Rosenhan is part of what is called ‘anti psychiatry movement’ He, and others, accept that mental suffering and deviant behaviours do exist. However, they question whether the most useful way of understanding such behaviour is through a rigid system of classification. One major concern Rosenhan had was the reliability and the validity of each diagnosis… to what extent can the sane be consistently and accurately distinguished from the insane?

Key research: Rosenhan (1973) Theory which led to this… Benedict (1934) normality and abnormality are not universal, but cultural specific Strong belief that an individual can present symptoms, these symptoms can be categorised, allowing the sane to be distinguishable from the insane

Can you tell the difference between sane and insane??

Background information: Beck et al. (1962) found when 153 patients were assessed by two psychiatrists, only 54% of diagnosis’ were agreed. This is due to vague criteria and inconsistencies when gathering data Cooper et al. (1972) found New York psychiatrists were twice as likely to diagnose schizophrenia as London psychiatrists who were twice as likely to diagnose depression when shown the same video taped clinical interviews This raised Rosenhan’s pinnacle question; can we tell sane from insane?

Rosenhan (1973) What does this mean? Wanted to look at whether psychiatrists can reliably tell the difference between people who are sane and those who are insane Consistency

Rosenhan’s aims: To test the reliability and validity of psychiatric diagnosis To observe and report on the experience of being a patient in a psychiatric hospital

Rosenhan (1973) Used 8 confederates (not ppts) attempted to gain entry to psychiatric hospital ALL sane people! Three women and five men One graduate student Three psychologists One pediatrician A painter A housewife A psychiatrist EXPERIMENTAL METHOD: Study is… Field experiment… why? Participant observation…. why? Self report… why?

Procedure 8 sane individuals all used fake names with fake occupations No alterations of person, history or circumstances were made These facts are important to remember. If anything, they strongly biased the subsequent results in favour of detecting sanity, since none of their histories or current behaviours were seriously pathological in any way.

Procedure Rosenhan selected 12 hospitals across five states in the USA, each ranging in age, resources and staff ratios

Procedure Each confederate complained that they had been hearing voices The voices were unfamiliar and the same sex as themselves The voices said 'empty', 'hollow', 'thud'.

What happened? All confederates were admitted to hospital All but one were diagnosed as suffering from schizophrenia The latter was diagnosed with manic-depressive psychosis Once admitted the ‘pseudo-patients’ stopped simulating ANY symptoms When asked how he was feeling, he would indicate he was fine and no longer experienced symptoms.

Findings They were treated the same as the other patients Given total of 2100 medication tablets They flushed them down the toilets

Findings The staff misinterpreted their normal behaviour Writing notes was described as - “The patient engaged in writing behavior” Arriving early for lunch described as “oral acquisitive syndrome” Normal behaviors were taken and used to ‘fit’ diagnosis Everything a patient does is interpreted in accordance with the diagnostic label once it has been applied

Findings 35 out of 118 patients voiced suspicions about the pseudo-patients It was the insane who noticed the sane… not the sane noticing the sane

The pseudo-patient’s observations If they approached staff with simple requests (NURSES & ATTENDANTS) 88% ignored them 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% ignored them 23% made eye contact 2% stopped for a chat (185 attempts)

Findings The pseudo-patients were never detected as being ‘under cover’ by the hospital All pseudo-patients wished to be discharged immediately BUT - they had to wait until they were diagnosed as “fit to be discharged”

How long did they stay 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!!

When released… Schizophrenia “IN REMISSION” The pseudo-patients were diagnosed as Schizophrenia “IN REMISSION”

The publication: The publication of Rosenhan’s findings sent shockwaves through psychiatry The hospital challenged Rosenhan to send more pseudo patients over the next 3 months and they would identify them all… Rosenhan agreed.

Part 2: Out of the patients patients which attended the hospital within a 3 month period… 41 were confidently judged by at least 1 staff member 23 were judged by at least 1 psychiatrist 19 were judged by a psychiatrist and a staff member At the end, the hospital proudly announced that they reported they found 83 (out of 193) pseudo patients However, Rosenhan send zero

This means… The psychiatrists could not reliably tell the sane from the insane (83 GENUINE patients were thought to be fake) The first study failed to detect sanity The second failed to detect insanity This confirms the beliefs Rosenhan had before and after his study

Conclusions Psychiatric diagnosis is extremely inaccurate – Rosenhan supports that we cannot distinguish sane from insane Hospitals seem to discourage help to those who need it, encourage depersonalisation and powerlessness rather than helping and supporting. Labelling is powerful – and sticks! (‘in remission’ compared to broken leg) DSM has poor reliability The diagnosis can be influenced by the situation

Misdiagnosis due to doctors have a strong bias towards Type 2 errors - they are more inclined to call a healthy person sick (a false positive) than to call a sick person healthy (a false negative, or Type 1 error). However, “A type 2 error in psychiatric diagnosis does not have the same consequences it does in medical diagnosis. A diagnosis of cancer that has been found to be in error is cause for celebration. But psychiatric diagnoses are rarely found to be in error. The label sticks, a mark of inadequacy forever.”

Strengths The use of observation…. What is good about this? It allowed for the pseudo patients to experience the ward from the patients perspective while also maintaining a degree of objectivity

Strengths The study was a field experiment Why is this a potential strength? It allows for variables such as pseudo patients behaviours to be controlled

What does this allow for? Strengths Rosenhan and participants attended a range of hospitals Why would this be a strength? Each hospital was different from the next – they were in different states, old and new, poorly staffed and well staffed, one private, federal and university funded What does this allow for? Generalisation

Weaknesses The hospital staff were deceived This of course is unethical! However, Rosenhan did not: Conceal the names of hospitals or staff Instead he tried to climate any clues which would lead to their identification

Weaknesses Was Rosenhan's experience as a pseudo-patient the same as a real patient?? Not necessarily Rosenhan, unlike the real patients, had comfort in knowing that the diagnosis he received was false.

What debates does this link to?

Usefulness of research Reviews diagnostic criteria, raises concerns about treatment of MH patients Nature/Nurture Rosenhan may support more of a nurture side due to effect of maltreatment, whereas history of MH consider it to be biological or supernatural

Freewill/Determinism People in MH lack free will Freewill/Determinism People in MH lack free will. The stickiness of labels outlined by Rosenhan suggest treatments of MH are determined by previous attitudes held about MH Reductionism/holism Definitions of statistical infrequency and deviation from social norms are limited and simplistic (reductionist) Deviation from ideal mental health is more holistic, considering how a number of factors interact DSM can be said to be reductionist due to simple nature of listing symptoms However, can be said to be holistic to some extent due to consideration to background and culture

Individual/situational MH is often described as an individual difference in psychology, the diagnosis system is there to assess the individual However, MH can be caused by the situational factors shown in Rosenhan, and how institutions create powerlessness and depersonalisation

Practice exam questions Outline one definition of abnormality (2) Explain why labelling people ‘abnormal’ could be considered unethical (3) Rosenhan (1973) hypothesised that psychiatrists cannot reliably tell the difference between people who are insane and those who are sane. With reference to the key research, discuss how classification of mental illness can result in a ‘stickiness of labels’ (5)

Outline one definition of abnormality (2) One definition of abnormality is Rosenhan’s Statistical infrequency when a behaviour which is seen infrequently can be classified as abnormal. For example the majority of people do not have depression, and therefore depression could be classed as abnormal. (2/2) One definition of abnormality is Jahoda’s definition of deviation from ideal mental health, where she suggested six criteria you should meet in order not to be abnormal. These are: high self-esteem, personal growth, integration, autonomy, an accurate perception of reality and mastery of the environment. (2/2)

Explain why labelling people ‘abnormal’ could be considered unethical (3) One reason why labelling people as abnormal can be considered unethical is the social sensitivity of such labelling. The stigma attached to abnormality by our society is such that people may be subject to prejudice if they have a label of abnormality and this might mean they are discriminated against in that they may be unable to get a job or promotion because of this label. (3/3)

Explain why labelling people ‘abnormal’ could be considered unethical (3) One reason why labelling people as abnormal can be considered unethical is that once people are given the label they are unable to lose it and are victims of stigma and discrimination. This is due to the “stickiness of labels” according to Rosenhan and so they may find their behaviour judged by such a label, and others might interpret everything they do in light of this label, which can then not be lost, like Rosenhan’s pseudo patients who were released with schizophrenia in remission (3/3) Labelling means giving someone a label which will stick with them forever. Marks 1/3

3. Rosenhan (1973) hypothesised that psychiatrists cannot reliably tell the difference between people who are insane and those who are sane. With reference to the key research, discuss how classification of mental illness can result in a ‘stickiness of labels’ (5) Rosenhan’s study which was carried out in 8 hospitals in the USA showed that when the patients were admitted with a diagnosis of schizophrenia, after being labelled in this way, the label stayed with them and they were treated in accordance with the label, even though they were acting perfectly sanely. Their behaviour such as writing in their diaries was classed as obsessive writing disorder, and this was seen as one more symptom of their mental illness. This shows that the label was used to explain everything they did and also they were released with the diagnosis of schizophrenia in remission which shows that the label stuck with them, even after several days (in one case 49 days) of sane behaviour, despite no longer meeting the diagnostic criteria

Stickiness of labels shows that when someone is diagnosed with a mental illness they are labelled with that illness, for example schizophrenia and this label is then used to judge all of their behaviour by, even if this behaviour doesn’t exist anymore they might be labelled as ‘in remission’. For example they might be writing and this could be seen as obsessive writing, or queuing might be seen as abnormal simply due to their label. This what Rosenhan found. Marks 3/5

Discuss the situational/individual explanations in relation to the historical context of mental illness (5) Explain both individual and situational explanations Discuss both explanations, linking to historical content