Rosenhan (1973)

1. Rosenhan (1973) Sane in Insane Places

2. Map to Spec – Page 61 4. Studies in detail a) Describe and evaluateRosenhan (1973) “On being sane in insane places”

3. Map to Spec – Page 59 3. Content c) Using the findings of studies, describe and evaluate reliability, validity and cultural issues with regard to the diagnosis of disorders (including use of Diagnostic and Statistical Manual (DSM)).

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

5. In other words…. • Do the characteristics of abnormality reside in the patients? or • In the environments in which they are observed? Does madness lie in the eye of the observer?

6. Background • A long history of attempting to classify abnormal behavior. • Most commonly accepted approach to understanding & classifying abnormal behavior is the medical 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

7. The Medical Model • Assumes that psychological disorders are mentalillnesses thatneed to be diagnosed & treated through therapy or medication

8. DSM-IV-TR • The Diagnostic and Statistical Manual of Mental Disorders provides anauthoritative classification scheme. • Describes disorders and their prevalence without presuming to explain their causes

9. Labels • Although diagnostic labels may facilitate communication and research, they can also biasourperception of people’s past and present behavior and unfairly stigmatize these individuals. CRAZY!

10. Background • 1960s - The anti-psychiatry movement (psychiatrists & psychotherapists) began to criticize the medical model • Rosenhan 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 unreliable

11. Background • Difficulty of judging what is 'normal' • Varies over time / between societies • Rosenhan asked "If sanity and insanity exist, how shall we know them?" • Research Q: if 'normal' people attempt admission to psychiatric hospitals, will they be detected? / how?

12. Aim • Test the hypothesis that psychiatrists cannot reliably tell the difference between people who are sane and those who are insane.

13. 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 Pseudo-Patients!

14. Procedures • Telephoned 12 psychiatric hospitals for urgent appointment (5 US states) • Arrived at admissions • Gave false names and occupations • Gave other ‘life’ details correctly

15. 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.

16. What symptom could they use? • And why?

17. Thud They said their only symptom was hearing a voice, the same sex as they are, saying the following: Hollow Empty

18. Procedures • Complained that they had been hearing voices • Unfamiliar and the same sex as themselves • Said 'empty', 'hollow', 'thud'. • Symptoms were partly chosen because they were similar to existential crisis symptoms (Who am I? What is it all for? – meaninglessness of one’s life) • Also chosen because there is no mention of existential psychosis in the literature.

19. Did they get let in? • All were admitted to hospital • All but one were diagnosed as suffering from schizophrenia • Once admitted the ‘pseudo-patients’ stopped simulating ANY symptoms • Took part in ward activities

20. Procedures • Kept notes on their experiences • Did this secretly to begin with • Then openly when they realised no one cared or paid any attention to them doing this

21. Findings • The pseudo-patients were never detected • All pseudo-patients wished to be discharged immediately • BUT - they waited until they were diagnosed as “fit to be discharged”

22. How did the staff perceive them? • Normal behavior was misinterpreted: • 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’ with diagnosis/label

23. 4 of the pseudo-patients carried out an observation on how patients were treated by staff…..

24. The pseudo-patients observations • If patients approached staff with simple requests (NURSES & ATTENDANTS) • 88% ignored them (walked away with head averted) • 10% made eye contact • 2% stopped for a chat • (1283 attempts)

25. The pseudo-patient’s observations • If they approached staff with simple requests (PSYCHIATRISTS) • 71% ignored them (walked away with head averted) • 23% made eye contact • 2% stopped for a chat • (185 attempts)

26. Observations • Nurses stayed in ward offices 90% of time • Each ‘real patient’ spent less than 7 minutes per day with psychiatric staff

27. 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

28. How long did they stay in hospital? The shortest stay was 7 days The longest stay was 52 days The average stay was 19 days They had agreed to stay until they convinced the staff they were sane!!

29. Were they treated in the same way as normal patients... Given total of 2100 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 !!

30. Did anyone suspect? • 35 out of 118 patients voicedsuspicions about the pseudo-patients • - “You’re not crazy”, • - “You’re a journalist”, • “You’re a professor, checking up on the hospital”

31. On Release • The pseudo-patients were diagnosed with Schizophrenia “IN REMISSION”

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

33. 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 be," said the Cat, "or you wouldn't have come here."

34. Summarise • What was the IV for this experiment? • What was the DV for this experiment? • What was the experimental method used?

35. 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

36. What happened……….? Staff members rated ‘new patients’ on scale 1 - 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)

37. AH HA HA HA! Just guess how many I’d really sent.......

38. How many of these SUSPECTSwere pseudo-patients?……... NONE No pseudo-patients were sent Staff were rating their regular intake

39. Summarise • What was the IV in this study? • What was the DV in this study?

40. What did Rosenhan conclude? Remember, his question was … Do the characteristics of abnormality reside in the patients? OR In the environments in which they are observed? Does madness lie in the eye of the observer?

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

42. Rosenhan’s study highlighted: The depersonalisationand powerlessness of patients in psychiatric hospitals That behaviour is interpreted according to expectations of staff and that these expectations are created by the labels SANITY & INSANITY

43. Another Rosenhan note…….. The pseudo-patients described their stay in the hospitals as a negative experience This is not to say that REAL patients have similar experiences Real patients do not know the diagnosis is false & are NOT pretending

44. Your Task • Complete Dominoes activity in your groups – first to do it wins!

45. Your Task • Exam conditions – past exam questions on methodology and findings of Rosenhan’s study • Peer mark using mark scheme provided

46. 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?