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”?

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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?”

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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”?