Rosenhan overview

1. Rosenhan (1973) On being sane in insane places (Individual differences approach)

2. Aims Briefly describe the individual differences approach Give a definition of abnormality Explain the problems with defining abnormality Hard to say what is normal Diagnosis may act as label, leading to discrimination List the key features of schizophrenia

3. The individual differences approach Individual difference psychology examines how people differ in their thinking, feeling and behaviour. (The other approaches tend to focus on similarities). For example, people can be classified according to intelligence and personality characteristics. Other areas studied might include values and self-esteem.

4. What is Abnormal Behaviour?

5. Joan of Arc

6. Rosenhan & Seligman: Criteria for diagnosing abnor m ality 1. Suffering . But some people ( e.g.psychopaths ) have no concept of suffering. And normal people suffer too.

7. Rosenhan & Seligman: Criteria for diagnosing abnormality 2.Maladapativeness . Behaviours that prevent people from living a fulfilling life Example: fear of leaving the house prevents them from doing anything

8. Rosenhan & Seligman: Criteria for diagnosing abnormality 3.Vividness and unconventionality But unconventionality doesn’t always indicate mental illness!

9. Rosenhan & Seligman: Criteria for diagnosing abnormality 4. Unpredictability and loss of control

10. Rosenhan & Seligman: Criteria for diagnosing abnormality 5. Irrationality and incomprehensibility We need to be careful when judging someone’s behaviour as irrational – perhaps their behaviour actually has a sensible cause.

11. Rosenhan & Seligman: Criteria for diagnosing abnormality 6.Observer discomfort

12. Rosenhan & Seligman: Criteria for diagnosing abnormality 7.Violation of moral and ideal standards E.g. committing murder.

13. Which of the 7 criteria occur in normal people? All of them! So you can see it’s difficult to diagnose someone as mentally ill.

14. Some definitions of abnormality Stratton & Hayes (1993) .. Abnormality is behaviour which: deviates from the norm most people don’t behave that way does not conform to social demands most people don’t like that behaviour is maladaptive or painful to the individual It’s not normal to harm yourself

15. Problem with definining abnormality…. All of these features sometimes appear in “normal” people, so it’s difficult to diagnose someone as mentally ill . Normality is also CULTURALLY DEFINED. .

16. Cultural definition of deviance

17. Categorising Mental Illness Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) International Statistical Classification of Diseases and Related Health Problems (ICD)

18. Diagnosis or Labelling?

19. Social Stigma? Many people misunderstand and may even fear those with a mental illness . Once a person has been diagnosed with mental illness, they may face social stigma where they may be misunderstood or even feared by others . They may find that their diagnosis labels them , so that their ordinary behaviour is interpreted as a symptom of illness. They may be discriminated against, for example when seeking employment . However, mental illness is widespread. Frank Bruno, one of the nations favourite Boxers who won the ABA Heavyweight Championship at just 18 had to be sectioned in 2003 for depression . This shows how anyone can be affected by mental illness, whether famous, successful or otherwise . Similarly Stephen Fry suffers from bipolar disorder.

20. What is Schizophrenia? A serious mental disorder Positive Symptoms (additional to normal behaviour) include: hallucinations, delusions and thought disorder Negative Symptoms (reduction in normal experiences or behaviour) include flattened affect and lack of motivation.

21. Schizophrenia: Case Study Gerald: a case study

22. What do you think it would be like to have Schizophrenia?

23. How did it feel? If you had a mental illness how would you like to be treated?

24. The Question If sanity and insanity exist How shall we recognise them?

25. Background summary Briefly describe the individual differences approach Give a definition of abnormality Explain the problems with defining abnormality Hard to say what is normal Diagnosis may act as label, leading to discrimination List the key features of schizophrenia Explain how schizophrenia is usually treated.

26. D.L. Rosenhan (1973) The ground breaking study : “On being sane in insane places”

27. Approach : Individual Differences Definition: Examines how people differ in their thinking, feeling, and behaviour.

28. Aim Overall: To see if psychiatrists could differentiate between sane and insane people .

29. Intro to the study

30. Method: Field experiment, with participant observation. Qualitative data – rich and detailed High ecological validity Fewer demand characteristics Difficult to replicate – lower reliability Difficult for researcher to remain objective – danger of subjective interpretation Time-consuming Ethical issues – deception Lack of control over confounding variables.

31. Aims of the 3 studies Study one: To see if sane people could get themselves admitted to psychiatric hospitals Study two: To see if the hospitals, who had been told they were going to be approached by pseudo-patients, would be able to tell the sane from the insane. Study three: To investigate patient/staff contact

32. Study 1: Participants Hospital staff and patients Also: the participant observers: EIGHT sane people one graduate student three psychologists a paediatrician a painter Housewives

33. Method Field experiment, with participant observation.

34. Procedure: Study 1 telephoned 12 psychiatric hospitals for urgent appointments gave false name and address complained of hearing unclear voices … saying “empty, hollow, thud ” Simulated ‘existential crisis’ “Who am I, what’s it all for ?” Once admitted,they stopped simulating any symptoms and took part in ward activities They took notes of their experiences while in the hospital.

35. IV and DV Study 1: IV: Participants pretence to get into hospital DV: Psychiatrists admission of participants, and strength of diagnostic label

36. Controls: Study One All Ps presented with the same symptom at the various hospitals – ie reporting hearing voices saying “empty”, “hollow”, or “thud”. All Ps behaved normally apart from this.

37. What happened? All were admitted to hospital All but one were diagnosed as suffering from schizophrenia

38. How did the ward staff ‘see’ them? Normal behaviour was misinterpreted Writing notes was described as - “The patient engaged in writing behaviour ” Arriving early for lunch described as “oral acquisitive syndrome” Behaviour distorted to ‘fit in’ with label

39. How long did they stay in hospital? The shortest stay was 7 days The longest stay was 52 days The average stay was 19 days They had agreed to stay until they convinced the staff they were sane. Role play: How would YOU convince someone you are sane?

40. Were they treated in the same way as normal patients? Given total of 2100 medication tablets they flushed them down the loos Noted that other patients did the same and that this was ignored as long as patients behaved themselves!

41. What sorts of records did they keep? Nurses stayed in ward offices 90% of time Each ‘real patient’ spent less than 7 minutes per day with psychiatric staff

42. Perhaps they behaved ‘abnormally’ Pseudo-patient’s visitors detected “No serious behavioural consequences ” DID ANYONE SUSPECT?

43. What about the REAL patients? 35 out of 118 patients voiced their suspicions

44. On release - The pseudo-patients were diagnosed as Schizophrenia “IN REMISSION ” Labels are “sticky” – they remain with you even when you are well.

45. Results: Study 1 All pseudo-patients admitted to hospital. Normal behaviour was interpreted as insane. “Patient engages in writing behaviour” Patients were powerless No staff members suspected them, although 35 patients voiced their suspicions. Evidence that their behaviour was in reality normal: Pseudo-patient’s visitors detected “ No serious behavioural consequences” Pseudo-patients stayed in hospital between 7 and 52 days (mean 19 ) Pseudo-patients recorded staff-patient interaction: noted that nurses stayed in ward offices 90% of time, and each ‘real patient’ spent less than 7 minutes per day with psychiatric staff 7 out of 8 diagnosed as schizophrenic. Discharged with diagnosis of “schizophrenia in remission”. “stickiness” of labels Labels as self-fulfilling prophecies

46. Conclusion: Study 1 Psychiatrists could not detect sanity.

47. Study 2: Participants Hospital staff at a large teaching and psychiatric hospital Opportunity sample Field experiment

48. Procedure: Study 2 A teaching and psychiatric hospital that was aware of the findings from study 1 was informed that over the next 3 months one or more pseudo-patients would try to get admitted to their hospital. Each member of staff was asked to rate the likelihood that the patients who sought to be admitted were pseudo-patients. In reality, no pseudo-patients were admitted.

49. Study Two IV: False information given to hospital DV: Number of patients that staff suspect of being pseudo-patients

50. Controls: Study 2 None

51. Results: Study 2 Staff members rated ‘new patients’ on scale 1 - 10 as ‘how likely to be a fraud ’ 193 patients ‘assessed’ 41 rated as a pseudo-patient (by at least two members of staff ) 23 rated as pseudo-patient (by at least one psychiatrist ) 19 rated as pseudo-patient (by a psychiatrist and one other member of staff)

52. Conclusions: Study 2 The staff were unable to detect insanity.

53. Study 3: Participants Doctors and staff in 4 of the hospitals used in Study One Opportunity sample Method: Field experiment with participant observation

54. Procedure: Study 3 In 4 of the hospitals pseudo-patients approached a member of staff and asked~ “ Pardon me, Mr/Mrs/Dr X, could you tell me when I will be eligible for ground privileges ?” The pseudo-patient did this as normally as possible and avoided asking the same member of staff more than once a day.

55. Study 3: IV and DV IV: “Patient” or visitor DV: Level of contact between staff and subject Control: Young female participant stopped faculty members on university campus and asked various questions eg “I’m looking for a psychiatrist”.

56. Results: Study3 Psychiatric Hospital Psychiatric Hospital University campus Responses (%) Psychiatrists Nurses Faculty Moves on, head averted 71 88 Makes eye contact 23 10 Pauses and chats 2 2 Stops and talks 4 0.5 100 No. of respondents 13 47 14 No. of attempts 185 1283 14

57. Conclusion: Study 3 Patients are powerless while on the mental ward The lack of eye contact between staff and patients depersonalises the patients.

58. Type 1 vs Type 2 errors Type 1 error: False negative (diagnose a sick person as healthy) Type 2 error: make a false positive choice (diagnose a healthy person as sick)

59. Why did the doctors not realise that the pseudo-patients were sane? Can’t blame… Quality of the hospitals Time available to observe them Their behaviour Recognised as sane by many PATIENTS! May be because doctors have a bias towards Type 2 errors ( false positives, where a healthy person is diagnosed as sick) over Type 1 errors (false negatives, where a sick person is diagnosed as healthy). Erring on the side of caution

60. Rosenhan’s conclusion “It is clear that we are unable to distinguish the sane from the insane in psychiatric hospitals” In the first study : We are unable to detect ‘sanity’ In the follow up study : We are unable to detect ‘insanity’

61. Rosenhan’s study highlighted The depersonalisation and powerlessness of patients in psychiatric hospitals That behaviour is interpreted according to expectations of staff and that these expectations are created by the labels SANITY & INSANITY

62. Powerlessness and Depersonalisation Depersonalisation: Where people are not treated as unique individuals, worthy of respect. Shown through the following: Patients were deprived of many human rights such as freedom of movement and privacy.  For example physical examinations were conducted in semi-private rooms. Medical records were open to all staff members regardless of status or therapeutic relationship with the patient Personal hygiene was monitored and many of the toilets did not have doors.  Some of the ward orderlies would be brutal to patients in full view of other patients but would stop as soon as another staff member approached.  This indicated that staff were credible witnesses but patients were not. Staff treated patients will little respect, beating them and swearing at them for minor incidents General activity around the patients was conducted as though they were invisible. Patients were unable to initiate contact with staff. This depersonalisation led to the patients feeling powerless.

63. Examples of depersonalisation Patients were deprived of many human rights such as freedom of movement and privacy.  They could not leave the hospital, and physical examinations were conducted in semi-private rooms. Medical records were open to all staff members regardless of status or therapeutic relationship with the patient Personal hygiene was monitored and many of the toilets did not have doors.  Some of the ward orderlies would be brutal to patients in full view of other patients but would stop as soon as another staff member approached.  This indicated that staff were credible witnesses but patients were not. Staff treated patients will little respect, beating them and swearing at them for minor incidents General activity around the patients was conducted as though they were invisible. Patients were unable to initiate contact with staff .

64. This depersonalisation led to the patients feeling powerless.

65. Rosenhan’s summary and conclusion… We cannot distinguish the sane from the insane all of the time. Hospitalisation for the mentally ill isn’t the solution as it results in powerlessness, depersonalisation, segregation, mortification and self-labelling- all counter-therapeutic.

66. What do the results of this study tell us about human behaviour? From the study we can infer that it is not always possible for doctors to differentiate between sane and insane people. Once given, a label of mental illness creates expectations. This can be seen in Study 1, where 7 out of 8 researchers were diagnosed as schizophrenic, and in Study 2, where both psychiatrists and staff members evaluated sick people as healthy. Therefore it may be better to place abnormal individuals in community healthcare to avoid the institutional context. It may also be better to focus on behavioural diagnoses rather than global labels such as “schizophrenia”.

67. Practical applications Perhaps should increase number of criteria used to diagnose mental illnesses. Reduce abuse of power in mental institutions by staff – CCTV Change number of professionals needed to diagnose disorders – can’t rely on just one individual.

68. Ethics Deception? Informed consent? Withdrawal? Protection? Undermine confidence of doctors and nurses

69. Ecological Validity Very high ecological validity Process of being admitted to a hospital, the experience of life in a hospital, and discharge, was true to life.

70. Qualitative and Quantitative Data Quantitative data: numbers admitted and discharged in Study 1; number of faulty diagnoses made in Study 2; social interaction data from Study 3. Qualitative data: experience of being in hospital, feelings of powerlessness and depersonalisation Problems with the qualitative data?

71. Longitudinal vs snapshot Study 1: 52 days Study 2: Took place over a 3 month period Long enough to see change over time.

72. Discussion question: Why might the reports of the pseudo-patients have been unreliable?

73. Strengths and Weaknesses Strengths Weaknesses High ecological validity Insightful Quantitative and qualitative data – increases validity High validity – covert observation Few demand characteristics – p’s don’t know they’re being studied – increases validity Reported same symptoms to each hospital – increases reliability Symptoms well-chosen – valid way of testing reliability of diagnostic systems Used a range of hospitals Unethical Ethnocentric Possibility of observer bias – P’s knew aim of experiment – Rosenhan was one of them ! Decreases validity Study 1: only 12 hospitals Study 2: only 1 hospital Unreliable: interactions after intake not controlled Difficult to record details accurately and promptly while participating . Decreases validity.

74. Alternative method Send a self-report questionnaire to doctors giving them scenarios (I’m hearing voices – hollow, thud, empty) and asking on a scale of 1-10 how likely they would be to put them into the hospital . Advantage: cheaper, easier, no ethical issues, more representative (larger sample possible) Disadvantage: people will probably not give accurate answers, either through lack of self-knowledge or because they want to give the socially desirable answer. Effect on results: results will be lower in validity but more reliable.

75. Alternative method Conduct the study cross-culturally: eg UK, USA, Australia Advantage: be able to see whether there are cross-cultural differences and similarities Disadvantage: Expensive, time-consuming. Ethical issues remain. Effect on the results: make the sample more representative, therefore will be able to generalise results.

76. The Simpsons Stark Raving Dad