Rosenhan (1973)

1. Rosenhan (1973) JMR ‘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 Rosenhan (1973)

5. 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? Rosenhan (1973)

6. 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) Rosenhan (1973)

7. 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 Rosenhan (1973)

8. 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 Rosenhan (1973)

9. 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! Rosenhan (1973)

10. 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!) Rosenhan (1973)

11. 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) Rosenhan (1973)

12. 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) Rosenhan (1973)

13. 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 Rosenhan (1973)

14. 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 Rosenhan (1973)

15. 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 Rosenhan (1973)

16. 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” Rosenhan (1973)

17. 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! Rosenhan (1973)

18. Staff attitudes 2 Rosenhan (1973)

19. 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) Rosenhan (1973)

20. 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? Rosenhan (1973)

21. 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) Rosenhan (1973)

22. Experiment 2 - results • All new patients were genuine – NO pseudopatients Rosenhan (1973)

23. 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 Rosenhan (1973)

24. 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”? Rosenhan (1973)