Rosenhan (1973) 'being sane in insane places'

The anti-psychiatry movement became popular in the 1960's challenging the mainstream medical model of abnormality.

• Foucalt (1961) argued that the concepts of sanity and insanity were social constructs (not real diseases)
• Laing (1960) argued that schizophrenia was best understood in terms of an individual's experience rather than a set of some symptoms.
• Szasz (1960) argued that the medical model is no more sophisticated than believing in demonology and is unhelpful to our understanding of psychiatry conditions. concept of mental illness was a way to exclude non-conformists.

Rosenhan was infuenced by these ideas. he observed that what is considered normal in one culture may be seen as quite abnormal in another.

• interested in legal implications of understanding insanity (muder trial - insanity may be used as adefence, but it's difficult to establish insanity - prosecution psychiatrist & defence psychiatrist present opposing views of defendant's sanity which suggests there is no 'reality'.
• not suggesting deviant or odd behaviours don't occur, ot that 'mental illness' isn't associated with personal anguish. 
• important question is about whether the diagnosis of insanity is based on characteristics of patients themselves or the context in which the patient is seen (and may be useless)

• Aimed to investigate whether psychiatrists could distinguish between people who are genuinely mentally ill, and those who are not.
• aimed to see whether personality or situation determines a diagnosis.
• argued that if 'pseudopatients' ('normal' people seeking admission to a psychiatric hospital) were diagnosed as sane this would show that the sane individual can be distinguished from the insane context. 
• if such pseudopatients were diagnosed as insane then this suggests that it is the context rather than the indivdual's characteristics that determines the diagnosis.

• Pseudopatients - 5 men and 3 women of various ages and occupations.
• Psychiatric hospitals - 12 different hospitals in 5 different states in the USA.
• gaining admission - each pseudopatient made an appointment at a hospital.
• he/she said he/she had been hearing voices (eg - empty, hollow) - such existential symptoms are rare.
• beyond these hallucinations each pseudopatient described their life events accurately.
• none had any history of abnormal behaviour.

• life in hospital - the pseudopatients were instructedto behave normally once admitted.
• spent their time talking to other patients, and making notes of observations of life on the wards.
• secretly didn't take any medicine, but otherwise followed ward routine.
• nurses reported that the patients were friendly, cooperative and 'exhibited no abnormal indications'

One hospital was surprised by the findings from study one and claimed it could not happen in their hospital.

Rosenhan informed them that some pseudopatients would present themselves in the next three months.

The staff were asked to rate, on a 10 point scale, their confidence level that any new patient was genuinely ill.

In the time period 193 genuine patients were admitted.

Rosenhan tested how staff responded to pseudopatients.

Pseudopatients approached a staff member and asked a question

(eg - "Pardon me, Mr/Mrs/Dr X, could you tell me when I will be eligible for grounds priveleges?")

All pseudopatients admitted, except 1 and diagnosed as a Schizophrenic.
Each was eventually discharged with a diagnosis of Schizophrenia 'in remission'.
Length of hospitalisation varied from 7 - 52 days, an average of 19.
Limited contact between staff and patients was observed, eg- staff spent about 11% of their time 'outside the cage' (glassed quarters) and this was doing chores rather than mingling with patients. On average the psychiatrists appeared on the ward 6.7 times a day and the average daily contact with patients was 6.8 minutes per day.
The 'real' patients regularly voiced their suspicions about the pseudopatients "you're not crazy", "you're a journalist".
The nurses may have judged the pseudopatients' behaviour as pathological (engages in writing behaviour)
Given 2,100 tablets.

Over the 3 months, 193 patients were aditted but none were actually pseudopatients.

however, at least 1 staff member judged 41 (21%) to be a speudopatients and at least 1 psychiatrist judged 23 (12%) to be a speudopatient.

Staff mainly gave a brief reply and continued walking ost without making any eye contact.

Only 4% of the psychiatrists and 0.5% of the nurses stopped,

[ 2% in each group paused and chatted ] 

As a control, a young lady approached staff members on the Stanford University campus.

All of the staff members stopped and answered all questions, maintaining eye contact.

Type 1 and 2 errors-

Diagnosing a healthy person as m=sick may be reasonable when dealing with physical illness but is less necessary in psychiatry, and also considerably more dangerous because of the stigma.

Psychodiagnostic Labels-

The effect of 'labels' has been demonsrated in psychological research. once a person is labelled 'abnormal', all subsequent data about them are interpreted in that light because such kabels are 'sticky' (eg- pseuodpatients were releeased with the label 'Schizophrenia in remission', suggesting they were still schizophrenic but temporatily sane.

Powerlessness and depersonalisation-

The behaviour of the staff in the study 3 showed that patients were depersonalised because contact was avoided. Such depersonalisation was created in the hospital by a lack of personal privacy (eg- anyone can read patients' files) lack of respect from staff (eg- beating them for small incidents) and by the use of psychotropic drugs. Such depersonalisation creates a sense of powerlessness. Rosenhan argued that we prefer to invent knowledge (eg- labelling someone as 'schizophrenic') rather than admit we don't know. once hospitalised, the patient is socialised by the bizarre setting, a process Goffman (1961) called mortification.

Real life application-

It is clear that we cannot distinguish the sane from the insane.

Possible solutions are

1) To use the community mental health facilities to avoud the effects of the institutional setting.

2) To use behavioural therapies which avoid psychiatric labels

3) To increase the sensitivity of mental health workers.

Method- Naturalistic Observation

strengths-

• What people say they do is often actually to what they actually do, so observations may be more valid
• gives a more realistic picture of spontaneous behaviours (high ecological validity)
• study 3 was a field experiment and because the environment is more similar to everyday life people are more inclined to act naturally (high ecological validity)
• study 3 was a field experiment and avoids participant effects as the participants are ften not aware they are taking part in a study so their behaviour is not affected by their expectations

weaknesses-

• if participants don't know they are being watched there are ethical problem such as deception and invasion of privacy.however, if participants now they are being observed they may alter their behaviour.
• as study 3 was a field experiment extraneous variables are less easy to control because the experiment is taking place im the real world (reduces validity)

8 pseuodpatients acted as observers.

strengths-

• as there were 8 pseudopatients there will be very rich, indepth qualitative data collected
• the qualitative data collected from the 8 pseudopatients can be cross referenced for inter-observer reliability (increases reliability as it can be checked against the others)

weaknesses-

• pseudopatients knew the aim of the study so could discuss and write the same things due to demand characteristics or the 'screw-you' effect
• as the data was qualitative it is harder to compare data as there are no figures or 'boxes' to fit as they may have all experienced very different things. 

Validity

Strengths-

• hospitals selected by Rosenhan were in 5 different states and included old and new hospitals with a variety of other differences. This increases the validity of the data collected because it is not restricted to one source and also it makes the findings more generalisable as it is not liminted to one type of hospital.
• Slater also found that psychiatrists diagnosed mental illness based on one symptom of auditory hallucination which confirms Rosenhan's findings (external validity)

Weaknesses-

• in real life a psychiatrist would not be presented with a 'normal' person trying to get into hospital. This means the findings may not generalise to real life.

The participants in the study were the staff (nurses and doctors)

Strengths-

• as they were based in a variety of hospitals they should be a reasonably representative sample (able to generalise)

The staff at the hospitals did not know they were being observed.

Strengths-

Weaknesses-

• no informed consent or privacy as they did not know about the study, there was also no right to withdraw.

Slater (2004)

Slater pesented herself to 9 psychiatric emergency rooms with the lone complaint of an isolated auditory hallucination (the word 'thud'). In most cases she was diagnosed with psychotic depression and was prescribed either antipsychotics or antidepressants. Slater concluded that psychiatry diagnoses are largely arbitrary and driven by a 'zeal to prescribe'

(supports as it proves Rosenhan's finding to be valid)

Kety (1974)

Argues that the same thing could happen with physical illness - if you arrived in an emergecny room vomiting blood (thatyou had just drank) you may be diagnosed as having a peptic ulcer.

Loring and Powell (1988)

gace a transcript of a patient interview to 290 psychiatristc who were more likely to ascribe violnce and suspiciousness to a client labelled as black rather than white.