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

2. 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)

3. 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)

4. 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)

5. 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)

6. 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)

7. 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)

8. 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)

9. 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)

10. 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)

11. 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)

12. 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)

13. 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)

14. 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)

15. 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)

16. 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)

17. 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)

18. 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)

19. 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)

20. 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)

21. 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)

22. 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)

23. 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)

24. 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 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)