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Rosenhan (1973)
Sane in Insane Places
Map to Spec – Page 61
4. Studies in detail
a) DescribeDescribe and evaluateevaluate Rosenhan (1973) “On being sane in insane places”
Map to Spec – Page 59
3. Content
c) Using the findings of studies, describe and evaluate reliabilityreliability, validity validity and cultural issues with regard to the diagnosisdiagnosis of disorders (including use of Diagnostic and Statistical Manual (DSM)).
"If sanity and insanity exist, how shall we know them?"
In other words….
Do the characteristics of abnormality reside in the patientspatients?
or In the environmentsenvironments in which they are
observed?
Does madness lie in the eye of the observer?
Background A long history of attempting to classifyclassify abnormal behavior.
Most commonly accepted approach to understanding & classifying abnormal behavior is the medical modelmedical model. Psychiatry Psychiatrists are medical doctors and regard mental
illness as another kind of illness (in addition to physical)
Beginning in the 1950s the medical model has used the Diagnostic and Statistical Manual of Mental Disorders (DSM) to classify abnormal behavior
The Medical Model
Assumes that psychological psychological disorders disorders are mentalmental illnesses illnesses that need to be diagnosed & diagnosed & treatedtreated through therapy or medication
DSM-IV-TR The Diagnostic and
Statistical Manual of Mental Disorders provides an authoritative authoritative classification classification scheme.scheme.
Describes disordersDescribes disorders and their prevalence without presuming to explain their causes
Labels Although diagnostic labelsdiagnostic labels may
facilitate communication and research, they can also biasbias our perceptionperception of people’s past and present behavior and unfairly stigmatizestigmatize these individuals.
Background
1960s - The anti-psychiatry movement (psychiatrists & psychotherapists) began to criticize criticize the medical model
RosenhanRosenhan was also a critic of the medical model – “Its a worrying thought that there could be thousands of people stuck in institutes that are just as ‘sane’ as we are.”
His study can be seen as an attempt to demonstrate that psychiatric classification is unreliableunreliable
Background
Difficulty of judging what is 'normalnormal'
Varies over time time / between societies societies
Rosenhan asked "If sanitysanity and insanityinsanity exist, how shall we know them?"
Research QResearch Q: if 'normal' people attempt admission to psychiatric hospitals, will they be detected? / how?
Aim
Test the hypothesis that psychiatrists cannot reliablyreliably tell the difference between people who are sanesane and those who are insane insane.
The Researchers Confederates (not the subjects)
EIGHT sane people! Three women and five men
One graduate student Three psychologists One pediatrician A painter A housewife A psychiatrist
Procedures
Telephoned 12 psychiatric hospitals12 psychiatric hospitals for urgent appointment (5 US states5 US states)
Arrived at admissions
Gave false names false names and occupations occupations
Gave other ‘life’ details correctly‘life’ details correctly
So here’s my cunning plan. I’m
going to send these people to a hospital and see what happens if they say they’ve got symptoms of
madness.
o What symptomsymptom could they use?
o And whywhy?
Thud
HollowEmpty
They said their only symptom was hearing a voice, the same sex as they are, saying the following:
Procedures Complained that they had been hearing hearing
voicesvoices Unfamiliar and the same sexsame sex as themselves Said 'empty', 'hollow', 'thud'empty', 'hollow', 'thud'. Symptoms were partly chosen because they were
similar to existential crisis symptomsexistential crisis symptoms (Who am I? What is it all for? – meaninglessness of one’s life)
Also chosen because there is no mentionno mention of existential psychosis in the literature.
Did they get let in?
AllAll were admitted to hospital
All but one were diagnosed as suffering from schizophreniaschizophrenia
Once admitted the ‘pseudo-patients’ stoppedstopped simulating ANY ANY symptoms
Took part in ward activitiesward activities
Procedures
Kept notes Kept notes on their experiences
Did this secretly secretly to begin with
Then openlyopenly when they realised no one cared or paid any attention to them doing this
Findings
The pseudo-patients were never detectednever detected
All pseudo-patients wished to be discharged discharged immediatelyimmediately
BUT - they waited until they were diagnosed as “fit to be discharged”“fit to be discharged”
How did the staff perceive them?
Normal behavior was misinterpretedmisinterpreted:- Writing notes described as -“The patient engaged in
compulsive writing behavior”- Arriving early for lunch described as - “oral acquisitive
syndrome” - Outburst from patient – never enquire what caused
response
Behavior distorted to ‘fit in’‘fit in’ with diagnosis/label
4 of the pseudo-patients carried out an observation on how patients were
treated by staff…..
The pseudo-patients observations
If patients approached staff with simple requests (NURSES & ATTENDANTS)
88% 88% ignored them (walked away with head averted) 10% made eye contact 2% stopped for a chat
(1283 attempts)
The pseudo-patient’s observations
If they approached staff with simple requests (PSYCHIATRISTS)
71%71% ignored them (walked away with head averted) 23% made eye contact 2% stopped for a chat
(185 attempts)
Observations
Nurses stayed in ward offices 90%90% of time
Each ‘real patient’ spent less than 7 7 minutes per dayminutes per day with psychiatric staff
Powerlessness and Depersonalization
Medical records were open to all staff regardless of status or therapeutic relationship with the patient
Personal hygiene monitored Many of the toilets did not have doors
Some of the ward orderlies were brutal to patients in front of other patients ~ would stop when another staff member approached This indicated that staff were credible witnesses but
patients were not
How long did they stay in hospital?
The shortest stay was 7 days
The longest stay was 52 days
The average stay was 19 days19 days
They had agreed to stay until they convinced the staff they were sane!!
Were they treated in the same way as normal patients...
Given total of 2100 medication tablets2100 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 !!
Did anyone suspect?
3535 out of 118 patients voicedvoiced suspicionssuspicions about the pseudo-patients
- “You’re not crazy”, - “You’re a journalist”, -“You’re a professor, checking up on the hospital”
On Release
The pseudo-patients were diagnosed with
Schizophrenia “IN REMISSION”
So… Lack of monitoring Distortion of behavior Lack of normal interaction Powerlessness & depersonalization
Alice In Wonderland
"But I don't want to go among mad people," Alice remarked.
"Oh, you can't help that," said the Cat: "we're all mad here. I'm mad. You're mad.“
"How do you know I'm mad?" said Alice.
""You must beYou must be," ," said the Cat, , ""or you wouldn't have come or you wouldn't have come herehere."."
Summarise
What was the IVIV for this experiment?
What was the DVDV for this experiment?
What was the experimental method experimental method used?
Rosenhan:The follow up study…
A teaching & research hospital heard of the first study – didn’t think they would make the same mistake
They were warned that …
Over the next three months ONE OR MORE pseudo-patient would attempt to be admitted
What happened……….?
Staff members rated ‘new patients’‘new patients’ on scale 1 - 101 - 10 as ‘how likely to be a fraud’
193 patients ‘assessed’ 41 rated as a pseudo-patient (by staff) 23 rated as pseudo-patient (by psychiatrist) 19 rated as pseudo-patient (by both)19 rated as pseudo-patient (by both)
AH HA HA HA!
Just guess how many I’d really sent.......
How many of these SUSPECTSwere pseudo-patients?……...
NONENONE NoNo pseudo-patients were
sentStaff were rating their regularregular intake
Summarise
What was the IVIV in this study?
What was the DVDV in this study?
What did Rosenhan conclude?
Remember, his question was … Do the characteristics of abnormality reside in
the patients?
OR OR In the environments in which they are
observed?
Does madness lie in the eye of the observer?
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‘sanity’ This is what’s known as a Type II errorType II error – diagnosing
healthy people as sick In the follow up study - We are unable to detect ‘ insanityinsanity’ This is what’s known as a Type I errorType I error – diagnosing sick
people as healthy
Rosenhan’s study highlighted:
The depersonalisationdepersonalisation and powerlessnesspowerlessness of patients in psychiatric hospitals
That behaviour is interpretedbehaviour is interpreted according to expectationsexpectations of staff and that these expectations are created by the labels labels SANITY & INSANITY
Another Rosenhan note……..
The pseudo-patients described their stay in the hospitals as a negative negative experienceexperience
This is not to say that REALREAL patients have similar experiences
Real patients do not know the diagnosis is false & are NOTNOT pretending
Your Task
Complete Dominoes activity in your groups – first to do it wins!
Your Task
Exam conditions – past exam questions on methodology and findings of Rosenhan’s study
Peer mark using mark scheme provided
Your Task
Evaluate the study! In your groups consider one issue (G R A V E)
How can the study be evaluated in terms of this issue?
Are there strengths? Weaknesses? Both?