JMR

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Rosenhan (1973)

• JMR

On Being Sane in Insane Places
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Diagnosing mental illness

• How do we diagnose mental illness?
• What are the pitfalls?
• What are the consequences of labelling someone as
  mentally ill?

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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?

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Mental illness

• Difficult to define. Medical classifications
  exist (eg. DSM IV or ICD 10) these list symptoms

• Problems with medical classification
• 1. Problems often arent physiological, cant be
  tested (eg. X-rays for broken bones)
• 2. Depends on whether we believe the patient

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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 isnt?

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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
• ? its a label society gives to odd behaviour
  (very subjective)

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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

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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

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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!

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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? Whats it all for? My life is empty
  and hollow!)

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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)

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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)

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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

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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 theyre stuck
  on, theyre hard to remove

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Normal seen as abnormal 1

• EG 1 Pseudos ordinary life histories
• Pseudos didnt 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

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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

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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!

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Staff attitudes 2
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Staff attitudes 3

• These attitudes produce powerlessness and
  depersonalisation
• ? see Zimbardo, its 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 arent credible
  witnesses)

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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?

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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)

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Experiment 2 - results

• All new patients were genuine NO pseudopatients

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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

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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 17-35 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?