Rosenhan - On Being Sane In Insane Places

Front 1

Give reasons why the study should have been done.

Back 1

• the ends justify the meansit tells us what is really going on behind the closed doors of a mental institution
  
• it tells us that psychiatric diagnosis of mental illness may be ambiguous
  
• it tells us that psychiatrists prefer to make a type 2 error if in doubt
  

Front 2

Give reason why the study should not have been done.

Back 2

• The participants (doctors, nurses, attendants) did not give full, informed consent
  
• The participants (doctors, nurses, attendants) were deceived
  
• It revealed the embarrassing nature of psychiatric institutional care
  

Front 3

Explain why the nurses responded to the requests in the way they did.

Back 3

it involves a situational explanation. Inmates are mentally ill and so cannot communicate/are non-people, etc.

Front 4

Suggest ways in which the study was true to real life.

Back 4

• The study took place in real mental institutions.
  
• The study involved real psychiatrists and nurses.
  
• Life on the ward was as it would be in everyday life.
  

Front 5

Suggest ways in which the study was not true to real life.

Back 5

• Those seeking admission were not genuine patients, they were pseudo-patients.
  
• The pseudo-patients claimed they were hearing voices.
  
• In study 2 Rosenhan said he would send more pseudo-patients.
  

Front 6

Give one advantage of participant observation used in this study.

Back 6

Participant observation is where the aim is to gain a close and intimate familiarity with a given group of individuals (in this case the psychiatrists, nurses, etc in the institutions) and their practices through an involvement with them in their natural environment. The participants do not know they are being observed, assuming the ‘participant’ is one of them.

Front 7

According to Rosenhan what distinguishes the sane from the insane?

Back 7

• Bleuler, Kretchmer and editors of Diagnostic and Statistical Manual of the American Psychiatric Association maintain that categorisation of patients’ symptoms distinguishes the sane from the insane.
  
• When categorising a patient's symptoms, it's important to distinguish between characteristics found within the patient themselves and those located in the environment or context in which the patient is being observed.
  

Front 8

Briefly describe what happened after the pseudo-patients were admitted to the mental hospitals.

Back 8

• were diagnosed as having schizophrenia in 11/12 cases;
  
• were admitted and placed on ward of institution;
  
• were detained for between 7 and 52 days;
  
• any other aspect of ‘life on the ward’ to be given credit as this is what happened after admittance.
  

Front 9

Suggest why Rosenhan did not use a self report interview or questionnaire to gather data.

Back 9

• If an interview or questionnaire were used then the participants would know they were taking part in a study and may respond to demand characteristics.
  
• The answers given would be that they would be able to spot pseudo-patients.
  
• This would result in false results and the study would not measure what it was claiming to measure.
  

Front 10

Suggest one advantage of the method Rosenhan did use to gather data.

Back 10

• observation gathers objective data;
  
• the participants did not know they were being observed;
  
• the observation was conducted in a real-life setting.
  

Front 11

Outline one advantage of using observation to gather data in this study.

Back 11

• Participant observation was used and the participants did not know they were being observed, assuming the ‘participant’ was one of them.
  
• The observation was naturalistic as it was in a real-life setting and the participants did not know they were being observed. 1 mark partial, 2 marks elaboration.
  

Front 12

Outline one disadvantage of using observation to gather data in this study.

Back 12

• Although Rosenhan took notes, there would not be the usual response categories.
  
• Rosenhan could not record all behaviours all the time, only partially.
  
• The observation was unethical as the participants were being deceived.
  

Front 13

Describe one possible reason why staff admitted the pseudopatients to the hospital.

Back 13

The staff may have made this mistake because they would rather be safe than sorry. It could be dangerous to send away an insane person.The staff made a type 2 error and diagnosed a healthy person as sick.The symptom, hearing voices, is not a normal behaviour and the staff felt they should admit the person.

Front 14

Outline one way this study can be considered useful

Back 14

Uncovered problems in psychiatric hospitals and many were then shut down.Staff need to treat patients better and try to help raise their self-esteem by paying attention to them.Psychiatrists need to spend more time with patients as they only spent on average 7 minutes per day with each patient.Staff should not label all behaviour as insane as this could cause the patients to think nothing they do is right.

Front 15

What is a type two error?

Back 15

A type two error is labelling a healthy person sick (a false positive) when they are actually healthy. Labelling pseudo-patients as schizophrenic when they are not.

Front 16

Give one disadvantage of participant observation.

Back 16

One disadvantage is that it is often unethical because those being observed are deceived. Neither do they give informed consent. Participants may begin to trust the observer and reveal ‘secrets’ which are later used against them.

Front 17

background of study

Back 17

Psychiatrists are medical doctors and are trained to regard mental illness as comparable to other kinds of (physical) illnesses. Beginning in the 1950s this medical approach has used the Diagnostic and Statistical Manual of Mental Disorders (DSM) to classify abnormal behaviour.However, in the 1960s a number of psychiatrists and psychotherapists, known as the anti-psychiatry movement, started to fiercely criticise the medical approach to abnormality. David Rosenhan was also a critic of the medical model and this study can be seen as an attempt to demonstrate that psychiatric classification is unreliable. He states: ’There is a view that psychological categorisation of mental illness is, at best, useless and, at worst, harmful, misleading and pejorative’

Front 18

Aim of the study

Back 18

• To show that psychiatrists cannot reliably tell the difference between sane and insane people; that psychiatric criteria for diagnosis are not valid.
  
• To investigate whether ‘the salient characteristics that lead to diagnosis reside in the patients themselves (the individual) or in the environments and contexts (the situation) in which observers find them’.
  

Front 19

Describe the pseudopatients

Back 19

The first part of the study involved eight sane people (3 women, 5 men):

• A psychology graduate student in his 20s
  
• Three psychologists
  
• A paediatrician
  
• A psychiatrist
  
• A painter
  
• A housewife
  

Attempting to gain admission to 12 different hospitals, in five different states in the USA. Those who were in mental health professions alleged another occupation in order to avoid the special attentions that might be accorded by staff, as a matter of courtesy or caution, to ailing colleagues

Front 20

Describe the hospitals

Back 20

The 12 hospitals in the sample were located in five different states on the East and West coasts. Some were old and shabby, some were quite new. Some had good staff-patient ratios, others were quite understaffed. Only one was a strict private hospital. All of the others were supported by state or federal funds or, in one instance, by university funds.

Front 21

How did the pseudo patients try to gain admission to the hospitals?

Back 21

• After calling the hospital for an appointment, the pseudopatient arrived at the admissions office complaining that he had been hearing voices. Asked what the voices said, he replied that they were often unclear, but as far as he could tell they said “empty,” “hollow,” and “thud.” The voices were unfamiliar and were of the same sex as the pseudo patient.
  
• The choice of these symptoms was occasioned by their apparent similarity to existential symptoms. Such symptoms are alleged to arise from painful concerns about the perceived meaninglessness of one’s life. It is as if the hallucinating person were saying, “My life is empty and hollow.”
  
• The choice of these symptoms was also determined by the absence of a single report of existential psychoses in the literature.
  
• The pseudo patients gave a false name and job (to protect their future health and employment records), but all other details they gave were true including general ups and downs of life, relationships, events of life history and so on.
  

Front 22

What happened after the pseudo patients have been admitted

Back 22

• After they had been admitted to the psychiatric ward, the pseudo patients stopped simulating any symptoms of abnormality. However, Rosenhan did note that the pseudo patients were nervous, possibly because of fear of being exposure as a fraud, and the novelty of the situation.
  
• The pseudo patients took part in ward activities, speaking to patients and staff as they might ordinarily. When asked how they were feeling by staff they were fine and no longer experienced symptoms.
  
• The pseudo patients spent time writing notes about their observations. Initially this was done secretly although as it became clear that no one was bothered the note taking was done more openly.
  

Front 23

How did the pseudo patients attempt to get discharged?

Back 23

The pseudopatient, very much as a true psychiatric patient, entered a hospital with no foreknowledge of when he would be discharged. Each was told that he would have to get out by his own devices, essentially by convincing the staff that he was sane.

Front 24

Results

Back 24

• All of the pseudo patients disliked the experience and wished to be discharged immediately.
  
• None of the pseudo patients was detected
  
• This diagnosis was made without one clear symptom of this disorder.
  
• They remained in hospital for 7 to 52 days (average 19 days)
  
• Visitors to the pseudo patients observed no serious behavioural consequences'.
  
• Although they were not detected by the staff, many of the other patients suspected their sanity (35 out of the 118 patients voiced their suspicions).
  
• Some patients voiced their suspicions very vigorously for example you’re not crazy. You’re a journalist, or a professor. You’re checking up on the hospital.While most of the patients were reassured by the pseudopatient’s insistence that he had been sick before he came in but was fine now, some continued to believe that the pseudopatient was sane throughout his hospitalization. The fact that the patients often recognized normality when staff did not raises important questions.
  

Front 25

What was the diagnosis of admission and discharge?

Back 25

All but one were admitted with a diagnosis of schizophrenia and were discharged with a diagnosis of 'schizophrenia in remission'

Front 26

How were the behaviours of pseudo patients interpreted by hospital staff?

Back 26

• The pseudo patients normal behaviours were often seen as aspects of their supposed illness. For example, nursing records for three of the pseudo patients showed that their writing was seen as an aspect of their pathological behaviour. 'Patient engages in writing behaviour’.
  
• Rosenhan notes that there is an enormous overlap in the behaviours of the sane and the insane. We all feel depressed sometimes, have moods, become angry and so forth, but in the context of a psychiatric hospital, these everyday human experiences and behaviours were interpreted as pathological.
  
• Another example of where behaviour was misinterpreted by staff as stemming from within the patient, rather than the environment, was when a psychiatrist pointed to a group of patients waiting outside the cafeteria half an hour before lunchtime. To a group of registrars (trainee psychiatrists) he suggested that such behaviour was characteristic of an oral-acquisitive syndrome. However, a more likely explanation would be that the patients had little to do, and one of the few things to anticipate in a psychiatric hospital is a meal.
  

Front 27

Responses of psychiatrists and nurses towards pseudo patients requests

Back 27

• Moves on with head averted : psychiatrists-71%, nurses-88%
  
• Makes eye contact: psychiatrists-23%, nurses-10%
  
• Pauses and chats: psychiatrists-2%, nurses-4%
  
• Stops and talks: psychiatrists-4%, nurses-0.5%
  

Front 28

How did Rosenhan explain the experience of hospitalization as explained by the pseudo patients?

Back 28

• Rosenhan noted that experience of hospitalisation for the pseudo patients was one of depersonalisation and powerlessness.
  
• Powerlessness and depersonalisation were evident in the ways in which the patients were deprived of many human rights such as freedom of movement and privacy. Medical records were open to al staff members regardless of status or therapeutic relationship with the patient and personal hygiene was monitored and many of the toilets did not have doors.
  
• Some of the ward orderlies would be brutal to patients in full view of other patients but would stop as soon as another staff member approached. This indicated that staffs were credible witnesses but patients were not.
  

Front 29

What did the pseudo patients do when given medication?

Back 29

It was estimated that the pseudo patients were given a total of 2,100 medication tablets, though only two were swallowed. The rest were either pocketed or flushed down the toilet.

Front 30

Describe the amount of time the hospital staff spent time in the ward

Back 30

• The average amount of time spent by attendants outside of the cage was 11.3 percent (range, 3 to 52 percent).
  
• On the average, daytime nurses emerged from the cage 11.5 times per shift, including instances when they left the ward entirely (range, 4 to 39 times). Later afternoon and night nurses were even less available, emerging on the average 9.4 times per shift (range, 4 to 41 times). Data on early morning nurses, who arrived usually after midnight and departed at 8 a.m., are not available because patients were asleep during most of this period.
  
• Physicians, especially psychiatrists, were even less available. They were rarely seen on the wards.On the average, physicians emerged on the ward 6.7 times per day (range, 1 to 17 times).
  

Front 31

How did the pseudo patients cope with the effects of depersonalization?

Back 31

• a graduate student in psychology asked his wife to bring his textbooks to the hospital so he could “catch up on his homework” – this despite the elaborate precautions taken to conceal his professional association.
  
• The same student, who had trained for quite some time to get into the hospital, and who had looked forward to the experience, “remembered” some drag races that he had wanted to see on the weekend and insisted that he be discharged by that time.
  
• Another pseudopatient attempted a romance with a nurse. Subsequently, he informed the staff that he was applying for admission to graduate school in psychology and was very likely to be admitted, since a graduate professor was one of his regular hospital visitors.
  
• The same person began to engage in psychotherapy with other patients – all of this as a way of becoming a person in an impersonal environment.
  

Front 32

Outline the procedure of the second experiment

Back 32

• In the secondary study, the staff of a teaching and research hospital, which was aware of the first study, was falsely informed that during the next three months one or more pseudo patients would attempt to be admitted into their hospital.
  
• Staff members were asked to rate on a 10-point scale each new patient as to the likelihood of them being a pseudo patient.
  
• This false information was the manipulated independent variable.
  
• The dependent variable was the number of patients which staff subsequently suspected of being pseudo patients.
  

Front 33

Outline the results of the second experiment

Back 33

• Number of patients judged =193
  
• Number of patients confidently judged as pseudo patients by at least one staff member =41
  
• Number of patients suspected by one psychiatrist =23
  
• Number of patients suspected by one psychiatrist and one other staff member =19
  

Front 34

What did Rosenhan conclude?

Back 34

• It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals. The hospital itself imposes a special environment in which the meaning of behavior can easily be misunderstood. The consequences to patients hospitalized in such an environment – the powerlessness, depersonalization, segregation, mortification, and self-labeling – seem undoubtedly counter-therapeutic.
  
• The main experiment illustrated a failure to detect sanity, and the secondary study demonstrated a failure to detect insanity.
  
• Failure to detect sanity during the course of hospitalization may be due to the fact that physicians operate with a strong bias toward what statisticians call the Type 2 error. This is to say that physicians are more inclined to call a healthy person sick (a false positive, Type 2) than a sick person healthy (a false negative, Type 1). The reasons for this are not hard to find: it is clearly more dangerous to misdiagnose illness than health. Better to err on the side of caution, to suspect illness even among the healthy.
  
• Rosenhan explains that psychiatric labels tend to stick in a way that medical labels do not and that everything a patient does is interpreted in accordance with the diagnostic label once it has been applied.
  
• He suggested that instead of labeling a person as insane we should focus on the individual’s specific problems and behaviours.
  

Front 35

Reliability of study

Back 35

Psychiatric diagnosis of mental illness is reliable. This means that all psychiatrists made the same decision to admit. This is good and the way it should be.

Front 36

Validity of study

Back 36

Psychiatric diagnosis of mental illness is not valid. People with lake symptoms were diagnosed as haVing mental illness and so psychiatrists cannot distinguish between who is sane and who is insane. This is n0t good at all and suggests incompetence.

Front 37

Explanation of why psychiatrists admitted patients

Back 37

The psychiatrists were not incompetent and did their jobs very well. So why diagnose as insane people who are sane? Symptoms: sane people do not telephone a mental institution and ask for an appointment; sane people do nOt claim to hear voices; hearing voices is a legitimate symptom of schizophrenia. This creates doubt for a psychiatrist. ls it better to send a sick person away or is it better to test further to be sure and admit? To say a sick person is healthy is a type 1 error and amounts to medical negligence. To admit someone who might be sick but is actually healthy is a type 2 error and, although an error, it is being cautious and, for these psychiatrists, was the correct decision.

Front 38

Strengths of the study

Back 38

• The participant observation meant that the pseudo patients could experience the ward from the patient’s perspective while also maintaining some degree of objectivity.
  
• The study was a type of field experiment and was thus fairly ecologically valid whilst still managing to control many variables such as the pseudo patient’s behaviour.
  
• Rosenhan used a range of hospitals. They were in different States, on both coasts, both old/shabby and new, research-orientated and not, well staffed and poorly staffed, one private, federal or university funded. This allows the results to be generalised.
  

Front 39

Weaknesses of study

Back 39

• The hospital staff was deceived - this is, of course, unethical. Although Rosenhan did not conceal the names of hospitals or staff and attempted to eliminate any clues which might lead to their identification
  
• Rosenhan did note that the experiences of the pseudo-patients could have differed from that of real patients who did not have the comfort of knowing that the diagnosis was false.
  
• Perhaps Rosenhan was being too hard on psychiatric hospitals, especially when it is important for them to play safe in their diagnosis of abnormality because there is always an outcry when a patient is let out of psychiatric care and gets into trouble.
  
• If you were to go to the doctors complaining of stomach aches how would you expect to be treated?
  
• Doctors and psychiatrists are more likely to make a type two error (that is, more likely to call a healthy person sick) or false positive than a type one error (that is, diagnosing a sick person as healthy) a false negative
  
• When Rosenhan did his study the psychiatric classification in use was DSM-II.
  
• However, since then a new classification has been introduced which was to address itself largely to the whole problem of unreliability - especially unclear criteria. It is argued that with the newer classification DSM-III, introduced in the 1980s, psychiatrists would be less likely to make the errors they did. The DSM is currently in its fourth edition (DSM-IV)
  

Front 40

Evaluation of explanation

Back 40

• The study demonstrates both the limitations of classification and importantly the appalling conditions in many psychiatric hospitals.
  
• This has stimulated much further research and has lead to many institutions improving their philosophy of care.
  
• Rosenhan, like other anti-psychiatrists, is arguing that mental illness is a social phenomenon. It is simply a consequence of labeling. This is a very persuasive argument, although many people who suffer from a mental illness might disagree and say that mental illness is a very real problem