Rosenhan

Question 1

Background & Aim

Answer 1

can we tell the sane from the insane?

Question 2

3 aims:

Answer 2

1- to build on work of previous researchers who submitted themselves to psychiatric hospitalisation only for short period of time and often with knowledge of hospital staff.
2- to test reliability and validity of diagnostic systems (DSM IV used at time of study)
3- to observe and report on the experience of being a patient in a psychiatric hospital.

Question 3

Method

Answer 3

field study.
participant observations
& self reports used.

Question 4

pseudo patients

Answer 4

8 sane people called pseudo patients (5 men, 3 women) psych graduate in his 20s, 3 psychologists, paediatrician, painter and housewife.

Question 5

Method: what the pseudo patients did initially:

Answer 5

telephoned hospital for appointment and arrived complaining of hearing voices, unfamiliar, same sex voice, unclear, said ‘empty’ and ‘hollow’ and ‘thud’ (selected by Rosenhan to represent existential crisis).
Ps gave fake name and job, all other details true.

Question 6

Sample

Answer 6

12 hospitals:
modern, old, well-staffed, poorly staffed, including public, private and university-funded hospitals.

Question 7

So sample could be generalised:

Answer 7

the psychiatric hospitals used were selected from different locations across America- 5 different states representing the different types of hospitals.
Staff to patient ratios varied greatly.

Question 8

After psychiatric ward admittance:

Answer 8

Pseudo patients no longer simulated any symptoms- although did display nervousness.
Took part in ward activities and when staff asked how they felt- they reported feeling fine and no longer experiencing symptoms.
They were told to get out of hospital they had to convince staff they were sane.
Pseudo patients secretly made notes of their observations; this became more often as staff were not bothered of this behaviour.
Pseudo patients did NOT take their medication.

Question 9

in 4 out of the 12 hospitals:

Answer 9

observations of staff behaviour towards patients were carried out.
Pseudo patients approached staff and asked:
“pardon me mr/mrs/dr… could you tell me when i will be presented at the staff meeting?”
“When am I likely to be discharged?”

Question 10

Results- how many patients were admitted and what was their diagnosis?

Answer 10

All were admitted.
11 diagnosed schizophrenic, 1 diagnosed bipolar.
Some pseudo-patients sought admission to more than one hospital.

Question 11

Results- length of stay

Answer 11

shortest= 7 days
longest= 52 days
average= 19 days
they had agreed to stay until they convinced staff they were ‘sane’.

Question 12

Results- schizophrenia in remission

Answer 12

-still ‘insane’ although not currently presenting the characteristics of their illness.

Question 13

Results- approaching staff with simple requests (nurses and attendants)

Answer 13

88% ignored and walked away with head averted.
10% made eye contact and walked away
2% stopped to chat
(out of 1,283 attempts)

Question 14

Results- approaching staff with simple requests
(psychiatrists)

Answer 14

71% ignored them
23% made eye contact
2% stopped to chat
(out of 185 attempts)

Question 15

Results- nurses staying in office

Answer 15

stayed in office 90% of time

Question 16

Results- time patients spent with staff

Answer 16

less than 7 mins per day spent with psychiatric staff

Question 17

Results- pills administered

Answer 17

2,100 administered- all but 2 were flushed down toilet / pocketed.
Other patients did the same- this was ignored as long as they behaved themselves.

Question 18

How staff treated patients:

Answer 18

Little respect, beating them, swearing at them for minor incidents- depersonalising and leads to patients feeling powerless.
Patients movements were watched and restricted, their quarters and possessions could be entered and examined by any staff member and notes were available to all staff. Little personal privacy,no toilet doors in some and examinations took place in semi public spaces.
Was also cases of serious physical abuse to patients- these abuses of power stopped when other staff were around.
All pseudo patients reported depersonalisation and powerlessness feelings.

Question 19

when discharged:

Answer 19

label of ‘schizophrenia in remission’ was given.
Note taking was assumed symptom of their illness. ‘patient engages in writing behaviour’
Walking corridors of boredom=anxiety.
Going early for lunch= ‘oral acquisitive behaviour’
Distress from pseudo patients was not thought to be over situation, but as a symptom of their illness.
Once labelled mentally ill, normal behaviour interpreted differently.

Question 20

Effects of a label:

Answer 20

results show a profound effect of a label on our perceptions of people.
Once labelled abnormal, all subsequent data about them is interpreted in that light and can become ‘self fulfilling’.

Question 21

STUDY 2

Answer 21

Nearby teaching & research hospital was told results of first study and were fairly confident the same mistakes would not occur in their hospital.
Rosenhan warned that over 3 months one or more pseudo patient will attempt to be admitted into their hospital.
Each staff member was asked to rate on 10 point scale each patient over the 3 months according to likelihood they were pseudo.

Question 22

Results of study 2

Answer 22

193 patients were assessed in total.
41 were rated as pseudo patient by staff.
23 were rated as pseudo by psychiatrist.
19 were rated as pseudo by both (inter rater reliability)
Rosenhan sent NO pseudo patients, staff were rating regular patient intake and FAILED to detect insanity.

Question 23

Conclusions

Answer 23

Rosenhan concluded diagnosis of mental illness as inaccurate, his view that ‘we cannot distinguish sane from insane in psychiatric hospitals’ is supported by his findings.

Question 24

Conclusion from study 1

Answer 24

We are unable to detect ‘sanity’. psychiatrists were unable to reliably identify pseudo patients (type 1 error=false positive) healthy patients were diagnosed as mentally ill.

Question 25

Conclusions from Study 2

Answer 25

We are unable to detect ‘insanity’. psychiatrists failed to reliably detect insanity (type 2 error=false negative)
misdiagnosing a mentally ill person as healthy.

Question 26

Effects of mental hospitals on patients

Answer 26

They exacerbate patients difficulties instead of helping and support staff were insensitive.
Mental health damaged further once institutionalised.
Powerlessness and depersonalisation occur.
Once labelled with diagnosis, all behaviour seen in relation to the label.

Question 27

Rosenhan’s suggestions for improvements

Answer 27

Instead of focusing on labelling individual as “insane”, Rosenhan supports alternatives such as community health centres and behavioural therapy programmes.
These would reduce the stigma while offering more personal treatment, with element of control for individual.
Also raising awareness of issues faced by psychiatric patients in hospital- staff could change experience of hospitalisation.
After such experience frontline medical staff may increase their sensitivity to position of hospitalised patients.

Question 28

DSM reliability

Answer 28

Study showed poor reliability of DSM IV and that the diagnosis of mental illness can be dependent on situation person is in.