to label all patients insane or schizophrenic on the basis of bizarre behaviors or cognitions. It seems more useful, as Mischel19 has pointed out, to limit our discussions to behaviors, the stimuli that provoke them, and their correlates.
It is not known why powerful impressions of personality traits, such as “crazy” or “insane,” arise. 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. When, on the other hand, the origins and stimuli are known and available, discourse is limited to the behavior itself. Thus, I may hallucinate because I am sleeping, or I may hallucinate because I have ingested a peculiar drug. These are termed sleep-induced hallucinations, or dreams, and drug-induced hallucinations, respectively. 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.
The Consequences of Labeling and Depersonalization
Whenever the ratio of what is known to what needs to be known approaches zero, we tend to invent “knowledge” and assume that we understand more than we actually do. We seem unable to acknowledge that we simply don’t know. The needs for diagnosis and remediation of behavioral and emotional problems are enormous. 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 had captured the essence of understanding. The facts of the matter are that we have known for a long time that diagnoses are often not useful or reliable, but we have nevertheless continued to use them. We now know that we cannot distinguish insanity from sanity. It is depressing to consider how that information will be used.
Not merely depressing, but frightening. How many people, one wonders, are sane but not recognized as such in our psychiatric institutions? How many have been needlessly stripped of their privileges of citizenship, from the right to vote and drive to that of handling their own accounts? 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? How many have been stigmatized by well-intentioned, but nevertheless erroneous, diagnoses? On the last point, recall again that a “type 2 error” in psychiatric diagnosis does not have the same consequences it does in medical diagnosis. A diagnosis of cancer that has been found to be in error is cause for celebration. But psychiatric diagnoses are rarely found to be in error. The label sticks, a mark of inadequacy forever.
Notes
1. P. Ash, Journal of Abnormal and Social Psychology 44 (1949): 272; A. T. Beck, American Journal of Psychiatry 119 (1962): 210; A. T. Boisen, Psychiatry 2 (1938): 233; J. Kreitman, Journal of Mental Science 107 (1961): 876; N. Kreitman, P. Sainsbury, J. Morrisey, J. Towers, and J. Scrivener, Journal of Mental Science 107 (1961): 887; H. O. Schmitt and C. P. Fonda, Journal of Abnormal Social Psychology 52 (1956): 262; W. Seeman, Journal of Nervous Mental Disorders 118 (1953): 541. For analysis of these artifacts and summaries of the disputes, see J. Zubin, Annual Review of Psychology 18 (1967): 373; L. Phillips and J. G. Draguns, Annual Review of Psychology 22 (1971): 447.
2. R. Benedict, Journal of General Psychology 10 (1934): 59.
3. See in this regard Howard Becker, Outsiders: Studies in the Sociology of Deviance (New York: Free Press, 1963); B. M. Braginsky, D. D. Braginsky, and K. Ring, Methods of Madness: The Mental Hospital As a Last Resort (New York: Holt, Rinehart and Winston, 1969); G. M. Crocetti and P. V. Lemkau, American Sociological Review 30 (1965): 577; Erving Goffman, Behavior in Public Places (New York: Free Press, 1964); R. D. Laing, The Divided Self: A Study of Sanity and Madness (Chicago: Quadrangle, 1960); D. L. Phillips, American Sociological Review 28 (1963): 963; T. R. Sarbin, Psychology Today 6 (1972): 18; E. Schur, American Journal of Sociology 75 (1969): 309; Thomas Szasz, The Myth of Mental Illness: Foundations of a Theory of Mental Illness (New York: Hoeber Harper, 1963). For a critique of some of these views, see W. R. Gave, American Sociological Review 35 (1970): 873.
4. Erving Goffman, Asylums (Garden City, NY: Doubleday, 1961).
5. T. J. Scheff, Being Mentally Ill: A Sociological Theory (Chicago: Aldine, 1966).
6. Data from a ninth pseudopatient are not incorporated in this report because, although his sanity went undetected, he falsified aspects of his personal history, including his marital status and parental relationships. His experimental behaviors therefore were not identical to those of the other pseudopatients.
7. A. Barry, Bellevue Is a State of Mind (New York: Harcourt Brace Jovanovich, 1971); I. Belknap, Human Problems of a State Mental Hospital (New York: McGraw-Hill, 1956); W. Caudill, F. C. Redlich, H. R. Gilmore, and E. B. Brody, American Journal of Orthopsychiatry 22 (1952): 314; A. R. Goldman, R. H. Bohr, and T. A. Steinberg, Professional Psychology 1 (1970): 427; Roche Report 1, no. 13 (1971): 8.
8. Beyond the personal difficulties that the pseudopatient is likely to experience in the hospital, there are legal and social ones that, combined, require considerable attention before entry. For example, once admitted to a psychiatric institution, it is difficult, if not impossible, to be discharged on short notice, state law to the contrary notwithstanding. I was not sensitive to these difficulties at the outset of the project, nor to the personal and situational emergencies that can arise, but later a writ of habeas corpus was prepared for each of the entering pseudopatients and an attorney was kept “on call” during every hospitalization. I am grateful to John Kaplan and Robert Bartels for legal advice and assistance in these matters.
9. However distasteful such concealment is, it was a necessary first step to examining these questions. Without concealment, there would have been no way to know how valid these experiences were; nor was there any way of knowing whether whatever detections occurred were a tribute to the diagnostic acumen of the staff or to the hospital’s rumor network. Obviously, since my concerns are general ones that cut across individual hospitals and staffs, I have respected their anonymity and have eliminated clues that might lead to their identification.
10. Interestingly, of the 12 admissions, 11 were diagnosed as schizophrenic and one, with the identical symptomatology, as manic-depressive psychosis. This diagnosis has a more favorable prognosis, and it was given by the only private hospital in our sample. On the relations between social class and psychiatric diagnosis, see A. B. Hollinghead and F. C. Redlich, Social Class and Mental Illness: A Community Study (New York: Wiley, 1958).
11. It is possible, of course, that patients have quite broad latitudes in diagnosis and therefore are inclined to call many people sane, even those whose behavior is patently aberrant. However, although we have no hard data on this matter, it was our distinct impression that this was not the case. In many instances, patients not only singled us out for attention, but came to imitate our behaviors and styles.
12. Scheff, Being Mentally Ill.
13. J. Cumming and E. Cumming, Community Mental Health 1 (1965): 135; A. Farina and K. Ring, Journal of Abnormal Psychology 40 (1965): 47; H. E. Freeman and O. G. Simmons, The Mental Patient Comes Home (New York: Wiley, 1963); W. J. Johannsen, Mental Hygiene 53 (1969): 218; A. S. Linsky, Social Psychology 5 (1970): 166.
14. S. E. Asch, Abnormal Social Psychology 41 (1946): 258; S. E. Asch, Social Psychology (New York: Prentice-Hall, 1952).
15. See also I. N. Mensch and J. Wishner, Journal of Personality 16 (1947): 188; J. Wishner, Psychological
