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ROSENHAN (1973)ON BEING SANE IN INSANE PLACES(INDIVIDUAL DIFFERENCES APPROACH)
Aims
Briefly describe the individual differences approach
Give a definition of abnormality Explain the problems with defining
abnormality Hard to say what is normal Diagnosis may act as label, leading to
discrimination List the key features of schizophrenia
The individual differences approach Individual difference psychology
examines how people differ in their thinking, feeling and behaviour. (The other approaches tend to focus on similarities).
For example, people can be classified according to intelligence and personality characteristics. Other areas studied might include values and self-esteem.
WHAT IS ABNORMAL BEHAVIOUR?
Joan of Arc
Rosenhan & Seligman: Criteria for diagnosing abnormality
1. Suffering. But some people
(e.g.psychopaths) have no concept of suffering. And normal people suffer too.
Rosenhan & Seligman: Criteria for diagnosing abnormality
2.Maladapativeness. Behaviours that prevent people from
living a fulfilling life Example: fear of leaving the house
prevents them from doing anything
Rosenhan & Seligman: Criteria for diagnosing abnormality
3.Vividness and unconventionality But unconventionality doesn’t always
indicate mental illness!
Rosenhan & Seligman: Criteria for diagnosing abnormality
4. Unpredictability and loss of control
Rosenhan & Seligman: Criteria for diagnosing abnormality
5. Irrationality and incomprehensibility We need to be careful when judging
someone’s behaviour as irrational – perhaps their behaviour actually has a sensible cause.
Rosenhan & Seligman: Criteria for diagnosing abnormality
6.Observer discomfort
Rosenhan & Seligman: Criteria for diagnosing abnormality
7.Violation of moral and ideal standards E.g. committing murder.
Which of the 7 criteria occur in normal people?
All of them! So you can see it’s difficult to
diagnose someone as mentally ill.
Some definitions of abnormalityStratton & Hayes (1993) ..
Abnormality is behaviour which: deviates from the norm
most people don’t behave that way
does not conform to social demands
most people don’t like that behaviour
is maladaptive or painful to the individual
It’s not normal to harm yourself
Problem with definining abnormality…. All of these features
sometimes appear in “normal” people, so it’s difficult to diagnose someone as mentally ill.
Normality is also CULTURALLY DEFINED..
Cultural definition of deviance
Categorising Mental Illness Diagnostic and Statistical Manual of
Mental Disorders (DSM-IV) International Statistical Classification
of Diseases and Related Health Problems (ICD)
Social Stigma? Many people misunderstand and may even fear those
with a mental illness. Once a person has been diagnosed with mental illness,
they may face social stigma where they may be misunderstood or even feared by others.
They may find that their diagnosis labels them, so that their ordinary behaviour is interpreted as a symptom of illness. They may be discriminated against, for example when seeking employment.
However, mental illness is widespread. Frank Bruno, one of the nations favourite Boxers who won the ABA Heavyweight Championship at just 18 had to be sectioned in 2003 for depression. This shows how anyone can be affected by mental illness, whether famous, successful or otherwise. Similarly Stephen Fry suffers from bipolar disorder.
What is Schizophrenia?
A serious mental disorder Positive Symptoms (additional to
normal behaviour) include: hallucinations, delusions and thought disorder
Negative Symptoms (reduction in normal experiences or behaviour) include flattened affect and lack of motivation.
WHAT DO YOU THINK IT WOULD BE LIKE TO HAVE SCHIZOPHRENIA?
How did it feel?
If you had a mental illness how would you like to be treated?
The Question
If sanity and insanity exist
How shall we recognise them?
Background summary
Briefly describe the individual differences approach
Give a definition of abnormality Explain the problems with defining
abnormality Hard to say what is normal Diagnosis may act as label, leading to
discrimination List the key features of schizophrenia Explain how schizophrenia is usually
treated.
D.L. Rosenhan (1973) The ground breaking study :
“On being sane in insane places”
Approach: Individual Differences Definition: Examines how people
differ in their thinking, feeling, and behaviour.
Aim
Overall: To see if psychiatrists could differentiate between sane and insane people.
Method: Field experiment, with participant observation.
Qualitative data – rich and detailed
High ecological validity
Fewer demand characteristics
Difficult to replicate – lower reliability
Difficult for researcher to remain objective – danger of subjective interpretation
Time-consuming Ethical issues –
deception Lack of control
over confounding variables.
Aims of the 3 studies
Study one: To see if sane people could get themselves admitted to psychiatric hospitals
Study two: To see if the hospitals, who had been told they were going to be approached by pseudo-patients, would be able to tell the sane from the insane.
Study three: To investigate patient/staff contact
Study 1: Participants
Hospital staff and patients
Also: the participant observers: EIGHT sane people one graduate student three psychologists a paediatrician a painter Housewives
Method
Field experiment, with participant observation.
Procedure: Study 1
telephoned 12 psychiatric hospitals for urgent appointments
gave false name and address complained of hearing unclear voices … saying
“empty, hollow, thud” Simulated ‘existential crisis’ “Who am I, what’s it all for?”
Once admitted,they stopped simulating any symptoms and took part in ward activities
They took notes of their experiences while in the hospital.
IV and DV
Study 1: IV: Participants pretence to get into hospital
DV: Psychiatrists admission of participants, and strength of diagnostic label
Controls: Study One
All Ps presented with the same symptom at the various hospitals – ie reporting hearing voices saying “empty”, “hollow”, or “thud”.
All Ps behaved normally apart from this.
What happened?
All were admitted to hospital
All but one were diagnosed as suffering from schizophrenia
How did the ward staff ‘see’ them? Normal behaviour was
misinterpreted Writing notes was described as -
“The patient engaged in writing behaviour”
Arriving early for lunch described as “oral acquisitive syndrome” Behaviour distorted to ‘fit in’ with label
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.
Role play: How would YOU convince someone you are sane?
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!
What sorts of records did they keep?
Nurses stayed in ward offices 90% of time
Each ‘real patient’ spent less than 7 minutes per day with psychiatric staff
Perhaps they behaved ‘abnormally’
Pseudo-patient’s visitors detected “No serious behavioural consequences”
DID ANYONE SUSPECT?
What about the REAL patients? 35 out of 118 patients voiced their
suspicions
On release -
The pseudo-patients were diagnosed as
Schizophrenia “IN REMISSION” Labels are “sticky” – they remain
with you even when you are well.
Results: Study 1 All pseudo-patients admitted to hospital. Normal behaviour was interpreted as insane.
“Patient engages in writing behaviour” Patients were powerless
No staff members suspected them, although 35 patients voiced their suspicions.
Evidence that their behaviour was in reality normal: Pseudo-patient’s visitors detected “No serious behavioural consequences”
Pseudo-patients stayed in hospital between 7 and 52 days (mean 19)
Pseudo-patients recorded staff-patient interaction: noted that nurses stayed in ward offices 90% of time, and each ‘real patient’ spent less than 7 minutes per day with psychiatric staff
7 out of 8 diagnosed as schizophrenic. Discharged with diagnosis of “schizophrenia in remission”.
“stickiness” of labels Labels as self-fulfilling prophecies
Conclusion: Study 1
Psychiatrists could not detect sanity.
Study 2: Participants
Hospital staff at a large teaching and psychiatric hospital
Opportunity sample Field experiment
Procedure: Study 2
A teaching and psychiatric hospital that was aware of the findings from study 1 was informed that over the next 3 months one or more pseudo-patients would try to get admitted to their hospital.
Each member of staff was asked to rate the likelihood that the patients who sought to be admitted were pseudo-patients.
In reality, no pseudo-patients were admitted.
Study Two
IV: False information given to hospital
DV: Number of patients that staff suspect of being pseudo-patients
Controls: Study 2
None
Results: Study 2
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 at
least two members of staff) 23 rated as pseudo-patient (by at least
one psychiatrist) 19 rated as pseudo-patient (by a
psychiatrist and one other member of staff)
Conclusions: Study 2
The staff were unable to detect insanity.
Study 3: Participants
Doctors and staff in 4 of the hospitals used in Study One
Opportunity sample Method: Field experiment with
participant observation
Procedure: Study 3
In 4 of the hospitals pseudo-patients approached a member of staff and asked~ “Pardon me, Mr/Mrs/Dr X, could you
tell me when I will be eligible for ground privileges?”
The pseudo-patient did this as normally as possible and avoided asking the same member of staff more than once a day.
Study 3: IV and DV
IV: “Patient” or visitor DV: Level of contact between
staff and subject Control: Young female participant
stopped faculty members on university campus and asked various questions eg “I’m looking for a psychiatrist”.
Results: Study3
Psychiatric Hospital
Psychiatric Hospital
University campus
Responses (%)
Psychiatrists Nurses Faculty
Moves on, head averted
71 88 0Makes eye contact
23 10 0Pauses and chats
2 2 0Stops and talks
4 0.5 100No. of respondents
13 47 14No. of attempts
185 1283 14
Conclusion: Study 3
Patients are powerless while on the mental ward
The lack of eye contact between staff and patients depersonalises the patients.
Type 1 vs Type 2 errors
Type 1 error: False negative (diagnose a sick person as healthy)
Type 2 error: make a false positive choice (diagnose a healthy person as sick)
Why did the doctors not realise that the pseudo-patients were sane?
Can’t blame… Quality of the hospitals Time available to observe them Their behaviour
Recognised as sane by many PATIENTS!
May be because doctors have a bias towards Type 2 errors ( false positives, where a healthy person is diagnosed as sick) over Type 1 errors (false negatives, where a sick person is diagnosed as healthy).
Erring on the side of caution
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’ In the follow up study :We are unable to detect ‘insanity’
Rosenhan’s study highlighted The depersonalisation and
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
Powerlessness and Depersonalisation Depersonalisation: Where people are not treated as unique individuals,
worthy of respect. Shown through the following: Patients were deprived of many human rights such as freedom of
movement and privacy. For example physical examinations were conducted in semi-private rooms.
Medical records were open to all staff members regardless of status or therapeutic relationship with the patient
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 staff were credible witnesses but patients were not.
Staff treated patients will little respect, beating them and swearing at them for minor incidents
General activity around the patients was conducted as though they were invisible.
Patients were unable to initiate contact with staff. This depersonalisation led to the patients feeling powerless.
Examples of depersonalisation Patients were deprived of many human rights
such as freedom of movement and privacy. They could not leave the hospital, and physical examinations were conducted in semi-private rooms.
Medical records were open to all staff members regardless of status or therapeutic relationship with the patient
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 staff were credible witnesses but patients were not.
Staff treated patients will little respect, beating them and swearing at them for minor incidents
General activity around the patients was conducted as though they were invisible.
Patients were unable to initiate contact with staff.
This depersonalisation led to the patients feeling powerless.
Rosenhan’s summary and conclusion… We cannot distinguish the sane from
the insane all of the time. Hospitalisation for the mentally ill
isn’t the solution as it results in powerlessness, depersonalisation, segregation, mortification and self-labelling- all counter-therapeutic.
What do the results of this study tell us about human behaviour? From the study we can infer that it is not always
possible for doctors to differentiate between sane and insane people. Once given, a label of mental illness creates expectations.
This can be seen in Study 1, where 7 out of 8 researchers were diagnosed as schizophrenic, and in Study 2, where both psychiatrists and staff members evaluated sick people as healthy.
Therefore it may be better to place abnormal individuals in community healthcare to avoid the institutional context. It may also be better to focus on behavioural diagnoses rather than global labels such as “schizophrenia”.
Practical applications
Perhaps should increase number of criteria used to diagnose mental illnesses.
Reduce abuse of power in mental institutions by staff – CCTV
Change number of professionals needed to diagnose disorders – can’t rely on just one individual.
Ethics
Deception? Informed consent? Withdrawal? Protection?
Undermine confidence of doctors and nurses
Ecological Validity
Very high ecological validity Process of being admitted to a
hospital, the experience of life in a hospital, and discharge, was true to life.
Qualitative and Quantitative Data
Quantitative data: numbers admitted and discharged in Study 1; number of faulty diagnoses made in Study 2; social interaction data from Study 3.
Qualitative data: experience of being in hospital, feelings of powerlessness and depersonalisation
Problems with the qualitative data?
Longitudinal vs snapshot
Study 1: 52 days Study 2: Took place over a 3 month
period Long enough to see change over
time.
Discussion question:
Why might the reports of the pseudo-patients have been unreliable?
Strengths and Weaknesses
Strengths Weaknesses High ecological validity Insightful Quantitative and
qualitative data – increases validity
High validity – covert observation
Few demand characteristics – p’s don’t know they’re being studied – increases validity
Reported same symptoms to each hospital – increases reliability
Symptoms well-chosen – valid way of testing reliability of diagnostic systems
Used a range of hospitals
Unethical Ethnocentric Possibility of observer bias –
P’s knew aim of experiment – Rosenhan was one of them! Decreases validity
Study 1: only 12 hospitals Study 2: only 1 hospital Unreliable: interactions after
intake not controlled Difficult to record details
accurately and promptly while participating. Decreases validity.
Alternative method
Send a self-report questionnaire to doctors giving them scenarios (I’m hearing voices – hollow, thud, empty) and asking on a scale of 1-10 how likely they would be to put them into the hospital.
Advantage: cheaper, easier, no ethical issues, more representative (larger sample possible)
Disadvantage: people will probably not give accurate answers, either through lack of self-knowledge or because they want to give the socially desirable answer.
Effect on results: results will be lower in validity but more reliable.
Alternative method
Conduct the study cross-culturally: eg UK, USA, Australia
Advantage: be able to see whether there are cross-cultural differences and similarities
Disadvantage: Expensive, time-consuming. Ethical issues remain.
Effect on the results: make the sample more representative, therefore will be able to generalise results.
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