Rosenhan (1973) 1 Rosenhan (1973) ‘On Being Sane in Insane Places’
Rosenhan (1973) 1
Rosenhan (1973)
‘On Being Sane in Insane Places’
Rosenhan (1973) 2
Diagnosing mental illness
How do we diagnose mental illness?
What are the pitfalls? What are the
consequences of labelling someone as “mentally ill”?
Rosenhan (1973) 3
Research question
“Do the characteristics that lead to a diagnosis of abnormality reside in the PATIENTS – or in the ENVIRONMENTS they are observed in?”
Operationalised “If ‘normal’ people attempted to be
admitted to psychiatric hospitals, would they be detected as being sane?”
Rosenhan (1973) 4
Mental illness
Difficult to define. Medical classifications exist (eg. DSM IV or ICD 10) – these list symptoms
Problems with medical classification:
1. Problems often aren’t physiological, can’t be tested (eg. X-rays for broken bones)
2. Depends on whether we believe the patient
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Important Issues
1. Reliability Does the system always
diagnose in the same way? 2. Validity Does the system really
measure mental illness can it tell who is ill and who
isn’t?
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Some studies
Kreitman (1961) 2 psychiatrists examining same
patients only agree on diagnosis in 28% of cases (neurosis)
Thomas Szasz (1961) Argues mental illness is a myth it’s a label society gives to ‘odd’
behaviour (very subjective)
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Diagnostic reliability
David Rosenhan investigates diagnostic reliability
Can doctors distinguish between sane and insane?
If they can, classification is VALID
If they fail, classification is useless, misleading and harmful
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The study Method: Field
experiment (participant observation)
Setting: 12 hospitals in different American State
Mix of old & new Some short-staffed,
some not 1 private, 11 state-
funded
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The participants 8 “pseudopatients”, 5 male, 3 female,
no history of mental disorder psychology student 3 psychologists (incl. Rosenhan –
bias?) psychiatrist paediatrician painter Housewife They will pretend to be mental
patients!
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Procedure 1 Change names & occupations Phone for appointment Arrive, claim to be “hearing voices” Voices unfamiliar, but same sex
Voices are unclear, but sound like saying “empty”, “hollow” and “thud”
Words chosen to suggest an existential crisis (Who am I? What’s it all for? My life is empty and hollow!)
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Procedure 2 If admitted, pseudopatients
stop pretending to be abnormal
They were nervous (novel situation, fear of discovery)
Pseudopatients have to get out by convincing staff they are sane
They are model patients but must write up observations (secretly, but overtly when found out)
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Diagnosis: schizophrenia All but one pseudopatient admitted with diagnosis of
schizophrenia Discharged not as “sane” but with diagnosis of
“schizophrenia in remission” (no such thing!) Diagnosis of schizophrenia Disorders of thought (delusions) Disorders of perception (hallucinations, eg. voices) Motor symptoms (odd movements) Affective symptoms (inappropriate emotions) Impaired life functioning (no job, friends, relationships) Sufferers show problems in a number of areas, but
pseudos showed only one symptom (voices)
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Results Results Length of stay 7 – 52 days (mean 19 days) Staff never detected
pseudopatents Other patients & visitors
knew they were sane (35 out of 118 patients
rumbled the pseudos) Significantly, staff
interpreted pseudos “sane” behaviour in the light of their “insane” label
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The “stickiness of labels” Labelling patients as
schizophrenic coloured other perceptions – eg:
Normal life experiences interpreted as “abnormal” by interviewers
Normal behaviours interpreted as pathological
Labels are “sticky” because, once they’re stuck on, they’re hard to remove
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Normal seen as abnormal 1 EG 1: Pseudos ordinary life histories Pseudos didn’t lie about these Close to mother in early childhood, close
to father during adolescence Medical staff distort this in case notes:
“the patient manifests a long history of considerable ambivalence in close relationships, which begins in early childhood”
fits in with theories about schizophrenia
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Normal seen as abnormal 2 EG 2: Pseudos took notes and feared
staff would realise the hoax from this. But staff viewed “writing behaviour” as part of the symptoms.
EG 3: Pseudo pacing up and down asked if he was nervous, when really he was bored.
EG 4: Patients with little to look forward to queue outside canteen 30mins before food served. Doctor described this as “the oral-acquisitive nature of their syndromes”
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Staff attitudes 1 Pseudos ask staff for info “Pardon me, Mr [or Dr or Mrs] X,
could you tell me when I will be presented at the staff meeting?" or "...when am I likely to be discharged?"
Patients frequently ignored! Rosenhan set up a Control condition a young person approaches
psychology staff at university or doctor in medical centre, responses noted
Control students usually acknowledged!
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Staff attitudes 2
Behaviour Psychiatrists Nurses/Attendants Control
Ignored 71% 88% 0%
Eye contact, no speech 23% 10% 0%
Stop to talk 6% 2% 100%
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Staff attitudes 3 These attitudes produce
powerlessness and depersonalisation
see Zimbardo, it’s like a prison
Patients deprived of legal rights Freedom of movement restricted Minimal privacy Physical punishments in front of
other patients (not other staff – ie. patients aren’t
credible witnesses)
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So why the mistakes? Doctors biased towards type-one
errors (playing safe) diagnose healthy people as sick
more often than sick people as healthy
Also called a false positive A type-two error is diagnosing
sick people as healthy (false negative)
Will doctors misdiagnose genuine patients as sane?
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Experiment 2 Setting: a large teaching hospital
for the mentally ill Staff warned that pseudopatients
would seek admission in next 3 months
Staff asked to rate new patients on 10-point scale to say if they were faking
(1 = definite faker, 10 = genuinely ill)
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Experiment 2 - results
All new patients were genuine – NO pseudopatients
New patients Misjudged by…
1 staff 1 psychiatrist Both
193 41 23 19
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Conclusions 1
We cannot distinguish the sane from the insane in psychiatric hospitals
The environment distorts the meaning of behaviour Sticky labelling, powerlessness etc. not conducive to
healing But there is hope: Community care facilities may change the environment
behaviour is seen in Mental health workers now trained to be aware of
labelling and sensitive to patients’ needs
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Conclusions 2 Easy to misdiagnose schizophrenia – does it really exist
at all or is it just a label of odd behaviour? Schizophrenia occurs in all cultures – recovery rate
faster in less developed countries Strong genetic link – MZ twin studies show varying
concordance (15%-69%) Affects 1% of population – males/females equally Starts 17-35 years (young adulthood) Sometimes gradual, sometimes sudden – may be
started by stress Can a plea of insanity justify reduced sentences if we
cannot define “insanity”?