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Psychology Factsheets www.curriculum-press.co.uk

Number 50

Rosenhan (1973) On being sane in insane places This Factsheet reviews Rosenhan’s (1973) research, which is an OCR core study. This Factsheet can also be used for AQA’s classification of psychological abnormality, and Edexcel’s clinical psychology.

2 What is Rosenhan’s study about? y

Exam Hint: You must know the aims, procedure, results and conclusions of Rosenhan’s two studies very well. You should also know: a) How the observational data was gathered. b) One or two examples of how the staff misinterpreted the patients’ behaviour. c) Strengths and limitations of using the observation procedure. d) Why a doctor might misdiagnose a patient. e) The ethics, strengths and weaknesses of using deception.

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He examined how clear cut the diagnoses of sanity/ insanity are. Rosenhan argues that “Psychiatric diagnoses…are in the mind of the observers”. He means that an observer diagnoses insanity based on what they perceive and/or expect in a certain situation (situational factors; see glossary).

3 What did Rosenhan do? y

1 What do ‘sane’ and ‘insane’ mean? ‘Sane’ = psychological normality (being mentally healthy). ‘Insane’ = psychological abnormality (being mentally ill).

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For more information, see Factsheet 38 ‘Psychological abnormality: definitions and classifications’ and powerpoint presentation ‘Defining psychological abnormality’.

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Rosenhan experiment 1

Rosenhan put ‘normal’ (sane) people into psychiatric hospitals to test whether the staff would realise that they were sane. If they did not realise that they were sane, then we can: (a) question the methods of diagnosing mental illness; and (b) show that situational factors affect diagnosis. Rosenhan did two experiments: o Experiment 1 tested how well staff in psychiatric hospitals can diagnose people as ‘sane’ or ‘insane’. o Experiment 2 tested whether the staff can reverse a diagnosis from ‘insane’ to ‘sane’.

Can psychiatric staff distinguish sanity and insanity? Aim Introduction See ‘What is Rosenhan’s study about?’

Method Participants Ö Eight confederates (three women, five men) who acted as patients (called pseudopatients). Rosenhan himself was one pseudopatient. The other seven were older and ‘established’ (three psychologists, one each of paediatrician, psychiatrist, painter and housewife). Pseudopatients gave false details: all gave pseudonyms, false occupations and pretended symptoms. The hospital’s administrator and chief psychologist knew Rosenhan was a pseudopatient, but no other staff knew of any pseudopatients or the research programme. All pseudopatients gave real life histories which showed no history/behaviour of serious mental illness. The confederates are a varied group. A pseudopatient is confederate pretending to be a real patient with a mental illness.

The real participants in the experiment were the hospital staff. These participants did not know that the pseudopatients were observing them. The pseudopatients, who were the observers, mixed with the participants.

Settings Ö Ö Used 12 psychiatric hospitals in USA. They varied as: 11 federal and one private; located in five different American states (counties); some hospitals were old and some new; and some understaffed and some had good staff-patient ratio. The study used a varied group of 12 hospitals. ‘Federal’ hospitals are the same as the UK’s NHS hospitals. (Some of the eight pseudopatients stayed in more than one hospital).

Procedure Ö Ö 1. Pseudopatient called the hospital for an appointment. 2. Pseudopatient arrived at admissions office complaining of having heard voices saying “empty”, “hollow” and “thud”. Voices were unclear, unfamiliar and of same sex as pseudopatient. Gave real personal history. At first, pseudopatients were nervous and anxious; they were afraid of being exposed as frauds and nervous of being in a psychiatric ward. They initially wrote in secret. However, as it became clear that no-one minded about their writing, the pseudopatients wrote openly and publicly.

3. Upon admission to psychiatric ward, pseudopatient immediately ceased pretending any symptoms and behaved normally (e.g., told staff that they felt fine, no longer have symptoms, pretended to swallow medication). Spent time writing observations about ward, patients and staff. 4. Pseudopatients knew beforehand that they would need to convince the staff that they were sane to get discharged. All pseudopatients (but one) found hospitalisation stressful, so they were highly motivated to behave sanely.

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50 - Rosenhan (1973) On being sane in insane places

Psychology Factsheet

Rosenhan experiment 1 continued... Results 1. The staff never detected the pseudopatients as being sane. 2. Nurses reported the pseudopatients’ behaviour as “cooperative”, and “exhibited no abnormal indications”. Nurses interpreted the pseudopatients’ behaviour in the context of their diagnosis – see text box below. 3. Staff admitted 11 pseudopatients with a diagnosis of schizophrenia, and one with manic-depression. 4. Hospitalisation time ranged from 7 to 52 days (average 19 days). 5. Staff discharged all pseudopatients with a diagnosis of schizophrenia ‘in remission’. The hospitals’ failure to detect their sanity was not due to: (i) the hospitals’ quality; (ii) a lack of time to observe the pseudopatients ( they stayed for 19 days on average); (iii) pseudopatients not behaving sanely (visitors did not detect serious behavioural problems, nor did other patients). The label of being ‘in remission’ means that they are not considered as being sane, but as still being mentally ill but just not showing any symptoms at that time.

Real patients could detect the pseudopatients’ sanity. In the first three hospitalisations, 35 of 118 real patients voiced suspicions, such as “You’re not crazy” and “You’re a journalist or a professor”. If real patients can detect their sanity, but staff cannot, it raises important issues about the method of diagnosis and biases in perception.

Discussion Physicians may fail to detect the pseudopatients’ sanity because they are strongly biased to say a healthy person is sick, than a sick person is healthy. It is more dangerous to misdiagnose illness than health, so they err on the side of caution. However, a misdiagnosis of being mentally ill has many negative effects (personal, legal and of social stigma).

Normal behaviours interpreted in context of diagnosis of being mentally ill The ‘insane’ label for some pseudopatients was so powerful that the staff completely overlooked or misinterpreted their normal behaviour: o The staff disregarded the pseudopatients’ sane personal history. Instead the circumstances of being in the hospital influenced the staff perceptions. For example, one pseudopatient described his relationships with parents, wife and children (all normal) and how they changed over time (again, normal). The hospital summary stated “Affective stability is absent”; staff distorted past behaviour to fit the theory of schizophrenia popular at the time. o Pseudopatients took notes extensively and in public; the nursing records for three pseudopatients suggested that the writing was pathological behaviour. o The nurses assumed that real patients’ behaviour stemmed from their illness, rather than from external events. For instance, real patients were waiting outside the cafeteria 30 minutes early. A psychiatrist informed student psychiatrists that this behaviour was characteristic of the “oral-acquisitive nature of the syndrome”. In reality, the patients had very few things to look forward to besides eating. These findings led Rosenhan to do another experiment.. Rosenhan experiment 2

Aim

Would staff reverse a diagnosis from insane back to sane? Introduction Rosenhan conducted this experiment at a hospital where the staff knew the findings of experiment 1, but doubted such an error could happen in their hospital.

Method

ParticipantsÖÖ Hospital staff The participants were the hospital staff

Setting Ö Ö A research and teaching hospital. ProcedureÖ Ö 1. Staff were told that the hospital would admit one or more pseudopatients sometime in the next three months. New patients during this time were all genuine patients who were not involved in the study at all. There were no confederates.

2. Each staff member rated how likely it was that any newly admitted patient was a pseudopatient. They rated on a ten-point scale (where 1 or 2 equalled high confidence that the patient was a pseudopatient). Actually, Rosenhan used no pseudopatients in this experiment at all!

Results

1. Staff rated 193 newly admitted patients in total.Staff incorrectly rated 83 of the 193 new patients as pseudopatients. The staff correctly diagnosed the remaining 110 new patients as mentally ill.

2. At least one member of staff alleged 41 patients to be pseudopatients, with high confidence on the rating scale. 3. At least one psychiatrist considered 23 patients as suspect pseudopatients. 4. At least one psychiatrist and one other staff member rated 19 patients as suspect pseudopatients. So, staff did consider some real patients as being sane.

Discussion The findings show that the diagnosis of being insane can be altered by staffs’ expectations. This shows that the diagnosis can be reversed. It also shows that the tendency to reverse diagnosis can occur when the stakes are high. Stakes include, for example, the risk of losing professional esteem and questioning of their expertise.

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50 - Rosenhan (1973) On being sane in insane places

Psychology Factsheet

4. What did Rosenhan conclude? A. His findings show that staff in psychiatric hospitals cannot always distinguish sanity from insanity. ~ Therefore, any method of diagnosing that can easily make such errors cannot be very reliable. B. His findings show that situational factors can affect diagnosis: ~ Patients’ behaviour was interpreted in the context of illness. ~ The findings highlight the role of labelling in psychiatric assessment. ~ Also, the label continues beyond discharge (i.e., they are considered to be ‘in remission’, not sane). C. His findings show that patients are powerless and depersonalised. ~ Staff deprived the pseudopatients of many legal rights (e.g., minimal personal privacy). ~ Staff actually spent a very low percentage of time with the patients. ~ There was strict segregation between staff and patients. ~ The staff’s response to patient-initiated contact was brief and often irrelevant or bizarre. For example, the pseudopatient approached a staff member with a polite request. The most common response by staff was brief, done while walking along, with head averted, or they gave no response at all. The lack of eye contact and verbal contact is depersonalising.

5. Research methods and evaluation of the study y y y y y y y y

The procedure is ‘participant observation’, where the observer joins the group that they are observing. ‘Participant observation’ obtains very detailed knowledge and has high ecological validity as long as the observer is not discovered. When using ‘participant observation’, it can be difficult to record data objectively, it is impossible to replicate exactly and has the ethical problem of deception. This study needed to use deception to test the hospitals. There was a lack of control groups as only the experimental condition could be done. Rosenhan did control some variables; all pseudopatients gave fake symptoms, did not admit that they were doing observations and there were no pseudopatients in experiment 2. Rosenhan did keep the data confidential. This study led to pressure to revise and improve the accuracy of diagnosing and classifying mental disorders.

Glossary Affective: emotional. Confederates: people involved in conducting the research who act as participants; involves deceiving the real participants. Manic-depression: a mental disorder where the person experiences cycles of low mood (depression) and then extremely high mood (mania). Pseudo: means ‘false’ (pseudopatients are ‘false’ patients). Pseudonym: a false name. Remission: when an illness is not cured, but is not currently showing any symptoms. Schizophrenia: a mental disorder where the person has disturbed behaviour, emotion and experiences, such as having auditory and visual hallucinations, blunted emotion and delusions. Situational variables: where something outside the person affects/explains their behaviour (e.g., the situation that they are in) rather than by something within them.

Acknowledgements: This Psychology Factsheet was researched and written by Amanda Albon. The Curriculum Press, Bank House, 105 King Street, Wellington, Shropshire, TF1 1NU. Psychology Factsheets may be copied free of charge by teaching staff or students, provided that their school is a registered subscriber. No part of these Factsheets may be reproduced, stored in a retrieval system, or transmitted, in any other form or by any other means, without the prior permission of the publisher. ISSN 1351-5136

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50 - Rosenhan (1973) On being sane in insane places

Psychology Factsheet

Worksheet: Rosenhan (1973) Name 1. What did Rosenhan examine? --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------2. Give the aims of experiments one and two. ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------3. Name the two types of participants used in experiments one and two. 1. -----------------------------------------------------------------------------------------------------------------------------------------------------------2. -----------------------------------------------------------------------------------------------------------------------------------------------------------4. Complete the table with details about the pseudopatients: Symptoms

Diagnosis

Admittance to hospital Discharge from hospital 5. What factors did Rosenhan control? --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------6. Summarise the results of experiments one and two --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------7. Give one explanation for why a doctor might misdiagnose a person. --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------8. Can a diagnosis be reversed and, if so, what factors might affect this? --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------9. Explain how and why Rosenhan uses deception. --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------10. What effects did the study have on pseudopatients? --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------11. What does Rosenhan’s study say about methods of diagnosing and classifying mental illness? ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

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