Rosenhan - On Being Sane In Insane Places

Question 1

Ethical issues

Answer 1

~ Distress:
> Experiment 1: distress caused to hospital staff by the participants… Once the staff found out the results of the study and realised how badly they had treated their patients
> Experiment 2: distress caused to staff, as misdiagnosed 41 genuine pseudopatients, denying them treatment they needed
~ Stress: on the pseudopatient participants because treated so badly by hospital staff
~ Consent:
> in experiment 1 none of the hospitals involved gave consent or informed consent for their hospitals and staff to be involved in the study. Although the hospital Rosenhan was admitted to was aware.
> in experiment 2 consent was not an issue as the hospital involved agreed to take part
~ Deception:
> In experiment 1 doctors at the hospitals were deceived by the pseudopatient a when they claimed to be ‘hearing voices’ that said ‘empty’, ‘hollow’ and ‘thud’.
> in experiment 2 when the selected hospital was informed that pseudopatients would attempt to be admitted but in fact no pseudopatient presented themselves.
~ Right to withdraw: As the staff did not know they were participating in a study they had no right to withdraw either themselves, or data referring to their behaviour
~ Invasion of privacy: In respect of the genuine patients who may have felt their ‘abnormal’ behaviour was being recorded unfairly
~ Confidentiality: not an issue in either experiment as neither the names of the hospitals not the participants were disclosed.

Question 2

3 changes that can be made in this study

Answer 2

1: Multiple locations of hospitals (hospitals with different backgrounds or in different countries)
2: Use of video
3: Observers as hospital staff

Question 3

What is the IV in this experiment?

Answer 3

Symptoms of the pseudopatients

Question 4

What is the DV?

Answer 4

Admission and diagnostic of the pseudopatient

Question 5

What was the research design ?

Answer 5

Field experiment

Question 6

Experiment ones aim

Answer 6

To test whether the psychiatric staff can distinguish sanity and insanity

Question 7

Aim of experiment 2

Answer 7

Test whether staff could ‘reverse’ a diagnosis from insane to sane

Question 8

Overall aim

Answer 8

To investigate whether the hospital staff could tell the sane from the insane, how situational factors bias a diagnosis, and to test the reliability of the DSM.

Question 9

Design of experiment one

Answer 9

Participant observation

Observe joins the group they are observing

Question 10

Sample Experiment 1

Answer 10

8 confederates (3 women)

• acted as pseudopatients
• some of these pseudopatients stayed in more than one hospital

Real participants = hospital staff who did not know about the experiment and that they were being observed

Question 11

Location

Answer 11

Tried to gain admission to 12 psychiatric hospitals in 5 different states in the USA

Question 12

Procedure Experiment 1

Answer 12

1: pseudopatient called hospital for an experiment
2: ~ Arrived complaining of having heard voices saying ‘empty, hollow, thud’.
~ Voices unclear, unfamiliar and same sex as pseudopatient.
~ Pseudopatients gave false names, occupations and symptoms, but gave real life histories.
3: ~ Once on ward, pseudopatients stopped pretending symptoms, behaved normally and wrote observations.
4: Pseudopatients discharged only when they convinced staff that they were sane.

Question 13

Results Experiment 1

Could hospital staff identify the pseudopatients as being ‘normal’?

Answer 13

~ On admission, staff diagnosed 11 pseudopatients with schizophrenia, and one with manic depression
~ Staff never detected their sanity
~ Nurses reported their behaviour as showing “no abnormal indications”, but did interpret their behaviour in the context of their diagnosis
~ Average hospital stay was 19 days
~ All pseudopatients discharged with diagnosis of schizophrenia ‘In remission’
~ 35 real patients detected the pseudopatients sanity eg. Said “You’re not crazy’

Question 14

Design experiment 2

Answer 14

Observation

Question 15

Setting Experiment 2

Answer 15

Research and teaching hospital where staff doubted such as error could happen

Question 16

Participants Experiment 2

Answer 16

Hospital staff

Question 17

Procedure Experiment 2

Answer 17

1: Staff told that hospital would admit one or more pseudopatients in the next three months
2: For every new patient, each staff member rated the likelihood that they were a pseudopatient
3: There are no pseudopatients, all were real patients not involved in the study

Question 18

Results of Experiment 2

Answer 18

Staff did regard some real patients as sane.

Incorrectly rating 83/193 patients as pseudopatients

Question 19

Conclusions:

Answer 19

• Psychiatric staff cannot always distinguish sanity from insanity
• Any diagnostic method that makes such errors cannot be very reliable or valid. However, physicians may not identify sanity because it is less risky to diagnoses healthy person as sick than vice versa.
• Situational factors affect diagnosis.
• Normal behaviour was interrupted in the context of illness (eg. Nursing records suggest writing is pathological).
• Staff reversed some diagnoses due to the situation (expecting pseudopatients).
• Staff may be more likely to reverse diagnoses when risk are high (loss of professional esteem)
• The findings show how the label continues beyond discharge (patients are ‘in remission’, not sane).

Question 20

What was the method?

Answer 20

Observation

Question 21

Method of Experiment 2

Answer 21

Observation of staff behaviour.

Question 22

Advantage of sample

Answer 22

Pseudopatient sample was a varied group

• 1 psychology graduate = Rosenhan
• 3 psychologists
• painter
• housewife

Question 23

2 Disadvantages of sample

Answer 23

• It can be difficult to record data objectively

- It is impossible to replicate exactly and observations may not be reliable.

Question 24

Advantage of setting

Answer 24

Used a variety of hospitals...
Varied:
- location
- building age
- staff ratio
- whether federal or private

Question 25

What were the controls in this experiment

Answer 25

• All pseudopatients had fake symptoms
• pseudopatients did not admit that they were doing observations
• No pseudopatients in experiment 2. (Compared to experiment)

There was a lack of a control group as could only do the experimental condition?!

Question 26

Quantitative data

Answer 26

Observational procedure…

- Staff rated new patients on a ten point scale

Question 27

Qualitative data

Answer 27

In observations - but may not be subjective and participants not say why they behaved as they did.

Question 28

How useful was this study?

Answer 28

This study led to pressure to revise and improve the accuracy of diagnosing/classifying mental illness

Question 29

High Ecological validity

Answer 29

• Observation obtains very detailed knowledge and records natural behaviour as participants (staff) are unaware of observers. This also means there are no demand characteristics.
• Study carried out in 12 real psychiatric hospitals in five different states on the East and West Coasts of America.
• Study led to pressure to revise and improve the accuracy of diagnosing/classifying mental illness.

Question 30

Does this study show situational effects?

Answer 30

Yes. Because staff interrupt behaviour according to context, diagnosis of being insane can be leered by staffs expectations.

Question 31

Does this study show individual explanations?

Answer 31

It is possible that misdiagnosis arose from values within psychiatrists, such as scared of losing professional esteem if wrong.

Question 32

What did the pseudopatients do?

Answer 32

Kept written records of the ward as a whole and how they were treated.

Question 33

How long did they spend in hospital?

Answer 33

Average 19 days

Question 34

What were they discharged as…

Answer 34

In remission - this means they were being treated for their illness and it was being managed.

Question 35

What were the type 1 errors?

Answer 35

(False positive)

Call healthy person sick

Question 36

What was the stickiness of labels?

Answer 36

After being diagnosed with schizophrenia… The pseudopatients ‘normal’ behaviour then became seen as part of their illness.

• For 3 of the patients the writing was seen as pathological behaviour
• The pseudopatients queuing early for meal time was seen as oral acquisitive nature, however it was just because they were bored.
• Pacing the corridor was interrupted as nervousness.

Rosenhan says… ‘Having once been labelled schizophrenic there is nothing the pseudopatient can do to overcome the tag and the tag profoundly colours others’

Question 37

How were the pseudopatients treated differently?

Answer 37

• If they were treated normally they would not have felt powerless Dan depersonalised, however they were watched and restricted by the staff.
• The staff kept themselves away from the patients except for administrative/practical duties
• Dr’s seemed to matron the greatest distance, only seen when they came on the ward to start their shift and when they departed. They spent their time in staff cage or office.
• On average the patients spent less than 7 minutes a day wi senior members of staff over the course of their stay.
• Staff lower down the hierarchy were influenced by the senior members, they had the most contact with patients however tried to avoid contact by spending most of their time in the staff cage.

Question 38

How did the pseudopatients feel powerless and depersonalised?

Answer 38

• Medical files were available, even volunteers.
• Acts of violence against patients were observed by other patients, some of whom were pseudopatients writing it all down. Abusive behaviour was immediately stopped when another member of staff appeared however the fact that staff were considered credible witnesses and patients were not is an indication of the patients lack of power
• Lack of time spent with staff added to the invisibility felt by the pseudopatients.
• They were given very little personal privacy eg. in the ward it wasn’t usual for the toilet cubicle to have no doors and for the personal hygiene and waste evacuation of patients to be monitored.
• Evidence from the study shows that patients could not initiate contact with the staff, that they were expected to be passive.

Question 39

What were the sources of depersonalisation?

Answer 39

Two sources of depersonalisation in psychiatric hospitals:

1: depersonalisation as product of predjudices towards mentally ill
- societies lepers, avoid contact with them at all costs.
- ingrained in the history of institutionalised care= locked up and subject to brutal treatment
- psychiatric wards are not immune from this predjudice, it influences them in the hospital setting
2: depersonalisation was a result of the heirarchical structure where doctors have all the power, patients have none and those staff in between follow the doctors model of avoidance of contact with patients
- the behaviour of the staff and the patients an be attributed to situational rather than individual factors

Other sources= where money is tight patient contact may be the first to suffer. This is facilitated by extensive use of drugs, which control the patients and keep them passive

Question 40

Strengths of the study

Answer 40

• Pseudopatients could experience the ward from the patients’ perspective
• Field experiment is ecological valid and controls many variables
• Range of hospitals –> phelps results to be generalised

Question 41

Weaknesses of study

Answer 41

• Ethics –> deceived but did not reveal hospital names
• Experiences of pseudopatients could have differed from real patients
• More likely to make a type 2 error to play it safe as better to diagnose a healthy person ill than an ill person healthy.

Question 42

Is the study useful?

Answer 42

• Highlighted problems with the DSM that needed to be addressed
• Current diagnostic criteria is a great deal more reliable
• Due to increased difficulty to gain admission to an institution in the USA since the time of Rosenhans study means the study would not be possible to replicate. This is a strength as demonstrates the impact of studies such as this one on the diagnostic system.

Question 43

Pseudopatients treatment in hospital

Answer 43

• Lack of contact with staff
• Abusive behaviour that went unchecked
• Reliance on medication rather than contact with caring and supportive staff in the treatment of psychiatric patients

Question 44

Low ecological validity

Answer 44

• Because the pseudopatients were not genuine. Although they tried to behave normally this may have been difficult in the strange hospital environments.
• Because the pseudopatients spent a lot of their time writing down their observations about the ward, staff and patients - an activity not normally indulged in by genuine patients.

Question 45

How did hospital staff misinterpret pseudopatients behaviour?

Answer 45

• Writing notes was seen as part of their pathological behaviour and so entered on their medical records as ‘patient engages in writing behaviour’.
• When a pseudopatient was found pacing the hospital corridors because he was bored the nurse presumed he was nervous.
• When a group of patients were seen sitting outside the cafeteria entrance half an hour before lunchtime the behaviour was seen as characteristic oral-acquisitive nature of their psychiatric condition.

Question 46

Why was the pseudopatients behaviour misinterpreted by the staff?

Answer 46

• The hospitals itself imposes a special environment in which the meaning of behaviour can be easily misunderstood
• Psychiatrists would not expect normal people to want to gain admittance to a psychiatric hospital so it was natural that their behaviour would be interpreted as part of their illness.
• Staff thought all patients had psychiatric problems and so viewed their behaviour in the light of their identified mental illness.

Question 47

What was Pseudopatients “abnormal behaviour” labelled by staff?

Answer 47

Hearing voices
Writing notes
Queueing early for lunch 
Pacing corridors
Asking questions

Question 48

What were reasons for why pseudopatients behaviour labelled as abnormal?

Answer 48

Because the participants had been labelled as mentally il, their behaviour was interpreted in light of that label.

Question 49

Stickiness of labels

Answer 49

Once someone is labelled mentally ill, all their behaviours were seen in a different perspective.