On being sane in insane places Rosenhan (1973) On being sane in insane places

The plan for today Brief recap of Sperry (1968). Introduction to Individual Differences approach. Procedure, Results and Conclusion for Rosenhan. Evaluation of Rosenhan. Summary quiz of Rosenhan.

Handout to recap Sperry

By the end of the lesson you should be able to … Appreciate the difficulties involved in objectively diagnosing abnormality. Describe the procedure for Study 1 and Study 2. Describe the findings for Study 1 and Study 2. Evaluate the ethics, ecological validity, generalisability and usefulness of this study. Discuss alternative ways of carrying out the study.

Introduction to the Individual Differences approach Main assumption To understand the complexity of human behaviour we need to study the differences between people rather than the things we have in common. Focus on personality differences and abnormality.

What is abnormality?

Choosing to live alone with ten guinea pigs.

Having conversations with a voice in your head.

Only eating food you’ve grown yourself.

Refusing to drink coffee or tea.

Having a diagnosis of Clinical Depression.

Being unhappy unless you’ve spent an hour at the gym each day.

Being afraid to speak in public.

Having a conversation with Jesus.

Telling stories to a tennis ball.

Being afraid of Clingfilm.

What is abnormal? Write down at least 2 behaviours that YOU consider to be a sign of psychological abnormality. Write down WHY you think each of these behaviours are abnormal.

Common definition of abnormality Stratton & Hayes (1993) : Abnormality is Behaviour which deviates from the norm (most people don’t behave that way) Behaviour which does not conform to social demands (most people don’t like that behaviour) Behaviour which is maladaptive or painful to the individual (it’s not normal to harm yourself)

What is abnormal? Did your examples fall into those categories? Do you think it’s easy to define abnormality?

Background - Diagnosis If symptoms are grouped together and classified into a ‘syndrome’ the true cause can eventually be discovered and appropriate physical treatment administered This is a Medical Model a.k.a Psychiatry. The model assumes biological causes.

Background – How is diagnosis made? DSM (Diagnostic and Statistical Manual of Mental Disorders) has been used since 1950s to classify abnormal behaviour by American psychiatrists. ICD-10 (International Classification of Diseases) used by psychiatrists in the UK.

Background - Labelling PROS AND CONS OF THIS APPROACH? Categorisation may help research and communication between professionals. Do YOU think there’s a stigma attached to mental illness? HOWEVER – they can bias our perception of past and present behaviour and stigmatise individuals. Think of some labels for madness? ‘Crazy’ ‘Psycho’ ‘Loony’

True or false? Homosexuality was considered a mental illness until 1973 (according to the DSM). One in six people will experience a mental health problem this year in the UK. British men are three times more likely to die by suicide than British women. 7 out of 10 prisoners in the UK has a mental health disorder. A quarter of people diagnosed with depression are also diagnosed with anxiety (USA).

True or false? 6) Men make up 10 – 15% of the population with anorexia or bulimia. 7) In some cultures Depression and Schizophrenia do not exist. 8) Schizophrenia is about having a split personality. 9) Around 800,000 people commit suicide every year across the world. 10) The UK has one of the highest rates of self harm in Europe (400 people per 100,000).

What is ‘Normal’? Think of your own example for each Cultural What is normal in one culture may not be normal in another. Historical Behaviours not seen as normal previously may be now and vice versa. Context Behaviours in one situation may be normal but not in another Think of your own example for each

Rosenhan’s idea Rosenhan disagreed with the Medical Model. He wanted to see if psychiatrists could really differentiate the sane from the insane.

What debate??? Rosenhan’s idea What if sane people acted as they did all the time but they were in a mental hospital? If they were then diagnosed as mentally ill this would suggest that this diagnosis had been given just because of their environment rather than the patients themselves. What debate???

Is madness in the eye of the beholder? In other words: Is madness in the eye of the beholder? https://www.youtube.com/watch?v=D8OxdGV_7lo Up to 6:06

Study 1 - Aim To investigate if sane people who present themselves to a psychiatric hospital would be diagnosed as being insane. Overall – to test the reliability & validity of psychiatric diagnosis. P43

Study 1 – The sample Pseudopatients Eight sane people; One graduate student, three psychologists (including Rosenhan), a pediatrician, a psychiatrist, a painter and a housewife. Three women and five men. Participants Telephoned 12 different hospitals, in five different states in the USA (old/modern, well-staffed and poorly-staffed). Doctors and nurses at each hospital were the real participants. p49

Study 1 - Procedure Telephoned 12 psychiatric hospitals for urgent appointments. Arrived at admissions. Gave false name and address. Gave all other ‘life’ details correctly. Complained of hearing unfamiliar voices … saying “empty, hollow, thud”. Once admitted the ‘pseudopatients’ stopped simulating ANY symptoms, took part in ward activities and would stay until discharged. P43

Study 1 - Methodology Independent Variable Dependent Variable Methodology Hearing voices Admission to hospital and label given by psychiatrist. Field experiment Participant Observation

True and False handout for Methodology

Use P44 to find the answers to these questions 1) How many of the Pseudopatients were admitted to hospital? 2) How many Pseudopatients were detected as being fake? 3) What was the diagnosis given to most Pseudopatients? 4) How long did the Pseudopatients spend on the wards?

Study 1 - Results How many were admitted to hospital? 100% were admitted to hospital. What were they diagnosed with? All but one were diagnosed as suffering from schizophrenia (the other was diagnosed as manic depressive). p44

Study 1 - How long did they stay in hospital? They had agreed to stay until they convinced the staff they were sane: The shortest stay was 7 days The longest stay was 52 days The average stay was 19 days How would YOU convince someone you are sane? p44

Study 1 - Results What % of the time do you think nurses spent in their office per day? 90% How many minutes a day do you think each ‘real patient’ spent with psychiatric staff? Less than 7. Given a total of 2100 tablets. Flushed down the toilet as did real patients.

Study 1 – Results (Labelling) Normal behaviour was misinterpreted to ‘fit in’ with label: Writing notes was described as - “The patient engaged in writing behaviour” Arriving early for lunch described as “oral acquisitive syndrome”

Study 1 – Results (Staff behaviour) Response % Making Contact with Patients Psychiatrists Nurses Moves on with head averted 71 88 Makes eye contact 23 10 Pauses & Chats 2 4 Stops & Talks 0.5 Responses of staff towards Pseudopatients if patient approached staff with simple request.

Results – Pseudopatients experience Pseudo-patients reported a sense of powerlessness and depersonalisation: Freedom of movement is restricted. Cannot initiate contact with staff but must respond to them. Personal privacy is minimal. Medical records available to all staff members (even volunteers). Many toilets had no doors. Patients physically abused. P46

Results – Labels on discharge The pseudopatients were diagnosed when discharged with “schizophrenia in remission”. Which is more sticky? Medical label Psychiatric label

Do you think anyone noticed they were faking it? 35 out of 118 patients voiced their suspicions that the pseudo patients were reporters!

Answer Q 1- 9 in Booklets P 52 - 54

Study 2 A teaching & research hospital was told of the first study and challenged Rosenhan to test them. Rosenhan warned them that over the next three months ONE OR MORE pseudo-patient will attempt to be admitted. AIM: To see if the potentially insane patients could be judged as sane. P47

Study 2 - Methodology Independent Variable Dependent Variable Hospital told to expect Pseudopatients to come over the next 3 months. Number of patients the staff suspected of being Pseudopatients.

Study 2 - Procedure and Results Staff members rated ‘new patients’ on scale 1 - 10 as ‘how likely to be a fraud’ 193 patients ‘assessed’ in total. 41 rated as a pseudo-patient (by staff) 23 rated as pseudo-patient (by psychiatrist) 19 rated as pseudo-patient (by both)

How many psuedo-patients had been sent? NONE! No pseudo-patients were sent – the staff had been rating their regular (genuine) intake!

What did Rosenhan conclude? Back to his original questions: Do the characteristics of abnormality reside in the patients? or in the environments in which they are observed? Is madness in the eye of the beholder??

What did Rosenhan conclude? In the first study we are unable to detect sanity In the second we are unable to detect insanity “It is clear that we are unable to distinguish the sane from the insane in psychiatric hospitals”

Conclusions That behaviour is misinterpreted according to expectations of staff due to labelling (SANE AND INSANE). The medical model of abnormality is prone to two types of error. Type I = diagnosing sick person as healthy Type II = diagnosing a healthy person as sick

Answer Q 10-13 in Booklets P54

Some things to consider Hospitals err on the side of caution – what if they released a patient and s/he hurt someone else or themselves? If you had a physical health problem would you rather your GP make a type 1 or type 2 error?

Which evaluation points do you think are relevant for this study?

Ethics EVALUATION Ecological Validity Methodology Usefulness Generalisability

Methodology STRENGTHS WEAKNESSES Participant observation Could experience ward from patient perspective whilst remaining objective. Field experiment High ecological validity Participant observation Ethical concerns. Experimenter bias. Field experiment Low control over extraneous variables.

Generalisability Range of hospitals used across America. Only studied America. Time-specific - DSM has changed since (Currently DSM-5) – so reliability and validity of diagnoses may have improved.

Ecological Validity Naturalistic settings. Staff did not know they were being observed so would have been behaving normally. Pseudopatients may have been acting strangely without intention (not used to being in this environment). Note writing is quite unusual for patients. Do sane people try to get admitted to mental hospitals?

Ethics Informed consent Deception Harm and distress Right to withdraw Invasion of privacy Confidentiality Ends justify means?

Ethics No informed consent (S1). Hospital staff deceived (S1 about voices, S2 about Pseudopatients). Harm and distress – Could have been dangerous for Pseudopatients, treated disrespectfully by staff, saw distressing abuse of patients. Harm and distress – to hospital staff. No right to withdraw (couldn’t leave once admitted). Invasion of privacy of real patients. Rosenhan did conceal names of staff and hospitals so they could not be identified.

Usefulness Demonstrates limitations of classification/labelling  Stimulated changes to classifications. Pointed out the appalling conditions of some psychiatric hospitals  Led to many hospitals improving their philosophy of care.

What changes would you make. Implications of this change What changes would you make? Implications of this change? Effects of this change?

HW – Make sure you’ve filled in the summary and evaluation pages P 56 - 58

Summary quiz How many hospitals were used in the first study? How many hospitals were used in the second study? What was the aim for study 1? What was the range of hospitalisation length in study 1? What was the main diagnosis given in study 1?

Summary quiz 6) What behaviour was labelled ‘Oral acquisitive syndrome’? 7) Give one way in which patients were depersonalised. 8) What is a type 1 error? 9) Give one strength of the methodology used for study 1. 10) Name three ethical guidelines broken during these 2 studies.