to
able that attendants not only spend attendants (column 2). Minor differ- talk. Indeed, many of the respondents
more time with patients than do any ences between these four institutions went out of their way to direct or take
other members of the staff-that is re- were overwhelmed by the degree to the questioner to the office she was
quired by their station in the hierarchy which staff avoided continuing contacts seeking, to try to locate "Fish Annex,"
-but also, insofar as they learn fromthat patients had initiated. By far, their or to discuss with her the possibilities
their superiors' behavior, spend as little
most common response consisted of of being admitted to the university.
time with patients as they can. Attend-either a brief response to the question, Similar data, also shown in Table 1
ants are seen mainly in the cage, which offered while they were "on the move" (columns 4, 5, and 6), were obtained
is where the models, the action, and and with head averted, or no responsein the hospital. Here too, the young
the power are. at all.
lady came prepared with six questions.
I turn now to a different set of The encounter frequently took the After the first question, however, she
studies, these dealing with staff re- following bizarre form: (pseudopatient) remarked to 18 of her respondents
sponse to patient-initiated contact. It "Pardon me, Dr. X. Could you tell me (column 4), "I'm looking for a psy-
has long been known that the amount when I am eligible for grounds priv- chiatrist," and to 15 others (column
of time a person spends with you can ileges?" (physician) "Good morning, 5), "I'm looking for an internist." Ten
be an index of your significance to him. Dave. How are you today?" (Moves offother respondents received no inserted
If he initiates and maintains eye con- without waiting for a response.) comment (column 6). The general de-
tact, there is reason to believe that he It is instructive to compare these gree of cooperative responses is con-
is considering your requests and needs.data with data recently obtained at siderably higher for these university
If he pauses to chat or actually stopsStanford University. It has been alleged groups than it was for pseudopatients
and talks, there is added reason to infer that large and eminent universities are
in psychiatric hospitals. Even so, differ-
that he is individuating you. In fourcharacterized by faculty who are so ences are apparent within the medical
hospitals, the pseudopatient approachedbusy that they have no time for stu- school setting. Once having indicated
the staff member with a request whichdents. For this comparison, a young that she was looking for a psychiatrist,
took the following form: "Pardon me, lady approached individual faculty mem- the degree of cooperation elicited was
Mr. [or Dr. or Mrs.] X, could you tellbers who seemed to be walking pur- less than when she sought an internist.
me when I will be eligible for groundsposefully to some meeting or teaching
privileges?" (or " . . . when I will be engagement and asked them the fol-
presented at the staff meeting?" or ". . .lowing six questions. Powerlessness and Depersonalization
when I am likely to be discharged?"). 1) "Pardon me, could you direct me
While the content of the question variedto Encina Hall?" (at the medical Eye contact and verbal contact re-
according to the appropriateness of theschool: ". . . to the Clinical Research flect concern and individuation; their
target and the pseudopatient's (appar-Center?"). absence, avoidance and depersonaliza-
ent) current needs the form was al- 2) "Do you know where Fish Annex tion. The data I have presented do not
ways a courteous and relevant request is?" (there is no Fish Annex at Stan- do justice to the rich daily encounters
for information. Care was taken never ford). that grew up around matters of deper-
to approach a particular member of the3) "Do you teach here?" sonalization and avoidance. I have rec-
staff more than once a day, lest the4) "How does one apply for admis- ords of patients who were beaten by
staff member become suspicious or ir-
sion to the college?" (at the medical staff for the sin of having initiated ver-
19 JANUARY 1973
255
you m-----f-----s, out of bed!" with regard to medications. All told, ambivalence leads, in this instance as
Neither anecdotal nor "hard" data the pseudopatients were administered in others, to avoidance.
nearly
can convey the overwhelming sense of 2100 pills, including Elavil, Second, and not entirely separate,
powerlessness which invades the Stelazine,
indi- Compazine, and Thorazine, the hierarchical structure of the psy-
to name
vidual as he is continually exposed to but a few. (That such a variety chiatric hospital facilitates depersonali-
the depersonalization of the psychiatric of medications should have been ad- zation. Those who are at the top have
hospital. It hardly matters whichministeredpsy- least to do with patients, and their be-
to patients presenting identi-
chiatric hospital-the excellent public cal symptoms is itself worthy of note.) havior inspires the rest of the staff.
ones and the very plush private hospital Only two were swallowed. The rest Average daily contact with psychia-
were better than the rural and shabby were either pocketed or deposited trists,in psychologists, residents, and
ones in this regard, but, again, the thetoilet. The pseudopatients were not physicians combined ranged from 3.9
features that psychiatric hospitals alone
hadin this. Although I have no pre- to 25.1 minutes, with an overall mean
in common overwhelmed by far cise theirrecords on how many patients of 6.8 (six pseudopatients over a total
apparent differences. rejected their medications, the pseudo- of 129 days of hospitalization). In-
Powerlessness was evident every- patients frequently found the medica- cluded in this average are time spent
where. The patient is deprived of manyof other patients in the toilet in the admissions interview, ward meet-
tions
of his legal rights by dint of his before psy- they deposited their own. As ings in the presence of a senior staff
chiatric commitment (21). He is shorn long as they were cooperative, their member, group and individual psycho-
behavior and the pseudopatients' own therapy contacts, case presentation con-
of credibility by virtue of his psychiatric
label. His freedom of movement is re- in this matter, as in other important ferences, and discharge meetings.
stricted. He cannot initiate contact with matters, went unnoticed throughout. Clearly, patients do not spend much
the staff, but may only respond to such Reactions to such depersonalization time in interpersonal contact with doc-
overtures as they make. Personal pri-among pseudopatients were intense. Al- toral staff. And doctoral staff serve as
vacy is minimal. Patient quarters and though they had come to the hospital models for nurses and attendants.
possessions can be entered and ex- as participant observers and were fully There are probably other sources.
amined by any staff member, for what- aware that they did not "belong," they Psychiatric installations are presently in
ever reason. His personal history and nevertheless found themselves caught serious financial straits. Staff shortages
anguish is available to any staff member up in and fighting the process of de- are pervasive, staff time at a premium.
(often including the "grey lady" and personalization. Some examples: a grad- Something has to give, and that some-
"candy striper" volunteer) who chooses uate student in psychology asked his thing is patient contact. Yet, while
to read his folder, regardless of their wife to bring his textbooks to the hos- financial stresses are realities, too much
therapeutic relationship to him. His per- pital so he could "catch up on his can be made of them. I have the im-
sonal hygiene and waste evacuation are homework"-this despite the elaborate pression that the psychological forces
often monitored. The water closets may precautions taken to conceal his profes- that result in depersonalization are
have no doors. sional association. The same student, much stronger than the fiscal ones and
At times, depersonalization reached who had trained for quite some time that the addition of more staff would
such proportions that pseudopatients to get into the hospital, and who not correspondingly improve patient
had
had the sense that they were invisible, looked forward to the experience, "re- care in this regard. The incidence of
or at least unworthy of account. Upon membered" some drag races that hestaff meetings and the enormous
being admitted, I and other pseudo- had wanted to see on the weekend and amount of record-keeping on patients,
patients took the initial physical exami-insisted that he be discharged by that for example, have not been as sub-
nations in a semipublic room, where time. Another pseudopatient attemptedstantially reduced as has patient con-
staff members went about their own a romance with a nurse. Subsequently, tact. Priorities exist, even during hard
business as if we were not there. he informed the staff that he was ap- times. Patient contact is not a signifi-
On the ward, attendants delivered plying for admission to graduate school cant priority in the traditional psychia-
verbal and occasionally serious physical in psychology and was very likely to be tric hospital, and fiscal pressures do not
abuse to patients in the presence of admitted, since a graduate professor account for this. Avoidance and de-
other observing patients, some of whom was one of his regular hospital visitors. personalization may.
(the pseudopatients) were writing it all The same person began to engage in Heavy reliance upon psychotropic
256 SCIENCE. VOL. 179
war's impact on the people and the This year's bluntly phrased resolution The full text of the resolution is as
environment of Indochina. At the same was introduced as an "emergency mo- follows:
time, the council in effect voted its tion" by seven council delegates, includ-
The Council of the AAAS condemns
own termination by approving a new ing Everett Mendelsohn, a Harvard
the United States' continued participation
and much-discussed set of bylaws thathistorian of science and a AAAS vice in the war in Vietnam, heightened in
will drastically reduce the size of the president, and E. W. Pfeiffer, a Univer-
the post-election bombing escalation.
council and allow the general member- sity of Montana zoologist who was in- As scientists we cannot remain silent