Being Sane In Insane Places D. L. ROSENHAN

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Being Sane in Insane PlacesIf sanity and insanity exist, how shall we knowthem?The question is neither capricious nor itselfinsane. However much we may be personallyconvinced that we can tell the normal from theabnormal, the evidence is simply not compelling. It is commonplace, for example, to readabout murder trials wherein eminent psychiatrists for the defense are contradicted by equallyeminent psychiatrists for the prosecution on thematter of the defendant's sanity. More generally, there are a great deal of conflicting data onthe reliability, utility, and meaning of such termsas "sanity," "insanity," "mental illness," and"schizophrenia"Finally, as early as 1934,Benedict suggested that normality and abnormality are not universalWhat is viewed asnormal in one culture may be seen as quite aberrant in another. Thus, notions of normality andabnormality 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 thatsome behaviors are deviant or odd. Murder isdeviant. So, too, are hallucinations. Nor doesraising such questions deny the existence of thepersonal anguish that is often associated with"mentalAnxiety and depression exist.Psychological suffering exists. But normalityand abnormality, sanity and insanity, and thediagnoses that flow from them may be less substantive than many believe them to be.At its heart, the question of whether the sanecan be distinguished from the insane (andwhether degrees of insanity can be distinguishedfrom each other) is a simple matter: do the salient characteristics that lead to diagnoses residein the patients themselves or in the environments and contexts in which observers findthem? . . . [T]he belief has been strong that patients present symptoms, that those symptomscan be categorized, and,that the saneare distinguishable from the insane. More recently, however, this belief has been questioned. . . . [T]he view has grown that psychological categorization of mental illness is uselessat best and downright harmful, misleading, andpejorative at worst. Psychiatric diagnoses, inD. L. ROSENHANthis view, are in the minds of the observers andare not valid summaries of characteristics displayed by the observedGains can be made in deciding which of theseis more nearly accurate by getting normal people(that people who do notand have neversuffered, symptoms of serious psychiatric disorders) admitted to psychiatric hospitals and thendetermining whether they were discovered tobe sane and, if so, how. If the sanity of suchpseudopatients were always detected, therewould be prima facie evidence that a sane individual can be distinguished from the insane context in which he is found.If, on the otherhand, the sanity of the pseudopatients werenever discovered, serious difficulties wouldarise for those who support traditional modesof psychiatric diagnosis. Given that the hospitalstaff was not incompetent, that the pseudopatient had been behaving as sanely as he had beenoutside of the hospital, and that it had neverbeen previously suggested that he belonged in apsychiatric hospital, such an unlikely outcomewould support the view that psychiatric diagnosis betrays little about the patient but muchabout the environment in which an observerfinds him.This article describes such an experiment.Eight sane people gained secret admission to 12hospitalsTheir diagnosticriences constitute the data of the first part ofthis article; the remainder is devoted to a description of their experiences in psychiatric institutions. . . .Pseudopatients and Their SettingsThe eight pseudopatients were a varied group.One was a psychology graduate student in hisThe remaining seven were older and "esAmong them were three psychologists, a pediatrician, a psychiatrist, a painter,and a housewife. Three pseudopatients werewomen, five were men. All of them employedpseudonyms, lest their alleged diagnoses embarrass them later. Those who were in mentalhealth professions alleged another occupation inReprinted from Science, Vol. 179 (January 1973), pp. 250-258, by permission of the publisher and author. Copyright 1973 by the American Association for the Advancement of Science.179

180The Effects of Contact with Control Agentsorder to avoid the special attentions that mightbe accorded byas a matter of courtesy orcaution, to ailing colleaguesWith the exception of myself (I was the first pseudopatient andmy presence was known to the hospital administrator and chief psychologist and, so far as I cantell, them alone), the presence of pseudopatientsand the nature of the research program was notknown to the hospital staffsThe settings were similarly varied. In order togeneralize the findings, admission into a varietyof hospitals was sought. The 12 hospitals in thesample were located in five different states onthe East and West coasts. Some were old andshabby, some were quite new. Some were research-oriented, others not. Some had goodstaff-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 universityfunds.After calling the hospital for an appointment,the pseudopatient arrived at the admissionsoffice complaining that he had been hearingvoices. Asked what the voices said, he repliedthat they were often unclear, but as far as hecould tell they saidand"thud." The voices were unfamiliar and were ofthe same sex as the pseudopatient. . . .Beyond alleging the symptoms and falsifyingvocation, and employment, no further alterations of person, history, or circumstanceswere made. The significant events of the pseudopatient's life history were presented as they hadactually occurred. Relationships with parentsandwith spouse and children, with people at work and in school, consistent with theaforementioned exceptions, were described asthey were or had been. Frustrations and upsetswere described along with joys and satisfactions. These facts are important to remember. Ifanything, they strongly biased the subsequentresults in favor of detecting sanity, since none oftheir histories or current behaviors were seriously pathological in any way.Immediately upon admission to the psychiatric ward, the pseudopatient ceased simulatingany symptoms of abnormality. In some cases,there was a brief period of mild nervousness andanxiety, since none of the pseudopatients reallybelieved that they would be admitted so easily.Indeed, their shared fear was that they would beimmediately exposed as frauds and greatly embarrassed. Moreover, many of them had nevervisited a psychiatric ward; even those who had,nevertheless had some genuine fears about whatmight 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, thepseudopatient behaved on the ward as he "normally" behaved. The pseudopatient spoke to patients and staff as he might ordinarily. Becausethere is uncommonly little to do on a psychiatricward, he attempted to engage others in conversation. When asked by staff how he was feeling,he indicated that he was fine, that he no longerexperienced symptoms. He responded to instructions from attendants, to calls for medication (which was not swallowed), and to dininginstructions. Beyond such activities as wereavailable to him on the admissions ward, hespent his time writing down his observationsabout the ward, its patients, and the staff. Initially these notes were written "secretly," butas 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 byhis own devices, essentially by convincing thethat he was sane. The psychological stressesassociated with hospitalization were considerable, and all but one of the pseudopatients desired to be discharged almost immediately afterbeing admitted. Theymotivatednot only to behave sanely, but to be paragons ofcooperation. That their behavior was in no waydisruptive is confirmed by nursing reports,which have been obtained on most of the patients. These reports uniformly indicate that thepatients were "friendly," "cooperative," and"exhibited no abnormalThe Normal Are Not Detectably SaneDespite their public "show" of sanity, thepseudopatients were never detected. Admitted,except in one case, with a diagnosis of schizophrenia [9], each was discharged with a diagnosis of schizophrenia "in remission." The label"in remission" should in no way be dismissed asa formality, for at no time during any hospitalization had any question been raised about any

Being Sane in Insane Places 181pseudopatient's simulation. Nor are there anyindications in the hospital records that thepseudopatient's status was suspect. Rather, theevidence is strong that, once labeled schizophrenic, the pseudopatient was stuck with thatlabel. If the pseudopatient was to be discharged,he must naturally be "in remission"; but he wasnot sane, nor, in the institution's view, had heever been sane.The uniform failure to recognize sanity cannotbe attributed to the quality of the hospitals. . . .Nor can it be alleged that there was simply notenough time to observe the pseudopatients.Length of hospitalization ranged from 7 to 52with an average of 19 days. The pseudopatients were not, in fact, carefully observed, butthis failure clearly speaks more to traditionswithin psychiatric hospitals than to lack of opportunity.Finally, it cannot be said that the failure torecognize thesanity was due tothe fact that they were not behaving sanely.While there was clearly some tension present inall of them, their daily visitors could detect noserious behavioralindeed,could other patients. It was quite common forthe patients to "detect" thesanity. . . . "You're not crazy. You're a journalist, or a professor [referring to the continualYou're checking up on the hospital." While most of the patients were reassured by the pseudopatient's insistence that hehad been sick before he came in but was finenow, some continued to believe that the pseudopatient was sane throughout his hospitalizationThe fact that the patients often recognizednormality when staff did not raises importantquestions.Failure to detect sanity during the course ofhospitalization may be due to the fact that . . .physicians are more inclined to call a healthyperson sick . . . than a sick person healthy. . . .The reasons for this are not hard to find: it isclearly more dangerous to misdiagnose illnessthan health. Better to err on the side of caution,to suspect illness even among the healthy.But what holds for medicine does not holdequally well for psychiatry. Medical illnesses,while unfortunate, are not commonly pejorative.Psychiatric diagnoses, on the contrary, carrywith them personal, legal, and social stigmasIt was therefore important to see whetherthe tendency toward diagnosing the sane insanecould be reversed. The following experimentwas arranged at a research and teaching hospitalwhose staff had heard these findings but doubtedthat such an error could occur in their hospital.The staff was informed that at some time duringthe following 3 months, one or more pseudopatients would attempt to be admitted into the psychiatric hospital. Each staff member was askedto rate each patient who presented himselfat admissions or on the ward according tothe likelihood that the patient was a pseudopatient. . . .Judgments were obtained on 193 patients whowere admitted for psychiatric treatment. Allstaff who had had sustained contact with or primary responsibility for thenurses, psychiatrists, physicians, and psycholoasked to make judgments. Fortyone patients were alleged, with highto be pseudopatients by at least one member oftheTwenty-three were considered suspectby at least one psychiatrist. Nineteen were suspected by one psychiatrist and one other staffmember. Actually, no genuine pseudopatient (atleast from my group) presented himself duringthis period.The experiment isIt indicates thatthe tendency to designate sane people as insanecan be reversed when the stakes (in this case,prestige and diagnostic acumen) are high. Butwhat can be said of the 19 people who were suspected of being "sane" by one psychiatrist andanother staff member? Were these people truly"sane?" . . . There is no way of knowing. Butone thing is certain: any diagnostic process thatlends itself so readily to massive errors of thissort cannot be a very reliable one.The Stickiness ofPsychodiagnostic LabelsBeyond the tendency to call the healthy sicktendency that accounts better for diagnosticbehavior on admission than it does for such behavior after a lengthy period ofdata speak to the massive role of labeling in psychiatric assessment. Having once been labeledschizophrenic, there is nothing the pseudopatient can do to overcome the tag. The tag profoundly colors others' perceptions of him andhis behavior.From one viewpoint, these data are hardlysurprising, for it has long been known that elements are given meaning by the context in which

182The Effects of Contact with Control Agentsthey occur. . . . Once a person is designatedabnormal, all of his other behaviors and characteristics are colored by that label. Indeed, thatlabel is so powerful that many of the pseudopatients' normal behaviors were overlooked entirely or profoundly misinterpreted. Some examples may clarify this issue.Earlier I indicated that there were no changesin the pseudopatient's personal history and current status beyond those of name, employment,and, where necessary, vocation. Otherwise, averidical description of personal history and circumstances was offered. Those circumstanceswere not psychotic. How were they made consonant with the diagnosis of psychosis? Or werethose diagnoses modified in such a way as tobring them into accord with the circumstances ofthe pseudopatient's life, as described by him?As far as I can determine, diagnoses were inno way affected by the relative health of the circumstances of a pseudopatient's life. Rather, thereverse occurred: the perception of his circumstances was shaped entirely by the diagnosis. Aclear example of such translation is found in thecase of a pseudopatient who had had a closerelationship with his mother but was rather remote from his father during his early childhood.During adolescence and beyond, however, hisfather became a close friend, while his relationship with his mother cooled. His present relationship with his wife was characteristicallyclose and warm. Apart from occasional angryexchanges, friction was minimal. The childrenhad rarely been spanked. Surely there is nothingespecially pathological about such a history. . . .Observe, however, how such a history wastranslated in the psychopathological context,this from the case summary prepared after thepatient was discharged.This white 39-year-old male . . . manifests a long history of considerable ambivalence in close relationships, which began in early childhood. A warm relationship with his mother cools during his adolescence.A distant relationship to his father is described as becoming very intense. Affective stability is absent. Hisattempts to control emotionality with his wife and children are punctuated by angry outbursts and, in thecase of the children, spankings. And while he says thathe has several good friends, one senses considerableambivalence embedded in those relationships also. . . .The facts of the case were unintentionally distorted by the staff to achieve consistency with apopular theory of the dynamics of a schizo-phrenic reactionNothing of an ambivalentnature had been described in relations with parents, spouse, or friends. . . . Clearly, the meaning ascribed to his verbalizations (that is, ambivalence, affective instability) was determinedby the diagnosis: schizophrenia. An entirely different meaning would have been ascribed if itwere known that the man wasAll pseudopatients took extensive notes publicly. Under ordinary circumstances, such behavior would have raised questions in the mindsof observers, as, in fact, it did among patients.Indeed, it seemed so certain that the noteswould elicit suspicion that elaborate precautionswere taken to remove them from the ward eachday. But the precautions proved needless. Theclosest any staff member came to questioningthese notes occurred when one pseudopatientasked his physician what kind of medication hewas receiving and began to write down the response. "You needn't write it," he was toldgently. "If you have trouble remembering, justask meIf no questions were asked of the pseudopatients, how was their writing interpreted? Nursing records for three patients indicate that thewriting was seen as an aspect of their pathological behavior. . . . Given that the patient is inthe hospital, he must be psychologically disturbed. And given that he is disturbed, continuous writing must be a behavioral manifestationof that disturbance, perhaps a subset of the compulsive behaviors that are sometimes correlatedwith schizophrenia.One tacit characteristic of psychiatric diagnosis is that it locates the sources of aberrationwithin the individual and only rarely within thecomplex of stimuli that surrounds him. Consequently, behaviors that are stimulated by the environment are commonly misattributed to thepatient's disorder. For example, one kindlynurse found a pseudopatient pacing the long hospital corridors. "Nervous, Mr. X?" she asked."No, bored," he said.The notes kept by pseudopatients are full ofpatient behaviors that were misinterpreted bywell-intentioned staff. Often enough, a patientwould go "berserk" because he had, wittinglyor unwittingly, been mistreated by, say, an attendant. A nurse coming upon the scene wouldrarely inquire even cursorily into the environmental stimuli of the patient's behavior. Rather,she assumed that his upset derived from hispathology, not from his present interactions with

Being Sane in Insane Places 183other staff members. . . . [N]ever were the stafffound to assume that one of themselves or thestructure of the hospital had anything to do witha patient's behavior. One psychiatrist pointed toa group of patients who were sitting outside thecafeteria entrance half an hour before lunchtime.To a group of young residents he indicated thatsuch behavior was characteristic of the oralacquisitive nature of the syndrome. It seemednot to occur to him that there were very fewthings to anticipate in a psychiatric hospital besides eating.A psychiatric label has a life and an influenceof its own. Once the impression has been formedthat the patient is schizophrenic, the expectationis that he will continue to be schizophrenic.When a sufficient amount of time has passed,during which the patient has done nothingbizarre, he is considered to be in remission andavailable for discharge. But the label enduresbeyond discharge, with the unconfirmed expectation that he will behave as a schizophrenicagain. Such labels, conferred by mental healthare as influential on the patient asthey are on his relatives and friends, and itshould not surprise anyone that the diagnosisacts on all of them as a self-fulfilling prophecy.Eventually, the patient himself accepts the diagnosis, with all of its surplus meanings and expectations, and behaves accordingly.Powerlessness andDepersonalizationEye contact and verbal contact reflect concern andtheir absence, avoidanceand depersonalization. The data I have presented do not do justice to the rich daily encounters that grew up around matters of depersonalization and avoidance. I have records of patientswho were beaten by staff for the sin of havinginitiated verbal contact. During my own experience, for example, one patient was beaten in thepresence of other patients for having approached an attendant and told him, "I likeOccasionally, punishment meted out topatients for misdemeanors seemed so excessivethat it could not be justified by the most radicalinterpretations of psychiatric canon. Nevertheless, they appeared to go unquestioned. Tempers were often short. A patient who had notheard a call for medication would be roundlyexcoriated, and the morning attendants wouldoften wake patients with, "Come on, youout of bed!"Neither anecdotal nor "hard" data can convey the overwhelming sense of powerlessnesswhich invades the individual as he is continuallyexposed to the depersonalization of the psychiatric hospital. . . .Powerlessness was evident everywhere. Thepatient is deprived of many of his legal rights bydint of his psychiatric commitmentHe isshorn of credibility by virtue of his psychiatriclabel. His freedom of movement is restricted.He cannot initiate contact with the staff, butmay only respond to such overtures as theymake. Personal privacy is minimal. Patient quarpossessions can be entered and examany staff member, for whatever reason.His personal history and anguish is available toany staff member (often including the "greyand "candywhoto read his folder, regardless of theirto him. His personal hygiene and waste evacuation are often monitored.The [toilets] may have no doors.At times,reached such proportions thatsense thatwere invisible, or at least unworthy of acadmitted, I and other pseudopatients took the initial physical examinations ina semipublic room, where staff members wentabout their own business as if we were not there.On the ward, attendants delivered verbal andoccasionally serious physical abuse to patientsin the presence of other observing patients,some of whom (the pseudopatients) were writingit all down. Abusive behavior, on the otherterminated quite abruptly when other staffmembers were known to be coming. Staff arecredible witnesses. Patients are not.Aunbuttoned her uniform to adjust herbrassiere in the presence of an entire ward ofviewing men. One did not have the sense thatshe was being seductive. Rather, she didn'tnoticeA group of staff persons might point toa patient in the dayroom and discuss him animatas if he were notOne illuminating instance of depersonalizationand invisibility occurred with regard to medications. All told, the pseudopatients were administered nearlypills. . .two wereswallowed. The rest were either pocketed or deposited in the toilet. The pseudopatients werenot alone in this. Although I have no preciserecords on how many patients rejected their

184 The Effects of Contact with Control Agentsmedications, the pseudopatients frequentlyfound the medications of other patients in thetoilet before they deposited their own. As longas they weretheir behavior and theown in this matter, as in otherimportantwent unnoticed throughout.Reactions to suchamongpseudopatients were intense. Although they hadcome to the hospital as participant observersand were fully aware that they did not "belong,"they nevertheless found themselves caught upin and fighting the process of depersonalization.inbecause craziness resides in them, asit were, but because they are responding to abizarre setting, one that may be unique to institutions which harbor nether people?[4] calls the process of socialization to such institutionsapt metaphorthat includes the processes of depersonalizationthat have been described here. And while it isimpossible to know whether theresponses to these processes are characteristicof allwere, after all, not real pais difficult to believe that these processes of socialization to a psychiatric hospitalprovide useful attitudes or habits of response forliving in the "real world."The Consequences of Labelingand DepersonalizationREFERENCES AND NOTESWhenever the ratio of what is known to whatneeds to be known approaches zero, we tend toinvent "knowledge" and assume that we understand more than we actuallyWe seem unableto acknowledge that we simply don't know. Theneeds for diagnosis and remediation of behavioral and emotional problems are enormous. Butrather than acknowledge that we are just embarking on understanding, we continue to labelpatients "schizophrenic," "manic-depressive,"and "insane," as if in those words we had captured the essence of understanding. The facts ofthe matter are that we have known for a longtime that diagnoses are often not useful or reliable, but we have nevertheless continued to usethem. We now know that we cannot distinguishinsanity from sanity. It is depressing to considerhow that information will be used.Not merely depressing, but frightening. Howmany people, oneare sane but not recognized as such in our psychiatric institutions?How many have been needlessly stripped oftheir privileges of citizenship, from the right tovote and drive to that of handling their own accounts? How many have feigned insanity in order to avoid the criminal consequences of theirbehavior, and, conversely, how many wouldrather stand trial than live interminably in a psychiatricare wrongly thought to bementally ill? How many have been stigmatizedby well-intentioned, but nevertheless erroneous,diagnoses? . . .diagnoses are rarelyfound to be in error. The label sticks, a mark ofinadequacy forever.Finally, how many patients might be "sane"outside the psychiatric hospital but seem insane1. P. Ash,Soc. Psychol. 44, 272 (1949);A. T. Beck, Amer. J. Psychiat.210 (1962); A. T.Boisen, Psychiatry 2, 233 (1938); N. Kreitman, J.Sci. 107, 876 (1961); N. Kreitman, P. Sainsbury,J.J. Towers, J. Scrivener,p. 887;H. O.and C. P. Fonda, J. Abnorm. Soc. Psychol.52, 262 (1956); W. Seeman, J. Nerv. Ment. Dis.541 (1953). For an analysis of these artifacts and summaries of the disputes, see J. Zubin,Rev.Psychol. 18, 373 (1967); L. Phillips and J. G. Draguns,22, 447 (1971).2. R. Benedict, J. Gen. Psychol. 10, 59 (1934).3. See in this regard H. Becker, Outsiders: Studiesin the Sociology of Deviance (Free Press, New York,1963); B. M. Braginsky, D. D. Braginsky, K. Ring,Methods of Madness: The Mental Hospital as a LastResort (Holt, Rinehart & Winston, New York,G. M. Crocetti and P. V. Lemkau, Amer. Sociol. Rev.30, 577 (1965); E. Goffman, Behavior in Public Places(Free Press, New York, 1964); R. D. Laing, The Divided Self: A Study of Sanity and Madness (Quadrangle, Chicago, 1960); D. L. Phillips, Amer. Sociol.Rev. 28, 963 (1963); T. R. Sarbin, Psychol. Today 6, 18(1972); E. Schur, Amer. J. Sociol. 75, 309 (1969); T.Szasz, Law, Liberty and Psychiatry (Macmillan, NewYork; 1963); The Myth of Mental Illness: Foundationsof a Theory of Mental Illness (Hoeber Harper, NewYork, 1963). For a critique of some of these views, seeW. R. Gove, Amer. Sociol. Rev. 35, 873 (1970).4. E. Goffman, Asylums (Doubleday, Garden City,N.Y., 1961).5. T. J. Scheff, Being MentallyA SociologicalTheory (Aldine, Chicago, 1966).6. Data from a ninth pseudopatient are not incorporated in this report because, although his sanity wentundetected, 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

Being Sane in Insane Places7. Beyond the personal difficulties that the pseudopatient is likely to experience in the hospital, there arelegal and social ones that, combined, require considerable attention before entry. For example, once admitted to a psychiatric institution, it is difficult, if notimpossible, to be discharged on short notice, state lawto the contrary notwithstanding. I was not sensitive tothese difficulties at the outset of the project, nor to thepersonal and situational emergencies that can arise,but later a writ of habeas corpus was prepared for eachof the entering pseudopatients and an attorney waskept "on call" during every hospitalization. I amgrateful to John Kaplan and Robert Bartels for legaladvice and assistance in these matters.8. However distasteful such concealment is, it wasa necessary first step to examining these questions.Without concealment, there would have been no wayto know how valid these experiences were; nor wasthere any way of knowing whether whatever detections occurred were a tribute to the diagnostic acumenof the staff or to therumor network. Obviously, since my concerns are general ones that cutacross individual hospitals and staffs, I have respectedtheir anonymity and have eliminated clues that mightlead to their identification.9. Interestingly, of the 12 admissions, were diagnosed as schizophrenic and one, with the identicalsymptomatology, as manic-depressive psychosis. This185diagnosis has a more favorable prognosis, and it wasgiven by the only private hospital in our sample. Onthe relations between social class and psychiatric diagnosis, see A. B.and F. C.Social Class and MentalA Community StudyNew York, 1958).10. It is possible, of course, that patients have quitebroad latitudes in diagnosis and therefore are inclinedto call many people sane, even those whose behavioris patently aberrant. However, although we have nohard data on this matter, it was our distinct impressionthat this was not the case. In many instances, patientsnot only singled us out for attention, but came to imitate our behaviors and styles.11. J.and E.Community135 (1965); A. Farina and K. Ring, J.70, 47 (1965); H. E. Freeman andO. G. Simmons, The Mental Patient Comes Home(Wiley, New York, 1963): W. J. Johannsen, Ment.giene 53, 218 (1969); A. S. Linsky, Soc. Psychiat. 5,166 (1970).12. For an example of a similar self-fulfillingprophecy, in this instance dealing with the "central"trait of intelligence, see R. Rosenthal and L. Jacobson,Pygmalion in the Classroom (Holt, Rinehart &ston, New York, 1968).13. D. B. Wexler and S. E. Scoville, Ariz.Rev.13, 1 (1971).

The remaining seven were older and "es-Among them were three psycholo-gists, a pediatrician, a psychiatrist, a painter, and a housewife. Three pseudopatients were women, five were men. All of them employed pseudonyms, lest their alleged diagnoses embar-rass them later. Those who were i

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