On Being Sane in Insane Places “This presentation contains copyrighted material under the educational fair use exemption to the U.S. copyright law” Rosenhan 1973 On Being Sane in Insane Places Science Vol 179 page250-258 VIDEO 1

On Being Sane in Insane Places Rosenhan 1973 Science Vol 179

I. Background to Study A. Key terms for this study 1. Insanity = Unsoundness of mind sufficient in the judgment of a civil court to render a person unfit to maintain a contractual or other legal relationship or to warrant commitment to a mental health facility. 2. pseudopatients = the name for the stooges (including Rosenhan) that went into the mental hospitals to conduct participant observation

I. Background to the study 3. Type I Error = rejecting the null hypothesis (there is no difference) when it is in fact true. For example a test tells you that you have a disease when in fact you do not. This is also known as a “false positive” 4. Type II Error = accepting the null hypothesis when in fact it is not true. This would be taking a test and finding out you do not have a disease when in fact you do?

B. Related concepts 1. Situational vs. Dispositional Attribution – ask yourself is it possible to remain sane if your are locked in a mental hospital? 2Validity and Reliability – Should we continue to use a system of diagnosis if it is neither reliable or valid? 3. The fundamental Attribution Error = the tendency to place undue emphasis on internal characteristics while ignoring environmental factors

II. Aim and Design A. The Aim and Hypothesis Rosenhan “…do the salient characteristics that lead to diagnoses reside in the patients themselves or in the environment and contexts in which observers find them? A. The Aim and Hypothesis 1. Rosenhan hypothesized that psychiatrist cannot reliably tell the difference between people who are sane and insane 2. If this is true then the entire classification system and perhaps the medical model must be rejected for lack of validity 3. A 2nd Aim was to describe the conditions in the hospitals

II. Aim and Design B. Design to test the H1 (hypothesis) 1. pseudo-patients who report hearing voices present themselves at mental hospitals complaining of hearing voices a. If they gain admission then the Dx (diagnosis) system is flawed b. The IV = false symptoms c. The DV’s = admission to hospital and Dx

II. Aim and Design 2. A second experiment was conducted to see if the reverse was true. For this exp they told a hospital that pseudo-patients would be checking in but none ever did a. The IV was the false claim that a sane person would be trying to gain admission b. The DV was the # of patients suspected

3. In a 3rd study conducted simultaneous in 4 of the hospitals the pseudo-patients approached the staff with a simple request for info a. IV The type of staff member doctor/nurse b. DV = behaviors such as eye contact, pause and chat etc. c. This portion of the study can be considered a Field experiment

II. Aim and Design 3. The pseudo-patients a. 8 people including Rosenhan himself b. Report hearing voices saying “empty” “hollow” and “thud” c. These words were meant to represent an existential crisis, not a psychotic experience d. With the exception of the first trial in which the hospital knew Rosenhan was there the subsequent hospitals and staff were blind to this fact

II. Aim and Design 4. The hospitals 5. Type of experiment a. 12 hospitals representing a generalizable sample b. 5 different states from West coast to East coast 5. Type of experiment a. Naturalist/field experiment b. Participant observation

Cue 1: Describe in detail the 8 pseudo patients Cue 2: Use your text book to define Situational and dispositional attributions Cue 3: Use your text book to define validity and reliability Cue 4: What ethical problems do you see with this type of participant observation? Cue 5: Describe the sample of hospitals in detail Cue 6. Use the study to explain why they choose the 3 words they chose. Cue 7. Summarize this video in 5 bullet points

On Being Sane in Insane Places “This presentation contains copyrighted material under the educational fair use exemption to the U.S. copyright law” Rosenhan 1973 On Being Sane in Insane Places Science Vol 179 page250-258 VIDEO 2

III. Procedures for Exp 1 Patients called for an appointment Gives false name and occupation Arrives at admission complaining of hearing voices saying, “empty, hollow and thud” Voices were unfamiliar and same sex as patient All other parts of patients histories were true and correct

Did not show outward signs of psychopathology (or so they believed) As soon as they were admitted, patients STOPPED simulating any symptoms of abnormality Although nervous, they behaved normally toward other patients and staff Complied with orders (took meds but did not swallow)

Answered staff questions saying they felt fine Spent their time writing down their observations about the ward, patients and staff At first the journaling was secret, but no one cared or said anything so they openly took notes They were admitted without knowing how long they would be there They knew discharge would come after convincing the staff that they were sane

IV. Results Exp 1 A. The Normal are not Detectably Sane 1. None were ever detected 2. All but 1 admitted with a Dx of Schizophrenia

3. Discharged with Dx of Schizophrenia in remission a. This doesn’t mean you no longer have schizophrenia but instead means that the symptoms are no longer prominent. b. It is implied that the symptoms can and will return and that you are still “sick” 4. Length of hospitalization was 7-52 days with an avg length of 19 days 5. During first 3 hospitalizations 35 out of 113 patients voiced suspicions saying they were journalists or professors

6. Rosenhan defends the doctors by suggesting they are strongly biased toward type one errors because a type two error is more reckless. 7. Explaining normal behaviors within the context of the mental hospital a. Excessive note-taking was ignored as part of their symptomology b. The fact that the patients liked to gather in the minutes before lunch was part of the “oral inquisitive” nature of the disorder

B. The experience of Psychiatric Hospitalization 1. Staff and patients strictly segregated..even eat in different areas 2. Staff spends only 11.3% of the time outside of the glass “cage.” They only come out for required activities. 3. Nurses “mingled” with the patients that the percentage was too small to even report. 4. On avg only left the cage 11.5 times per shift during the day and only 9.4 x for night shifts 5. More power = less time with patients (ie doctors nurses less, custodians more

Results of Study 3

C. Powerlessness and Depersonalization 1. Beatings 2. Verbal abuse 3. No eye contact 4. Ignoring direct questions 5. Beating patients for direct questions 6. Bathrooms without doors 7. Nurse changed in front of male patients as if they were not even there

Cue 8: Referring to the footnotes on page 258, what was the only other Dx, why was it given and by which hospital? Cue 9: On page 252 at the bottom of the middle column, Rosenhan states that psychiatric labels differ from medical labels in that they are pejorative. What does he mean by this word? Cue 10: How is the treatment of the patients in this study similar to the treatment of the prisoners in HBZ Cue 11. In 6 words only define Pathological Prisoner Syndrome CUE 12: Summarize this video in 5 bullet points

On Being Sane in Insane Places “This presentation contains copyrighted material under the educational fair use exemption to the U.S. copyright law” Rosenhan 1973 On Being Sane in Insane Places Science Vol 179 page250-258 VIDEO 3

V. Exp 2 Procedures and Results A. Rosenhan in attempt to see if people who were truly reporting for problems would be diagnosed as faking ran a 2nd experiment 1. He told a hospital who had heard about his experiment and claimed it couldn’t have happened at their hospital that he would be sending a fake patient to the hospital 2. HE NEVER DID (I really like his devious nature)

3. Each member of the staff was asked to rate the patients they came into contact with on a 10 point scale on how much they believed the patient was a pseudo-patient B. Results 1. 193 patients were admitted during the 3 month period 2. 41 patients were confidentially alleged to be fake by at least 1 staff member

3. 23 were suspected by at least 1 psychiatrist 4. 19 were suspected by at least 1 psychiatrist and 1 other staff member 5. So it seems not only can the hospitals not distinguish a sane person from an insane person, but they also can not distinguish truly sick patients from sane ones.

C. Why were they not detected? 1. Could not be due to lack of time. Average stay was 19 days 2. Could not be due to the fact that they were not acting sanely. In fact many of the patients knew right away 3. Could not be due to quality of hospital or location 4. It must be because doctors are predisposed toward making type II disorders D. Labels ARE STICKY

VI. Evaluation A. Theoretical Issues 1. Does mental illness actually exist? a. Some like Thomas Szasz believe there is no such thing as mental illness. b. Others go so far as to say the Dx of schizophrenia is a violent act perpetrated by the medical community (The conspiratorial model)

3. In defense of classification 2. Labeling may explain behavior after Dx but how do you explain the behaviors prior to Dx that led the person to seek help? 3. In defense of classification a. Kendell (1983) Claims all patients has attributes at 3 levels Those shared with ALL other psychiatric patients Those shared only with SOME other psychiatric patients Those that are unique to them b. It is those that are only shared by some that allow us to classify. In other words people with depression have different characteristics than those with anxiety

B. Methodological Issues c. Several studies done where psychiatrist/psychologists use similar criteria they show impressive inter-rater reliability in their B. Methodological Issues 1. Field study/naturalistic observation a. Not an experiment even though there were IV’s and DV’s. b. Only one group/condition so no cause and effect relationship established.

2. The sample – a. Are the pseudo-patients or the hospitals the “sample? b. How did Rosenhan attempt to create generalization with the sample of hospitals? 3. Data a. Quanitative Data – see chart on slide 17 b. Qualitative data included the pseudo-patients notes and recollections of what happened

C. Ethical issues 1. Were the stooges (pseudo-patients) put under undue stress? 2. The doctors and hospitals were unaware and therefore were deceived. This violates certain ethical principles but could it have been done otherwise?

D. Ecological Validity and Reliability 1. Field studies generally have more ecological validity a. Fact that staff didn’t know makes their reactions and interactions with the patients more likely to be typical. b. As with all field studies you lose control. Can we be sure that the patient acted as sane as they thought they were acting? 2. Reliability of psuedo-patient reports a. Relying on psuedo-patient notes and recollections could limit the reliability of this data b. Would two pseudo-patients have inter-rater reliability?

E. Situational for Dispositional attributions 1. What does the study show about the impact of labels on how others interpret our behavior 2. Was it unreasonable for the doctor to suspect something was really wrong? How often do patients show up at hospitals with fake symptoms just to see how the doctor will diagnose them. 3. How do you explain disturbed behavior that occurs prior to hospitalization

CUE 13: Rosenhan comes to the conclusion that hospitals cannot tell sane patients from sick ones nor can they distinguish truly sick ones from healthy ones. How does this relate to Type I and Type II errors? Cue 14: Summarize video 3 in 5 bullet points Cue 15: When trying to gain ecological validity we often give up control? Give examples of lack of control in this study? Cue 16: Write 3 questions you would like answered before the quiz?