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Rosenhan (1973) On Being Sane in Insane Places

WJEC PY2 Core Study
by

nigel cannar

on 18 March 2014

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Transcript of Rosenhan (1973) On Being Sane in Insane Places

Rosenhan (1973) 'On Being Sane in Insane Places
By the end of the lesson students will be able to:-
Define the term schizophrenia
Describe Rosenhan's study
Context
Aims
Procedures
Findings
Conclusions
Some questions for you.
1.How do we define sane?
2. How about insane?
3. Is there a difference?
4. How do we tell?
In your groups think about what you associate with the word 'schizophrenia'
Laing (1960) argued that schizophrenia was best understood in terms of an individual's experience rather than a set of symptoms.
Foucault (1961) described the development of the concept of mental illness in the 17th and 18th centuries, when 'unreasonable members of the public were locked away, institutionalised and subjected to some quite inhumane treatments, such as using freezing showers and straightjackets.
Foucalt argued that the concepts of sanity and insanity were in fact social constructs. What did he mean by this?
That the idea of sanity and insanity were not 'real' but, instead, constructions made by a particular society.
Rosenhan was influenced by these ideas and believed that we may be able to tell the normal from the abnormal, but the evidence for this ability is not quite as compelling.
Is 'normal' a universal concept?
The big question for Rosenhan was whether the diagnosis of insanity is based on characteristics of patients themselves or the context in which the patient is seen.
Evidence suggests that the diagnosis of mental illness is 'useless at best and downright harmful, misleading, and negative at worst.'
Rosenhan's aim was to investigate whether psychiatrists could distinguish between people who are genuinely mentally ill and those who are not.
He argued that this could be investigated by getting 'normal' people to seek to be admitted to a psychiatric hospital.
If such 'pseudopatients' were diagnosed as sane, this would show that the sane person can be distinguished from the insane context in which he is found.
On the other hand, if such 'pseudopatients' were diagnosed as insane, then this suggests that it is the context rather than the individual's characteristics that determines the diagnosis.
If this was found to be the case it would seem that the psychiatric diagnosis of 'insanity' has less to do with the patient and more about the environment in which they are found.
3 Study's within 1 study
Study One
The Pseudopatients
5 men and three women of varying occupations (psychologist, graduate student, paediatrician, psychiatrist, painter, and housewife) including Rosenhan
Attempted to gain access to 12 different hospitals in five different states in America which represented a wide range of different kinds of institutions.
Each pseudopatient called a hospital and asked for an appointment. When they arrived at the hospital, they told the admissions officer that they had been hearing voices such as 'empty', 'hollow', and 'thud'.
In the hospital the pseudopatients were instructed to behave normally and apart from being tense about being found out, they did act normally.
They spent their time talking to the other patients and taking notes about life on the ward. These notes were taken covertly at first, but they soon realised the nurses didn't care. The pseudopatients secretly did not take their medication but other than that they followed the ward routine.
The pseudopatients didn't know when they would be discharged; one of the conditions of taking part in the study was that they had to get out by their own devices.
Study Two
After the results of study one were publicised, staff in another hospital challenged Rosenhan claiming that it could not happen in their hospital.
Rosenhan then informed them that in the next three months, one or more pseudopatients would present themselves.
The staff were asked to rate on a 10-point scale their confidence level that the person was genuinely ill. Judgements were taken for 193 patients over the three months.
Study Three
Rosenhan also included a mini-study of the way staff responded to pseudopatients.
In four of the 12 hospitals, pseudopatients approached a staff member with the following question; 'Pardon me, Mr/Mrs/Dr X, could you tell me when I will be eligible for grounds privileges? The pseudopatient did this as normally as possible and avoided asking a person more than once in a day.
Study One
All the pseudopatients were admitted and all but one diagnosed with schizophrenia.
Each was eventually discharged with a diagnosis of schizophrenia 'in remission.'
Very limited contact between staff and patients was observed in the study.
The staff were rarely seen on the wards, appearing an average of 6.7 times per day, with the average daily contact between patients and psychiatrists being 6.8 minutes per day.
While the pseudopatients were at the hospital, the 'real' patients regularly voiced their suspicions saying things like 'you're not crazy', and 'you're a journalist'
During the research (lasting between 7-52 days), the pseudopatients were given a total of 2100 tablets.
Nursing records for three pseudopatients indicate their writing was seen as an aspect of their pathological behaviour ('patient engages in writing behaviour.')
Study Two
Over the three months, 193 patients were admitted for treatment. None of them were actually pseudopatients but:
41 were judged to be pseudopatients by at least one staff member
23 were suspected of being pseudopatients by at least one psychiatrist
19 were suspected of being pseudopatients by a psychiatrist and one other staff member
Study Three
The most common response was a brief reply as the member of staff continued walking past without pausing or making eye contact. Only 4% of the psychiatrists and 0.5% of the nurses stopped; 2% in each group stopped and chatted.
Three conclusions from this study; type 1 and type 2 errors, psychodiagnostic labels, and powerlessness and depersonalisation.
Type 1 and 2 errors.
- Does anyone know what these types of errors are?
Type 1 error is not believing something is true when it is - could lead to an innocent person being sent to prison
A type 2 error is believing something to be true when it isn't, such as letting a criminal free when they are guilty.
In study 1 the psychiatrists failed to detect the pseudopatients' sanity despite the fact that they were clearly sane - this may be because doctors have a strong bias towards a type 2 error- they are more inclined to call a healthy person sick than a sick person healthy as it is more dangerous to misdiagnose illness than health.
However in study two the hospital staff were now making more type 1 errors presumably because they were trying not to make type 2 errors.
Psychodiagnostic Labels - the results show the profound effect of 'label' on our perceptions of people. Once a person is labelled 'abnormal', this means that all subsequent data about them are interpreted in that light because such labels are 'sticky'.
Powerlessness and Depersonalisation.
The behaviour of the staff in study three shows how the patients were depersonalised.
In general staff treated the patients with little respect; punishing them for small incidents and beating them. Such treatment is depersonalising, and creates an overwhelming sense of powerlessness.
Another source of depersonalisation was the use of psychotropic drugs. Drugs convince staff that treatment is being conducted and therefore further patient contact is not necessary.
What do these results imply for mental health care?
It is clear from this study that we cannot distinguish the sane from the insane. Hospitalisation for the mentally ill results in powerlessness, depersonalisation, mortification, and self-labelling -all of which are counter-therapeutic.
Methods
Remember the mnemonic = Maggie Really Values Soft Eggs
M = Methods
R = Reliability
V = Validity
S = Sample
E = Ethics
Method
This was a naturalistic experiment, the experimenter makes use of a naturally varying IV instead of deliberately manipulating it.
The observations were made by the pseudopatients, a kind of participant observation. Study 3 was a field experiment - the IV was deliberately manipulated by the experimenter.
Reliability
The conclusions from the first study were based on on the experience of eight pseudo patients in a number of different hospitals. In study 2 only one hospital was used.
Slater (2004)
Lauren Slater wrote that she had presented herself at the emergency room of multiple hospitals with a single auditory hallucination. She claimed she was given perscriptions for either antipsychotics or antidepressants
This has caused an enormous amount of controversy. See the following article for an overview: http://psychnews.psychiatryonline.org/newsarticle.aspx?articleid=109856 In essence people have questioned if she actually carried out the study. she has been asked to provide evidence to support the claim but has failed to do so.
Validity
The willingness to commit a patient on flimsy evidence could be because the psychiatrist wouldn't suspect for a minute that someone might be pretending.
The hospitals selected by Rosenhan were in five different states, including new and old buildings. This gives a certain amount of validity, why do you think?
Sample Size
The participants this time were the staff of the hospital, i.e. the nurses and the doctors in the hospitals. In what way is this unique and what does this mean?
Ethical Issues
The pseudo patients did not inform the staff at the hospital that they were being observed as part of a research - what can you conclude from this?
Alternative Evidence
Slater (2004)
In that same journal (psychiatric news),
Spitzer, Lilienfeld, and Michael B. Miller, Ph.D.
, published a study in which they presented 74 emergency room psychiatrists with a case vignette modeled on the description in Slater's book and asked them a series of questions regarding diagnosis and treatment recommendations. In contrast to what Slater reported, just four psychiatrists offered a diagnosis of psychotic depression, and only a third recommended medication
Spitzer (1976)
Took issue with Rosenhan’s conclusions. Psychiatrists have to rely upon the verbal reports of the patients who come to them for help. It is not expected that an individual would try to trick their way into a psychiatric institution. Would the conclusion be the same if it was a physical illness which was being faked?
Kety (1974)
If I were to drink a quart of blood, and conceling whatI had done, come to an emergency room of any hospital vomiting blood, the behaviour of the staff would be quite predicatabele. If they labelled and treated me as having a peptic ulcer, I doubt I could argue convingly that medical science does not know how to diagnose that condition.
DSM-III
(Diagnostic and Statistical Manual of Mental Disorders - version III 1980)
Newer version with more reliability, Sarbin and
Mancuso (1980)
noted that with the newer version Rosenhan's pseudo patients would not be admitted.

Carson (1991)
argued that DSM-III had fixed the problem of reliability once and for all.
Diagnosis is unreliable
Even with newer versions there is still little evidence that the DSM is routinely used with high reliability.
Inter-rater reliability
The extent to which different clinicians give the same diagnosis when dealing with the same patient. Research (Whaley, 2001) has found inter-rater reliability correlations to be as low as +0.11
Langwieler and Linden (1993)
Sent a trained pseudo patient to four physicians with different backgrounds. All diagnosed a differently with different treatments
Loring and Powell (1988)
Gave 290 psychiatrists a transcript of a patient interview and told half that patient was black and the other half the patient was white. They concluded "clinicians appear to ascribe violence, suspiciousness, and dangerousness toblack clients even though the case studies are the same as the case studies for the white clients.
Is it better to let somebody like this free?
The End
Courtesy of Rachel Allison,

Schizophrenia has been variously described as a disintegration of the personality.
A main feature is a split between thinking and emotion.
It involves a range of psychotic symptoms (where there is a break from reality).
Generally, schizophrenic patients lack insight into their condition, i.e. they do not realise that they are ill.

Thomas Szasz (1961)
Argues mental illness is a myth. It’s a label society gives to ‘odd’ behaviour (very subjective).
He also said "if you talk to god you are preying. If god talks to you you have schizophrenia"
Full transcript