Rosenhan (1973)

Sane in Insane Places

Map to Spec – Page 61

4. Studies in detail

a) DescribeDescribe and evaluateevaluate Rosenhan (1973) “On being sane in insane places”

Map to Spec – Page 59

3. Content

c) Using the findings of studies, describe and evaluate reliabilityreliability, validity validity and cultural issues with regard to the diagnosisdiagnosis of disorders (including use of Diagnostic and Statistical Manual (DSM)).

"If sanity and insanity exist, how shall we know them?"

In other words….

Do the characteristics of abnormality reside in the patientspatients?

or In the environmentsenvironments in which they are

observed?

Does madness lie in the eye of the observer?

Background A long history of attempting to classifyclassify abnormal behavior.

Most commonly accepted approach to understanding & classifying abnormal behavior is the medical modelmedical model. Psychiatry Psychiatrists are medical doctors and regard mental

illness as another kind of illness (in addition to physical)

Beginning in the 1950s the medical model has used the Diagnostic and Statistical Manual of Mental Disorders (DSM) to classify abnormal behavior

The Medical Model

Assumes that psychological psychological disorders disorders are mentalmental illnesses illnesses that need to be diagnosed & diagnosed & treatedtreated through therapy or medication

DSM-IV-TR The Diagnostic and

Statistical Manual of Mental Disorders provides an authoritative authoritative classification classification scheme.scheme.

Describes disordersDescribes disorders and their prevalence without presuming to explain their causes

Labels Although diagnostic labelsdiagnostic labels may

facilitate communication and research, they can also biasbias our perceptionperception of people’s past and present behavior and unfairly stigmatizestigmatize these individuals.

Background

1960s - The anti-psychiatry movement (psychiatrists & psychotherapists) began to criticize criticize the medical model

RosenhanRosenhan was also a critic of the medical model – “Its a worrying thought that there could be thousands of people stuck in institutes that are just as ‘sane’ as we are.”

His study can be seen as an attempt to demonstrate that psychiatric classification is unreliableunreliable

Background

Difficulty of judging what is 'normalnormal'

Varies over time time / between societies societies

Rosenhan asked "If sanitysanity and insanityinsanity exist, how shall we know them?"

Research QResearch Q: if 'normal' people attempt admission to psychiatric hospitals, will they be detected? / how?

Aim

Test the hypothesis that psychiatrists cannot reliablyreliably tell the difference between people who are sanesane and those who are insane insane.

The Researchers Confederates (not the subjects)

EIGHT sane people! Three women and five men

One graduate student Three psychologists One pediatrician A painter A housewife A psychiatrist

Procedures

Telephoned 12 psychiatric hospitals12 psychiatric hospitals for urgent appointment (5 US states5 US states)

Arrived at admissions

Gave false names false names and occupations occupations

Gave other ‘life’ details correctly‘life’ details correctly

So here’s my cunning plan. I’m

going to send these people to a hospital and see what happens if they say they’ve got symptoms of

madness.

o What symptomsymptom could they use?

o And whywhy?

Thud

HollowEmpty

They said their only symptom was hearing a voice, the same sex as they are, saying the following:

Procedures Complained that they had been hearing hearing

voicesvoices Unfamiliar and the same sexsame sex as themselves Said 'empty', 'hollow', 'thud'empty', 'hollow', 'thud'. Symptoms were partly chosen because they were

similar to existential crisis symptomsexistential crisis symptoms (Who am I? What is it all for? – meaninglessness of one’s life)

Also chosen because there is no mentionno mention of existential psychosis in the literature.

Did they get let in?

AllAll were admitted to hospital

All but one were diagnosed as suffering from schizophreniaschizophrenia

Once admitted the ‘pseudo-patients’ stoppedstopped simulating ANY ANY symptoms

Took part in ward activitiesward activities

Procedures

Kept notes Kept notes on their experiences

Did this secretly secretly to begin with

Then openlyopenly when they realised no one cared or paid any attention to them doing this

Findings

The pseudo-patients were never detectednever detected

All pseudo-patients wished to be discharged discharged immediatelyimmediately

BUT - they waited until they were diagnosed as “fit to be discharged”“fit to be discharged”

How did the staff perceive them?

Normal behavior was misinterpretedmisinterpreted:- Writing notes described as -“The patient engaged in

compulsive writing behavior”- Arriving early for lunch described as - “oral acquisitive

syndrome” - Outburst from patient – never enquire what caused

response

Behavior distorted to ‘fit in’‘fit in’ with diagnosis/label

4 of the pseudo-patients carried out an observation on how patients were

treated by staff…..

The pseudo-patients observations

If patients approached staff with simple requests (NURSES & ATTENDANTS)

88% 88% ignored them (walked away with head averted) 10% made eye contact 2% stopped for a chat

(1283 attempts)

The pseudo-patient’s observations

If they approached staff with simple requests (PSYCHIATRISTS)

71%71% ignored them (walked away with head averted) 23% made eye contact 2% stopped for a chat

(185 attempts)

Observations

Nurses stayed in ward offices 90%90% of time

Each ‘real patient’ spent less than 7 7 minutes per dayminutes per day with psychiatric staff

Powerlessness and Depersonalization

Medical records were open to all staff regardless of status or therapeutic relationship with the patient

Personal hygiene monitored Many of the toilets did not have doors

Some of the ward orderlies were brutal to patients in front of other patients ~ would stop when another staff member approached This indicated that staff were credible witnesses but

patients were not

How long did they stay in hospital?

The shortest stay was 7 days

The longest stay was 52 days

The average stay was 19 days19 days

They had agreed to stay until they convinced the staff they were sane!!

Were they treated in the same way as normal patients...

Given total of 2100 medication tablets2100 medication tablets

They flushed them down the loos

Noted that other patients did the same and that this was ignored as long as patients behaved themselves !!

Did anyone suspect?

3535 out of 118 patients voicedvoiced suspicionssuspicions about the pseudo-patients

- “You’re not crazy”, - “You’re a journalist”, -“You’re a professor, checking up on the hospital”

On Release

The pseudo-patients were diagnosed with

Schizophrenia “IN REMISSION”

So… Lack of monitoring Distortion of behavior Lack of normal interaction Powerlessness & depersonalization

Alice In Wonderland

"But I don't want to go among mad people," Alice remarked.

"Oh, you can't help that," said the Cat: "we're all mad here. I'm mad. You're mad.“

"How do you know I'm mad?" said Alice.

""You must beYou must be," ," said the Cat, , ""or you wouldn't have come or you wouldn't have come herehere."."

Summarise

What was the IVIV for this experiment?

What was the DVDV for this experiment?

What was the experimental method experimental method used?

Rosenhan:The follow up study…

A teaching & research hospital heard of the first study – didn’t think they would make the same mistake

They were warned that …

Over the next three months ONE OR MORE pseudo-patient would attempt to be admitted

What happened……….?

Staff members rated ‘new patients’‘new patients’ on scale 1 - 101 - 10 as ‘how likely to be a fraud’

193 patients ‘assessed’ 41 rated as a pseudo-patient (by staff) 23 rated as pseudo-patient (by psychiatrist) 19 rated as pseudo-patient (by both)19 rated as pseudo-patient (by both)

AH HA HA HA!

Just guess how many I’d really sent.......

How many of these SUSPECTSwere pseudo-patients?……...

NONENONE NoNo pseudo-patients were

sentStaff were rating their regularregular intake

Summarise

What was the IVIV in this study?

What was the DVDV in this study?

What did Rosenhan conclude?

Remember, his question was … Do the characteristics of abnormality reside in

the patients?

OR OR In the environments in which they are

observed?

Does madness lie in the eye of the observer?

Rosenhan’s conclusion…..

“It is clear that we are unable to distinguish the sane from the insane in psychiatric hospitals”

In the first study - We are unable to detect ‘sanity‘sanity’ This is what’s known as a Type II errorType II error – diagnosing

healthy people as sick In the follow up study - We are unable to detect ‘ insanityinsanity’ This is what’s known as a Type I errorType I error – diagnosing sick

people as healthy

Rosenhan’s study highlighted:

The depersonalisationdepersonalisation and powerlessnesspowerlessness of patients in psychiatric hospitals

That behaviour is interpretedbehaviour is interpreted according to expectationsexpectations of staff and that these expectations are created by the labels labels SANITY & INSANITY

Another Rosenhan note……..

The pseudo-patients described their stay in the hospitals as a negative negative experienceexperience

This is not to say that REALREAL patients have similar experiences

Real patients do not know the diagnosis is false & are NOTNOT pretending

Your Task

Complete Dominoes activity in your groups – first to do it wins!

Your Task

Exam conditions – past exam questions on methodology and findings of Rosenhan’s study

Peer mark using mark scheme provided

Your Task

Evaluate the study! In your groups consider one issue (G R A V E)

How can the study be evaluated in terms of this issue?

Are there strengths? Weaknesses? Both?