On Being Sane in Insane Places (1973) D.L. Roshenhan – The Psychology of Individual Differences

Introduction  Case Study – “On Being Sane in Insane Places” (1973)  Author – D. L. Rosenhan  Approach to Psychology – Psychology of Individual Differences  Determining/studying the differences, or abnormalities among people (certain population).  What makes us different!?  Study of abnormalities  Schizophrenia in the Roshenhan case

Background  Overarching Question – If sanity and insanity exist, how we shall know (recognize) them?  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?  Overarching Question – How reliable are diagnosis of abnormality?  If “normal” people attempt admission, how, or will, they be detected?

Background  A long history of attempting to classify abnormal behavior. medical model  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 (physical) illness  Beginning in the 1950s the medical model has used the Diagnostic and Statistical Manual of Mental Disorders (DSM) to classify abnormal behavior

Background, Cont’d  The Medical Model:  Assumes that psychological disorders are mental illnesses that need to be diagnosed & cured through therapy or medication  DSM – IV – TR  The Diagnostic and Statistical Manual of Mental Disorders provides a classification scheme.  Describes disorders and their prevalence without presuming to explain their causes

Labels  Labels  Although diagnostic labels may facilitate communication and research, they can also bias our perception of people’s past and present behavior and unfairly stigmatize these individuals.

Aims/Theories 1.Rosenhan hypothesized that psychiatrists cannot reliably tell the difference between people who are sane and insane  If this is true then the entire classification system and perhaps the medical model must be rejected for lack of validity 2.To investigate whether the “salient” (important) characteristics that lead to diagnosis reside in patients themselves (the individual) or in the environments and contexts (situation) in which observers find them). 3.To describe the conditions in the hospitals

Psychological Jargon  Sanity  Insanity  Type 1 Error – rejecting the null hypothesis when in fact it is true  Sick person = healthy, send them away!  For example, a test tells you that you have a disease when in fact you do not. This is also known as a “false negative”.  Type 2 Error – accepting the null hypothesis (there is difference) when it is not true.  rejecting the null hypothesis when in fact it is true.  Admit somebody who might be sick, but is actually healthy.  False – positive  Pseudo – Patients  Representative Sample  Depersonalization  Doctors  Staff (nurses)  Label

Essential Vocabulary  Sanity  Definition: the ability to think and behave in a normal and rational manner; sound mental health.  Application: If sanity and insanity exist, how we shall know (recognize) them  Insanity  Definition: a state of being seriously mentally ill; madness.  Application: If sanity and insanity exist, how we shall know (recognize) them  Pseudo – Patients  Definition: A researcher that poses as a patient.  Application: name for the stooges (including Rosenhan) that went into the mental hospitals to conduct participant observation

Essential Vocabulary  Representative Sample  Definition: group of participants selected from a larger population that closely matches the characteristics of the population as a whole.  Fairly accurate reflection of the population from with the sample is drawn.  Application: To be able to generalize findings, a variety of hospitals were chosen in the United States of America to provide valid and reliable data.  Label  Definition: identity and behavior of people are influenced by how society classifies them.  Application: Doctors and nursing staff assigned the label of insanity to the pseudo – patients, even though they were not insane. Therefore, this presented a major challenge of getting out of the hospital.  Depersonalization  Definition: social alienation resulting from the loss of individuation in the community.  Application: The pseudo – patients underwent depersonalization as they were assigned the label of insanity; they were treated as part of the insane groups, which was less than human.

Essential Vocabulary  Individual Differences  Definition: the study of the differences that exist between individuals in a society; study of abnormal behavior.  Application: Rosenhan studies how people with abnormal behaviors (insanity) are treated differently by members of society (doctors and nursing staff).

Methodologies  Participant observation  the researcher (Rosenhan and pseudo – patients) faked illness to ‘hide away’ among patients  Natural/field experiment  Appointment  Appointment (interview) between doctor and “insane” pseudo – patients.  10 point ‘confidence’ scale (study #2)

Procedure – Study #1  The Pseudo – patient telephone a hospital and made an appointment  The pseudo – patient arrived at the admissions office and complained of hearing voices: the voices were often unclear but said: ‘empty’, ‘hollow’, and ‘thud’.  The voices were unrecognizable but the same sex.  Controls!  Other than making up a name, job, and auditory hallucinations, every other detail (upbringing, relationships), was correct.  All pseudo – patients were admitted (including Rosenhan)  Did not show outward signs of psychopathology (or so they thought!)  As soon as they were admitted, patients STOPPED simulating any symptoms of abnormality  Complied with all orders (took meds but did not swallow pills).  Spent time writing down observations about the ward, patients, and staff  They knew discharge would come after convincing staff that they were sane

Participants & Experimenters  Participants:  The “participants” where the doctors in nurses who happened to work in the 12 hospitals chosen for the study.  They did not know that they were taking part in the study.  Experimenters:  Rosenhan and his confederates:  Pseudo – patients: An actor who participates in a psychological experiment pretending to be a subject but in actuality working for the researcher (also known as a "stooge").  7 (8 including Rosenhan) sane people  Psychology graduate, three psychologists, a psychiatrist, a painter, a pediatrician, and a housewife.  Three women and five men.

Ethical Guidelines  This study is completely unethical, no doubt about it.  Participants (doctors and nursing staff) in the 12 hospitals had no idea that they were taking part in an experiment.  No consent was given.  However, do the ends justify the means?  Was this study by Rosenhan needed in order to discover numerous important aspects about the psychological community as a whole?  Labels?  Diagnosis?  Conditions of mental instructions?  How to prove that a person is sane (possibly the shedding of labels)?

Data Collection  Data was gathered both quantitatively and quantitatively.  Quantitatively data was gathered by Rosenhan and his fellow pseudo – patients by recording self – initiated contact by pseudo – patients with psychiatrists and nurses/attendants.  Example:  Moves on, averted  Makes eye contact  Pauses and chats  Qualitative data was gathered through the notes that Rosenhan and his fellow pseudo – patients took during their stay in the mental institution.  Rosenhan’s study was longitudinal.  Remember, some peoples’ stay in the mental institution was up to 52 days.

Findings & Results, Study #1 1.All twelve experiments were admitted  11 diagnosed with schizophrenia  1 diagnosed with manic depression 2.Patients had been labeled.  Earliest release of a sane experimenter was 7 days, the longest was 52 days  Average 19 days  A label of insanity had been assigned to each experimenter, which made it complicated to get out.  Once out, patients were not cured, but labeled with “schizophrenia in remission”. 3.Patients were treated, judged, and labeled possibly unfair by society, as seen in the ward of the mental institutions by each experimenter through participant observation.  “Normal” behavior was seen as abnormal, or led to false assumptions, by doctor and staff.  Example: Bored pacing was a sign of nervousness or anxiety.

Findings & Results, Study #1 Cont’d 4.Many of the real mental patients “discovered” that the pseudo – patients were no real patients at all.  However, none of the doctors and medical staff ever busted the pseudo – patients. 5.Numerous staff members were verbally and physically abusive in the presence of other patients.  However, the abuse ceased when other staff was present. 6.Privacy was limited and controlled  Example, no door for the toilets  Quoted for safety reasons. 7.Contact was limited between staff and patients.  Nurses retreated to their designated areas, “cages”, in the nursing areas. 8.Demonstrating their sanity, pseudo – patients attempted to interact with the ward’s staff.  Staff was uninterested in interacting with patients, even a simple conversation!

Explanations of Rosenhan’s Findings 1.Psychiatrists are not incompetent. In fact, Rosenhan would summarize that the psychiatrists did their jobs very well.  Somebody calls a mental institution, makes an appointment and says they hear voices.  Easy call, this person is insane and is a schizophrenic. Admit him/her!  Is it better to have medical negligence or admit somebody that is healthy but being cautious.  Type 1 vs. Type 2 error 2.Situation dictated the labeling of the patients by the nursing staff.  Only insane people are in an insane asylum. 3.Stickiness of psycho – diagnostic labels  It is extremely difficult for an individual to shed themselves of the label of mentally insane/ill. 4.Pseudo – patients, and the mentally ill, are victims of powerlessness and depersonalization.

Methods – Study #2  One hospital selected who doubted the findings from study 1  Goal – in 3 months, one or more pseudo – patients would attempt to gain admittance into the psychiatric hospital.  Each patient that was admitted was rated on a 10 point scale  1 = extremely confident patient was fake  10 = not a pseud – patient  193 patients admitted!

Results of Study #2  41 patients were judged with high confidence to be insane.  83 (43%) were judged in some way to be pseudo – patients.  23 were judged as “suspect” by at least one psychiatrist.  19 were suspected as fake by one psychiatrist and one other staff member.  Psychiatric diagnosis raises major questions concerning reliability and validity  Study 2 claimed real patients were possible fakes.  And, the best part of it all…  Rosenhan did no send anyone at all!

Methodological Issues – Reliability & Validity  Reliability:  The diagnosis of mental illnesses is reliable  All psychiatrists made the same decision to admit (the way it should be)  Validity:  Psychiatric diagnosis of mental illness is NOT valid!  People with fake symptoms were diagnosed as having mental illness  Psychiatrists cannot distinguish between who is sane and insane.  Suggests incompetence

Strengths and Limitations  Strengths: 1.Pseudo – patients could experience the ward from the patients’ perspective due to participant observation. 2.Since this is a field experiment, there is higher ecological validity. 3.Controls – pseudo – patients behavior  Gaining access to the hospital (story)  Actions inside the hospital to achieve release. 4.Representative sample – Rosenhan used a variety of hospitals so results can be generalized.  Different states, both coasts, old and new.  Some hospitals were private while others were federal  Staff and understaffed

Strengths and Limitations  Limitations: 1.Ethics  Since the hospital staff was deceived, this case study is unethical.  However, we do not know the precise hospital names and their staff members, so Rosenhan was attempting to be ethical. 2.Pseudo – patients experience differed from a real patient because they were not actually insane.  The knew that their diagnosis was false. 3.More type 2 errors than type 1  Playing it safe!  Was Rosenhan overly critical?