On Being Sane in Insane Places

Their nervousness, then, was quite appropriate to the novelty of the hospital setting, and it abated rapidly.

What is viewed as normal in one culture may be seen as quite aberrant in another.

One tacit characteristic of psychiatric diagnosis is that it locates the sources of aberration within the individual and only rarely within the complex of stimuli that surrounds him.

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.

Affective stability is absent.

Otherwise, staff keep to themselves, almost as if the disorder that afflicts their charges is somehow catching.

All of them employed pseudonyms, lest their alleged diagnoses embarrass them later.

This white 39-year-old male . . . manifests a long history of considerable ambivalence in close relationships, which begins in early childhood.

Nothing of an ambivalent nature had been described in relations with parents, spouse, or friends.

Neither anecdotal nor “hard” data can convey the overwhelming sense of powerlessness which invades the individual as he is continually exposed to the depersonalization of the psychiatric hospital.

Clearly, the meaning ascribed to his verbalizations (that is, ambivalence, affective instability) was determined by the diagnosis: schizophrenia.

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.

But it is more likely that an exquisite ambivalence characterizes their relations with psychiatric patients, such that their avowed impulses are only part of their entire attitude.

First are attitudes held by all of us toward the mentally ill – including those who treat them – attitudes characterized by fear, distrust, and horrible expectations on the one hand, and benevolent intentions on the other.

In a more benign environment, one that was less attached to global diagnosis, their behaviors and judgments might have been more benign and effective.

Often enough, a patient would go “berserk” because he had, wittingly or unwittingly, been mistreated by, say, an attendant.

When a sufficient amount of time has passed, during which the patient has done nothing bizarre, he is considered to be in remission and available for discharge.

The question is neither capricious nor itself insane.

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 cogniti

However much we may be personally convinced that we can tell the normal from the abnormal, the evidence is simply not compelling.

However much we may be personally convinced that we can tell the normal from the abnormal, the evidence is simply not compelling.

And given that he is disturbed, continuous writing must be behavioral manifestation of that disturbance, perhaps a subset of the compulsive behaviors that are sometimes correlated with schizophrenia.

By far, their most common response consisted of either a brief response to the question, offered while they were “on the move” and with head averted, or no response at all.

(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 than often promote them.

Conventional wisdom suggests that specially trained professionals have the ability to make reasonably accurate diagnoses.

And given that he is disturbed, continuous writing must be behavioral manifestation of that disturbance, perhaps a subset of the compulsive behaviors that are sometimes correlated with schizophrenia.

Staff are credible witnesses.

Indeed, many readers may see a similar pattern in their own experiences, with no markedly deleterious consequences.

But that they affect the professionals – attendants, nurses, physicians, psychologists and social workers – who treat and deal with the mentally ill is more disconcerting, both because such attitudes are self-evidently pernicious and because they a

Their perceptions and behaviors were controlled by the situation, rather than being motivated by a malicious disposition.

The facts of the case were unintentionally distorted by the staff to achieve consistency with a popular theory of the dynamics of a schizophrenic reaction.

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 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 captured the essence of understanding.

And while he says that he has several good friends, one senses considerable ambivalence embedded in those relationships also .

The staff emerge primarily for care-taking purposes – to give medication, to conduct therapy or group meeting, to instruct or reprimand a patient.

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.

If patients were powerful rather than powerless, if they were viewed as interesting individuals rather than diagnostic entities, if they were socially significant rather than social lepers, if their anguish truly and wholly compelled our sympathies

Better to err on the side of caution, to suspect illness even among the healthy.

How many have been stigmatized by well-intentioned, but nevertheless erroneous, diagnoses?

A patient who had not heard a call for medication would be roundly excoriated, and the morning attendants would often wake patients with, “Come on, you m_ _ _ _ _ f _ _ _ _ _ s, out of bed!”

The choice of these symptoms was occasioned by their apparent similarity to existential symptoms.

But it is more likely that an exquisite ambivalence characterizes their relations with psychiatric patients, such that their avowed impulses are only part of their entire attitude.

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?

Gestalt psychology made the point vigorously, and Asch[5] 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 impressi

It is as if the hallucinating person were saying, “My life is empty and hollow.”

The hierarchical organization of the psychiatric hospital has been commented on before, but the latent meaning of that kind of organization is worth noting again.

Consequently, it is understandable that attendants not only spend more time with patients than do any other members of the staff – that is required by their station in the hierarchy – but, also, insofar as they learn from their superior’s behavior,

There is by now a host of evidence that attitudes toward the mentally ill are characterized by fear, hostility, aloofness, suspicion, and dread.

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.

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.

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).

When asked by staff how he was feeling, he indicated that he was fine, that he no longer experienced symptoms.

To the extent that ambivalence could be inferred, it was probably not greater than is found in all human’s relationships.

The inferences to be made from these matters are quite simple.

I turn now to a different set of studies, these dealing with staff response to patient-initiated contact.

Care was taken never to approach a particular member of the staff more than once a day, lest the staff member become suspicious or irritated .

The hierarchical organization of the psychiatric hospital has been commented on before, but the latent meaning of that kind of organization is worth noting again.

At issue here is a matter of magnitude.

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.

Their perceptions and behaviors were controlled by the situation, rather than being motivated by a malicious disposition.

Indeed, that label is so powerful that many of the pseudopatients’ normal behaviors were overlooked entirely or profoundly misinterpreted.

How do we know precisely what constitutes “normality” or mental illness?

They were, therefore, motivated not only to behave sanely, but to be paragons of cooperation.

If anything, they strongly biased the subsequent results in favor of detecting insanity, since none of their histories or current behaviors were seriously pathological in any way.

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 pe

But that they affect the professionals – attendants, nurses, physicians, psychologists and social workers – who treat and deal with the mentally ill is more disconcerting, both because such attitudes are self-evidently pernicious and because they a

Staff shortages are pervasive, and that shortens patient contact.

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 tot

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 o

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.

All of them employed pseudonyms, lest their alleged diagnoses embarrass them later.

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 catego

The choice of these symptoms was also determined by the absence of a single report of existential psychoses in the literature.

His attempts to control emotionality with his wife and children are punctuated by angry outbursts and, in the case of the children, spankings.

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 needs for diagnosis and remediation of behavioral and emotional problems are enormous.

Admitted, except in one case, with a diagnosis of schizophrenia,[4] each was discharged with a diagnosis of schizophrenia “in remission.”

The staff emerge primarily for care-taking purposes – to give medication, to conduct therapy or group meeting, to instruct or reprimand a patient.

His freedom of movement is restricted.

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 pati

Staff and patients are strictly segregated.

Immediately upon admission to the psychiatric ward, the pseudopatient ceased simulating any symptoms of abnormality.

Psychiatric diagnoses, on the contrary, carry with them personal, legal, and social stigmas.

If anything, they strongly biased the subsequent results in favor of detecting insanity, since none of their histories or current behaviors were seriously pathological in any way.

But normality and abnormality, sanity and insanity, and the diagnoses that flow from them may be less substantive than many believe them to be.

One tacit characteristic of psychiatric diagnosis is that it locates the sources of aberration within the individual and only rarely within the complex of stimuli that surrounds him.

Clearly, the meaning ascribed to his verbalizations (that is, ambivalence, affective instability) was determined by the diagnosis: schizophrenia.

Beyond alleging the symptoms and falsifying name, vocation, and employment, no further alterations of person, history, or circumstances were made.