‘On Being Sane in Insane Places’ Rosenhan (1973) ‘On Being Sane in Insane Places’ Rosenhan (1973)

Diagnosing mental illness How do we diagnose mental illness? What are the pitfalls? What are the consequences of labelling someone as “mentally ill”? Rosenhan (1973)

Research question “Do the characteristics that lead to a diagnosis of abnormality reside in the PATIENTS – or in the ENVIRONMENTS they are observed in?” Operationalised “If ‘normal’ people attempted to be admitted to psychiatric hospitals, would they be detected as being sane?” Rosenhan (1973)

Mental illness Difficult to define. Medical classifications exist (eg. DSM IV or ICD 10) – these list symptoms Problems with medical classification: 1. Problems often aren’t physiological, can’t be tested (eg. X-rays for broken bones) 2. Depends on whether we believe the patient Rosenhan (1973)

Important Issues 1. Reliability Does the system always diagnose in the same way? 2. Validity Does the system really measure mental illness  can it tell who is ill and who isn’t? Rosenhan (1973)

Some studies Kreitman (1961) 2 psychiatrists examining same patients only agree on diagnosis in 28% of cases (neurosis) Thomas Szasz (1961) Argues mental illness is a myth  it’s a label society gives to ‘odd’ behaviour (very subjective) Rosenhan (1973)

Diagnostic reliability David Rosenhan investigates diagnostic reliability Can doctors distinguish between sane and insane? If they can, classification is VALID If they fail, classification is useless, misleading and harmful Rosenhan (1973)

The study Method: Field experiment (participant observation) Setting: 12 hospitals in different American State Mix of old & new Some short-staffed, some not 1 private, 11 state-funded Rosenhan (1973)

The participants 8 “pseudopatients”, 5 male, 3 female, no history of mental disorder psychology student 3 psychologists (incl. Rosenhan – bias?) psychiatrist paediatrician painter Housewife They will pretend to be mental patients! Rosenhan (1973)

Procedure 1 Change names & occupations Phone for appointment Arrive, claim to be “hearing voices” Voices unfamiliar, but same sex Voices are unclear, but sound like saying “empty”, “hollow” and “thud” Words chosen to suggest an existential crisis (Who am I? What’s it all for? My life is empty and hollow!) Rosenhan (1973)

Procedure 2 If admitted, pseudopatients stop pretending to be abnormal They were nervous (novel situation, fear of discovery) Pseudopatients have to get out by convincing staff they are sane They are model patients but must write up observations (secretly, but overtly when found out) Rosenhan (1973)

Diagnosis: schizophrenia All but one pseudopatient admitted with diagnosis of schizophrenia Discharged not as “sane” but with diagnosis of “schizophrenia in remission” (no such thing!) Diagnosis of schizophrenia Disorders of thought (delusions) Disorders of perception (hallucinations, eg. voices) Motor symptoms (odd movements) Affective symptoms (inappropriate emotions) Impaired life functioning (no job, friends, relationships) Sufferers show problems in a number of areas, but pseudos showed only one symptom (voices) Rosenhan (1973)

Results Results Length of stay 7 – 52 days (mean 19 days) Staff never detected pseudopatents Other patients & visitors knew they were sane (35 out of 118 patients rumbled the pseudos) Significantly, staff interpreted pseudos “sane” behaviour in the light of their “insane” label Rosenhan (1973)

The “stickiness of labels” Labelling patients as schizophrenic coloured other perceptions – eg: Normal life experiences interpreted as “abnormal” by interviewers Normal behaviours interpreted as pathological Labels are “sticky” because, once they’re stuck on, they’re hard to remove Rosenhan (1973)

Normal seen as abnormal 1 EG 1: Pseudos ordinary life histories Pseudos didn’t lie about these Close to mother in early childhood, close to father during adolescence Medical staff distort this in case notes: “the patient manifests a long history of considerable ambivalence in close relationships, which begins in early childhood”  fits in with theories about schizophrenia Rosenhan (1973)

Normal seen as abnormal 2 EG 2: Pseudos took notes and feared staff would realise the hoax from this. But staff viewed “writing behaviour” as part of the symptoms. EG 3: Pseudo pacing up and down asked if he was nervous, when really he was bored. EG 4: Patients with little to look forward to queue outside canteen 30mins before food served. Doctor described this as “the oral-acquisitive nature of their syndromes” Rosenhan (1973)

Staff attitudes 1 Pseudos ask staff for info  “Pardon me, Mr [or Dr or Mrs] X, could you tell me when I will be presented at the staff meeting?" or "...when am I likely to be discharged?" Patients frequently ignored! Rosenhan set up a Control condition  a young person approaches psychology staff at university or doctor in medical centre, responses noted Control students usually acknowledged! Rosenhan (1973)

Staff attitudes 2 Behaviour Psychiatrists Nurses/Attendants Control Ignored 71% 88% 0% Eye contact, no speech 23% 10% Stop to talk 6% 2% 100% Rosenhan (1973)

Staff attitudes 3 These attitudes produce powerlessness and depersonalisation  see Zimbardo, it’s like a prison Patients deprived of legal rights Freedom of movement restricted Minimal privacy Physical punishments in front of other patients (not other staff – ie. patients aren’t credible witnesses) Rosenhan (1973)

So why the mistakes? Doctors biased towards type-one errors (playing safe)  diagnose healthy people as sick more often than sick people as healthy Also called a false positive A type-two error is diagnosing sick people as healthy (false negative) Will doctors misdiagnose genuine patients as sane? Rosenhan (1973)

Experiment 2 Setting: a large teaching hospital for the mentally ill Staff warned that pseudopatients would seek admission in next 3 months Staff asked to rate new patients on 10-point scale to say if they were faking (1 = definite faker, 10 = genuinely ill) Rosenhan (1973)

Experiment 2 - results New patients Misjudged by… 1 staff 1 psychiatrist Both 193 41 23 19 All new patients were genuine – NO pseudopatients Rosenhan (1973)

Conclusions 1 We cannot distinguish the sane from the insane in psychiatric hospitals The environment distorts the meaning of behaviour Sticky labelling, powerlessness etc. not conducive to healing But there is hope: Community care facilities may change the environment behaviour is seen in Mental health workers now trained to be aware of labelling and sensitive to patients’ needs Rosenhan (1973)

Conclusions 2 Easy to misdiagnose schizophrenia – does it really exist at all or is it just a label of odd behaviour? Schizophrenia occurs in all cultures – recovery rate faster in less developed countries Strong genetic link – MZ twin studies show varying concordance (15%-69%) Affects 1% of population – males/females equally Starts 17-35 years (young adulthood) Sometimes gradual, sometimes sudden – may be started by stress Can a plea of insanity justify reduced sentences if we cannot define “insanity”? Rosenhan (1973)