Rosenhan (1973)

Background

How do we define abnormality? There has been many attempts to classify abnormal behaviour. The most commonly used approach to classify abnormal behaviour is known as the medical model. This model assumes that mental illness should be treated in a similar way to a physical illness, and thus it is possible to identify characteristics of different mental illnesses and to group them as categories. This has been done using diagnostic tools such as the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and the International Statistical Classification of Diseases and Related Health Problems (ICD-10). These tools categorise all known disorders with the according symptoms. Once an illness has been identified it can be studied, hopefully the cause can be discovered and a treatment can be applied.

However, many individuals within the field of psychiatry have criticised the use of the medical model as a way of classifying abnormal behaviour, questioning the reliability of diagnosis. If patient symptoms are not diagnosed in the same way by all clinicians, this can result in either a Type 1 error (diagnosing a sick person as healthy) or a Type 11 error (diagnosing a healthy person as sick). Consequently, huge implications may arise, such as that of institutionalisation or labelling, in which a person is categorised as insane and, as a result, any behaviour they display is interpreted in light of their diagnosis.

Aim

1. To find out whether mental health professionals could tell the difference between the sane from the insane.

2. To investigate the consequences of being labelled as insane.

Experiment One:

Method

Field experiment

The study also involved participant observation, since, once admitted, the pseudo-patients kept written records of how the ward as a whole operated, as well as how they personally were treated.

Independent variable:

  1. the pseudo patients false psychosis

Dependent variable:

  1. whether the pseudopatient was diagnosed with illness
  2. whether the pseudopatient was hospitalised
  3. how the pseudo patient was treated by staff and patients while in hospital

Techniques used: Observation and (written) self-reports by the pseudo-patients. Both qualitative and quantitative data collected.

Sample

12 psychiatric hospitals (in five USA states)

Procedure

Eight sane people (the psuedopatients: a psychology graduate student in his 20s, three psychologists, a paediatrician, a psychiatrist, a painter, and a ‘housewife’)) attempted to gain admission to 12 psychiatric hospitals. There were five males and three females.

Once they arrived at the admissions they gave a false name, occupation and address, but all other ‘life’ details were true including general ups and downs of life, relationships, and events of life history. They complained that they had been hearing voices. They said the voice, which was unfamiliar and the same sex as themselves, was often unclear but it said ’empty’, ‘hollow’, ‘thud’. These symptoms were partly chosen because they were similar to existential symptoms (Who am I? What is it all for?) which arise from concerns about how meaningless  life is. They were also chosen because there is no mention of existential psychosis in the literature.

All pseudo patients were admitted to hospital. Seven were diagnosed as suffering from schizophrenia and one with manic-depressive psychosis. This diagnosis was made without one clear symptom of this disorder. Once admitted the ‘pseudo-patients’ stopped simulating ANY symptoms and behaved as normal. They obeyed all instructions, and tried to engage staff and patients in conversation. Each pseudo patient had been told they would have to get out by their own devices by convincing staff they were sane.

The pseudo patients spent time writing notes about their observations. Initially this was done secretly although as it became clear that no one was bothered the note taking was done more openly.

Results

The pseudo patients were never detected. They remained in hospital for 7 to 52 days (average 19 days). Although they were not detected by the staff, many of the other patients suspected their sanity (35 out of the 118 patients voiced their suspicions). Some patients voiced their suspicions very vigorously for example “You’re not crazy. You’re a journalist, or a professor. You’re checking up on the hospital.”

The pseudo patients were given a total of 2100 medication tablets, only 2 of these were swallowed, they flushed the others down the loos. It was noted that other patients did the same and that this was ignored as long as patients behaved themselves!

The pseudo patients normal behaviours were often seen as aspects of their supposed illness. For example, nursing records for three of the pseudo patients showed that their writing was seen as an aspect of their pathological behaviour. ‘Patient engages in writing behaviour’. Rosenhan argued that in the context of a psychiatric hospital, these everyday human experiences and behaviours were interpreted as pathological.

Another example of where behaviour was misinterpreted by staff as stemming from within the patient, rather than the environment, was when a psychiatrist pointed to a group of patients waiting outside the cafeteria half an hour before lunchtime and suggested that such behaviour was characteristic of an oral-acquisitive syndrome.

In four of the hospitals the pseudo patients carried out an observation of behaviour of staff towards patients that illustrate the experience of being hospitalised on a psychiatric ward. The results were compared with a university study. In the university study, nearly all the requests were acknowledged and responded to unlike the psychiatric hospital where the pseudo patients were treated as if they were invisible.

Nurses stayed in ward offices 90% of time. Each ‘real patient’ spent less than 7 minutes per day with psychiatric staff (psychiatrists and registrars).

Rosenhan noted that the experience of hospitalisation for the pseudo-patients was one of depersonalisation and powerlessness. Powerlessness and depersonalisation were evident in the ways in which the patients were deprived of many human rights such as freedom of movement and privacy. Medical records were open to all staff members regardless of status or therapeutic relationship with the patient and 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.

When released, the pseudo-patients were diagnosed as Schizophrenic “IN REMISSION”. This demonstrates the stickiness of labels. Labelling leads to expectations from others and reinterpretation of their behaviour.

Experiment Two:

Method/Procedure

A teaching & research hospital was told of the first study and falsely told that over the next three months ONE OR MORE pseudo-patient would attempt to be admitted to their hospital.

Staff members were asked to rate ‘new patients’ on scale 1 – 10 on ‘how likely to be a fraud’.

Independent Variable: the false information

Dependent Variable: the number of patients which staff subsequently suspected of being pseudo patients

Results

The table shows that many patients of the hospitals regular intake were judged to be pseudo patients. None of these patients were pseudo-patients!

Conclusion

Rosenhan concluded that: “It is clear that we are unable to distinguish the sane from the insane in psychiatric hospitals.

The first study demonstrated the inability to detect ‘sanity’ whilst the follow up study demonstrated the inability to detect ‘insanity’.

The lack of eye contact between staff and patients depersonalises the patients, leaving them feeling powerless. Rosenhan noted that the failings of the hospital staff should be attributed to the situation and are not motivated by a malicious disposition. He suggested that in a more caring environment, one that was less attached to global diagnosis, the behaviour of the staff might have been more compassionate and effective. Often the context seemed to determine what was viewed abnormal rather than salient features of the individual.

Evaluation

Strengths

+ The study has real life implications by clearly depicting  the deficiencies in the classification for mental disorders and the negative associations of being labeled and institutionalized for a mental disorder. This led to a review and improvement of the classification system for mental disorders.

+ High in ecological validity. The study was conducted in genuine psychiatric hospitals in which participant observation allowed the researcher to gain a genuine insight as they are experiencing what it is like to be labelled as schizophrenic and institutionalised. Staff at hospitals unaware of the presence of the pseudo-patients (covert research) – hence their behaviour and decisions are likely to be natural.

+ High in generalisability. The researchers took steps to ensure that their sample of institutions was representative (i.e. different staff/patient ratios, funding and resources, private and state owned, etc).

+ Usefulness. Challenges assumptions about both the definition abnormality, and the dispositional nature of mental illness (in that it suggests that the label of “mental disorder” arises out of the context in which people find themselves). Suggests that the dominant “medical model” of mental illness should be questioned – perhaps a “social model” is more appropriate

+ Both quantitative and qualitative data obtained, which allows us to analyse and compare data between the hospitals as well as providing a more holistic view of the phenomenon under study, i.e. experiences of those who are labelled as insane.

Weaknesses

– The study raised many ethical issues. Staff and patients in the institutions were deceived – thus no informed consent was collected and no right to withdraw. Furthermore, in second study, vulnerable patients may have been suspected as “fake patients” and thus not received help for their illness.

– Validity – Rosenhan did note that the experiences of the pseudo-patients could have differed from that of real patients who did not have the comfort of knowing that the diagnosis was false.

– Rosenhan may have been too hard on psychiatric hospitals as the pseudo-patients were simulating symptoms of schizophrenia. They were merely following the guidelines of the DSM. If you were to go to the doctors complaining of stomach aches how would you expect to be treated? Therefore, the psychiatrists diagnosis is based on the symptoms given and not because they couldn’t tell they were normal.

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