Rosenhan 1973 Study Evaluation Essay

The Rosenhan experiment or Thud experiment was an experiment conducted to determine the validity of psychiatricdiagnosis. The experimenters feigned hallucinations to enter psychiatric hospitals, and acted normally afterwards. They were diagnosed with psychiatric disorders and were given antipsychotic drugs. The study was conducted by psychologistDavid Rosenhan, a Stanford University professor, and published by the journal Science in 1973 under the title "On being sane in insane places".[1][2] It is considered an important and influential criticism of psychiatric diagnosis.[3]

Rosenhan's study was done in two parts. The first part involved the use of healthy associates or "pseudopatients" (three women and five men, including Rosenhan himself) who briefly feigned auditory hallucinations in an attempt to gain admission to 12 psychiatric hospitals in five states in the United States. All were admitted and diagnosed with psychiatric disorders. After admission, the pseudopatients acted normally and told staff that they felt fine and had no longer experienced any additional hallucinations. All were forced to admit to having a mental illness and had to agree to take antipsychotic drugs as a condition of their release. The average time that the patients spent in the hospital was 19 days. All but one were diagnosed with schizophrenia "in remission" before their release.

The second part of his study involved an offended hospital administration challenging Rosenhan to send pseudopatients to its facility, whom its staff would then detect. Rosenhan agreed and in the following weeks out of 193 new patients the staff identified 41 as potential pseudopatients, with 19 of these receiving suspicion from at least one psychiatrist and one other staff member. In fact, Rosenhan had sent no pseudopatients to the hospital.

While listening to a lecture by R. D. Laing, who was associated with the anti-psychiatry movement, Rosenhan conceived of the experiment as a way to test the reliability of psychiatric diagnoses.[4] The study concluded "it is clear that we cannot distinguish the sane from the insane in psychiatric hospitals" and also illustrated the dangers of dehumanization and labeling in psychiatric institutions. It suggested that the use of community mental health facilities which concentrated on specific problems and behaviors rather than psychiatric labels might be a solution, and recommended education to make psychiatric workers more aware of the social psychology of their facilities.

Pseudopatient experiment[edit]

Rosenhan himself and seven mentally healthy associates, called "pseudopatients," attempted to gain admission to psychiatric hospitals by calling for an appointment and feigning auditory hallucinations. The hospital staff were not informed of the experiment. The pseudopatients included a psychology graduate student in his twenties, three psychologists, a pediatrician, a psychiatrist, a painter, and a housewife. None had a history of mental illness. Pseudopatients used pseudonyms, and those who worked in the mental health field were given false jobs in a different sector to avoid invoking any special treatment or scrutiny. Apart from giving false names and employment details, further biographical details were truthfully reported.

During their initial psychiatric assessment, the pseudopatients claimed to be hearing voices of the same sex as the patient which were often unclear, but which seemed to pronounce the words "empty," "hollow," "thud," and nothing else. These words were chosen as they vaguely suggest some sort of existential crisis and for the lack of any published literature referencing them as psychotic symptoms. No other psychiatric symptoms were claimed. If admitted, the pseudopatients were instructed to "act normally," reporting that they felt fine and no longer heard voices. Hospital records obtained after the experiment indicate that all pseudopatients were characterized as friendly and cooperative by staff.

All were admitted, to 12 psychiatric hospitals across the United States, including rundown and underfunded public hospitals in rural areas, urban university-run hospitals with excellent reputations, and one expensive private hospital. Though presented with identical symptoms, seven were diagnosed with schizophrenia at public hospitals, and one with manic-depressive psychosis, a more optimistic diagnosis with better clinical outcomes, at the private hospital. Their stays ranged from 7 to 52 days, and the average was 19 days. All were discharged with a diagnosis of schizophrenia "in remission," which Rosenhan considered as evidence that mental illness is perceived as an irreversible condition creating a lifelong stigma rather than a curable illness.

Despite constantly and openly taking extensive notes on the behavior of the staff and other patients, none of the pseudopatients were identified as impostors by the hospital staff, although many of the other psychiatric patients seemed to be able to correctly identify them as impostors. In the first three hospitalizations, 35 of the total of 118 patients expressed a suspicion that the pseudopatients were sane, with some suggesting that the patients were researchers or journalists investigating the hospital. Hospital notes indicated that staff interpreted much of the pseudopatients' behavior in terms of mental illness. For example, one nurse labeled the note-taking of one pseudopatient as "writing behavior" and considered it pathological. The patients' normal biographies were recast in hospital records along the lines of what was expected of schizophrenics by the then-dominant theories of its cause.

The experiment required the pseudopatients to get out of the hospital on their own by getting the hospital to release them, though a lawyer was retained to be on call for emergencies when it became clear that the pseudopatients would not ever be voluntarily released on short notice. Once admitted and diagnosed, the pseudopatients were not able to obtain their release until they agreed with the psychiatrists that they were mentally ill and began taking antipsychotic medications, which they flushed down the toilet. No staff member noticed that the pseudopatients were flushing their medication down the toilets and did not report patients doing this.

Rosenhan and the other pseudopatients reported an overwhelming sense of dehumanization, severe invasion of privacy, and boredom while hospitalized. Their possessions were searched randomly, and they were sometimes observed while using the toilet. They reported that though the staff seemed to be well-meaning, they generally objectified and dehumanized the patients, often discussing patients at length in their presence as though they were not there, and avoiding direct interaction with patients except as strictly necessary to perform official duties. Some attendants were prone to verbal and physicalabuse of patients when other staff were not present. A group of bored patients waiting outside the cafeteria for lunch early were said by a doctor to his students to be experiencing "oral-acquisitive" psychiatric symptoms. Contact with doctors averaged 6.8 minutes per day.

I told friends, I told my family: "I can get out when I can get out. That's all. I'll be there for a couple of days and I'll get out." Nobody knew I'd be there for two months ... The only way out was to point out that they're [the psychiatrists] correct. They had said I was insane, "I am insane; but I am getting better." That was an affirmation of their view of me.

— David Rosenhan in the BBC program "The Trap"[5]

Non-existent impostor experiment[edit]

For this experiment, Rosenhan used a well-known research and teaching hospital, whose staff had heard of the results of the initial study but claimed that similar errors could not be made at their institution. Rosenhan arranged with them that during a three-month period, one or more pseudopatients would attempt to gain admission and the staff would rate every incoming patient as to the likelihood they were an impostor. Out of 193 patients, 41 were considered to be impostors and a further 42 were considered suspect. In reality, Rosenhan had sent no pseudopatients; all patients suspected as impostors by the hospital staff were ordinary patients. This led to a conclusion that "any diagnostic process that lends itself too readily to massive errors of this sort cannot be a very reliable one".

There was also a significant reduction in the number of admissions to the hospital.[citation needed] This suggested that psychiatrists had been over-admitting before the non-experiment was conducted.

Impact and controversy[edit]

Rosenhan published his findings in Science, in which he criticized the reliability of psychiatric diagnosis and the disempowering and demeaning nature of patient care experienced by the associates in the study.[2] His article generated an explosion of controversy.

Many defended psychiatry, arguing that as psychiatric diagnosis relies largely on the patient's report of their experiences, faking their presence no more demonstrates problems with psychiatric diagnosis than lying about other medical symptoms. In this vein, psychiatrist Robert Spitzer quoted Kety in a 1975 criticism of Rosenhan's study:[6]

If I were to drink a quart of blood and, concealing what I had done, come to the emergency room of any hospital vomiting blood, the behavior of the staff would be quite predictable. If they labeled and treated me as having a bleeding peptic ulcer, I doubt that I could argue convincingly that medical science does not know how to diagnose that condition.

Kety also argued that psychiatrists should not necessarily be expected to assume that a patient is pretending to have mental illness, thus the study lacked realism.[7] Rosenhan called this the "experimenter effect" or "expectation bias", something indicative of the problems he uncovered rather than a problem in his methodology.[8]

The experiment "accelerated the movement to reform mental institutions and to deinstitutionalize as many mental patients as possible".[9]

Related experiments[edit]

In 1887 American investigative journalistNellie Bly feigned symptoms of mental illness to gain admission to a lunatic asylum and report on the terrible conditions therein. The results were published as Ten Days in a Mad-House.

In 1968 Maurice K. Temerlin split 25 psychiatrists into two groups and had them listen to an actor portraying a character of normal mental health. One group was told that the actor "was a very interesting man because he looked neurotic, but actually was quite psychotic" while the other was told nothing. Sixty percent of the former group diagnosed psychoses, most often schizophrenia, while none of the control group did so.[10]

In 1988, Loring and Powell gave 290 psychiatrists a transcript of a patient interview and told half of them that the patient was black and the other half white; they concluded of the results that "clinicians appear to ascribe violence, suspiciousness, and dangerousness to black clients even though the case studies are the same as the case studies for the white clients."[11]

Psychologist and writer Lauren Slater claimed to have conducted an experiment very similar to Rosenhan's for her 2004 book Opening Skinner's Box.[3] Slater wrote that she had presented herself at 9 psychiatric emergency rooms with auditory hallucinations, resulting in being diagnosed "almost every time" with psychotic depression. However, when challenged to provide evidence of actually conducting her experiment, she could not.[12]

In 2008, the BBC's Horizon science program performed a somewhat related experiment over two episodes entitled "How Mad Are You?". The experiment involved ten subjects, five with previously-diagnosed mental health conditions, and five with no such diagnosis. They were observed by three experts in mental health diagnoses and their challenge was to identify the five with mental health problems solely from their behavior, without speaking to the subjects or learning anything of their histories.[13] The experts correctly diagnosed two of the ten patients, misdiagnosed one patient, and incorrectly identified two healthy patients as having mental health problems. Unlike the other experiments listed here, however, the aim of this experiment was not to criticize the diagnostic process, but to minimize the stigmatization of the mentally ill. It aimed to illustrate that people with a previous diagnosis of a mental illness could live normal lives with their health problems not obvious to observers from their behavior.[14]

See also[edit]

References[edit]

Notes[edit]

  1. ^Gaughwin, Peter (2011). "On Being Insane in Medico-Legal Places: The Importance of Taking a Complete History in Forensic Mental Health Assessment". Psychiatry, Psychology and Law. 12 (1): 298–310. doi:10.1375/pplt.12.2.298. 
  2. ^ abRosenhan, David (19 January 1973). "On being sane in insane places". Science. 179 (4070): 250–258. doi:10.1126/science.179.4070.250. PMID 4683124. Archived from the original on 17 November 2004. 
  3. ^ abSlater, Lauren (2004). Opening Skinner's Box: Great Psychological Experiments of the Twentieth Century. W. W. Norton. ISBN 0-393-05095-5. 
  4. ^Rosenhan's Experiment: Being Sane in Insane Places speaker's voice over at 2:50Archived February 1, 2015, at the Wayback Machine.
  5. ^An excerpt from the BBC program with this statement by David Rosenhan can be viewed in Drug Pushers, Drug Users, Antidepressants, & School ShootersArchived 2017-02-19 at the Wayback Machine..
  6. ^Spitzer, Robert (October 1975). "On pseudoscience in science, logic in remission, and psychiatric diagnosis: a critique of Rosenhan's "On being sane in insane places"". Journal of Abnormal Psychology. 84 (5): 442–52. doi:10.1037/h0077124. PMID 1194504. 
  7. ^"Archived copy". Archived from the original on 2012-04-05. Retrieved 2012-04-13. 
  8. ^"The Rosenhan experiment examined"Archived 2012-05-12 at the Wayback Machine., Frontier Psychiatrist
  9. ^Kornblum, William (2011). Mitchell, Erin; Jucha, Robert; Chell, John, eds. Sociology in a Changing World(Google Books) (9th ed.). Cengage learning. p. 195. ISBN 978-1-111-30157-6. 
  10. ^Temerlin, Maurice (October 1968). "Suggestion effects in psychiatric diagnosis". The Journal of Nervous and Mental Disease. 147 (4): 349–353. PMID 5683680. Archived from the original on 2011-07-14. 
  11. ^Loring, Marti; Powell, Brian (March 1988). "Gender, race, and DSM-III: a study of the objectivity of psychiatric diagnostic behavior". Journal of Health and Social Behavior. 29 (1): 1–22. doi:10.2307/2137177. JSTOR 2137177. PMID 3367027. 
  12. ^Moran, Mark (7 April 2006). "Writer Ignites Firestorm With Misdiagnosis Claims". Psychiatric News. American Psychiatric Association. 41 (7): 10–12. ISSN 1559-1255. Retrieved 30 December 2009. 
  13. ^BBC Headroom Horizon: How Mad Are You?
  14. ^How Mad Are You? - SpotlightArchived July 2, 2010, at the Wayback Machine.

Bibliography[edit]

  • Slater, Lauren (2004). Opening Skinner's Box: Great Psychological Experiments of the Twentieth Century. W. W. Norton. pp. 64–94. ISBN 0-393-05095-5. 

External links[edit]

This is a Classic Study so everyone learns it and the Examiner will expect you to know it in detail. While the Exam could ask general questions about the procedure or evaluation, it could also ask specific questions, like, What did the pseudopatients say about their symptoms? or, What explanations did Rosenhan give for the failure of the hospital staff to diagnose the pseudopatients? or, What made this study ethical (or unethical)?

ROSENHAN (1973)
THE CLASSIC STUDY: THE PSEUDOPATIENT STUDY

This study was carried out by David Rosenhan. It is a famous naturalistic observation with aspects of a field experiment included. Rosenhan was a young academic who attended R.D. Laing's lectures on the anti-psychiatry movement: Laing argued that schizophrenia was "a theory not a fact" and rejected "the medical model of mental illness", especially the use of drugs. Rosenhan wanted to test the reliability of diagnosis for mental disorders.

This study is significant for students in other ways:
  • It shows how scientific research proceeds, because Rosenhan is testing and criticising established scientific theories and procedures concerning mental illness.
  • It illustrates problems with the reliability and validity of diagnosis of mental disorders while DSM-II was in use
  • It illustrates the power of the observational method, since it is a covert participant observation in a naturalistic setting

THE PSEUDOPATIENTS

After attending R.D. Laing's inspirational lecture, Rosenhan contacted a group of friends and colleagues to test Laing's criticisms of mental health diagnosis. The group would try to get admitted to mental hospitals, observe what they saw going on inside and see how long it took medical staff to realise they were healthy.

Rosenhan called this group PSEUDOPATIENTS (fake patients). There were 3 women and 5 men: a psychology graduate student in his 20s, three psychologists (including Rosenhan himself), a paediatrician, a psychiatrist, a painter, and a 'housewife'. Rosenhan trained them in how to address psychiatric health workers and how to avoid swallowing medication.

In order to be admitted, the pseudopatients had to attend a clinical interview at the hospital to be diagnosed. They told the truth about their backgrounds, except for the psychologists and the psychiatrists, who invented different careers. All of them reported the same symptoms: hearing an unfamiliar voice repeating the words 'empty', 'hollow' and 'thud'.
Such symptoms are alleged to arise from painful concerns about the perceived meaninglessness of one’s life. It is as if the hallucinating person were saying, “My life is empty and hollow” - David Rosenhan
Rosenhan also chose these symptoms because they didn't match up with the diagnostic classification of any mental illness at the time (using DSM-II).

DIAGNOSING SCHIZOPHRENIA

All of the 8 pseudopatients were admitted to mental hospitals with adiagnosis of schizophrenia. At the time of the study, DSM-IIwas in use. This manual described conditions like schizophrenia without clear criterion: it was described as a group of disorders that showed disturbances of thought, often leading to reality distortions, delusions and hallucinations. Schizophrenic behaviour was described as "highly deviant" with a reduced capacity for "empathy with others".

Although the pseudopatients reported one odd symptom (hearing voices), they described normal healthy lifestyles: they were not delusional or deviant and had no abnormal problems in their work or relationships. Even by the vague standards of DSM-II, they shouldn't have been diagnosed with schizophrenia, so this is a false positive.
7-minute video summing up the study

ROSENHAN'S STUDY
APRC

Aim

Rosenhan wanted to test the reliability of mental health diagnosis, to see if medical professionals could tell the sane from the insane in a clinical setting. He also wanted to investigate the effect of labeling on medical diagnosis.

In particular, Rosenhan investigated whether healthy pseudopatients would be given a diagnosis of mental illness and whether their imposture would be recognised by medical staff and other patients. Later, he investigated whether genuine patients would be identified as pseudopatients by suspicious staff.

IV & DV

This is an observation, not an experiment, so there is no IV or DV.

Sample
A common mistake students make is to write about the pseudopatients as if they were the participants in the study. The pseudopatients were the observers, not the participants (although Rosenhan does make some observations about the effect the study had on them).
The participants were the staff and patients in 12 psychiatric hospitals (mental asylums) in the United States.

The hospitals were in 5 different states, on the East and West coasts of the country.
Some were old and shabby, some were quite new. Some had good staff-patient ratios, others were quite understaffed. Only one was a strict private hospital - David Rosenhan
How could there be 12 hospitals if there were only 8 pseudopatients? Some of the pseudopatients applied to be admitted to more than one hospital. They then chose which hospital they would stay in.
Procedure

The pseudopatients went to clinical interviews and reported their symptoms.

Rosenhan approached the head of the hospital he went to and informed him of the deception, but the other pseudopatients weren't known to anyone on the staff. Rosenhan also briefed lawyers to get the pseudopatients out if anything went wrong.

When they were admitted to a hospital, they started behaving normally and stopped reporting hearing voices. They took a notepad and pen along with them to record what they heard and saw (unstructured observation). They tried to do this covertly, but if the staff detected them they carried on recording things overtly.
As soon as they were admitted, the pseudopatients requested to be discharged. They secretly disposed of any medication they were given (eg they flushed pills down the toilet) but otherwise they were friendly and polite and did everything that was asked of them - Rosenhan instructed them to be "paragons of cooperation".
Structured observations: Rosenhan carried out two structured observations during the study:
  • In 3 hospitals, a record was kept of how many patients voiced suspicions about the pseudopatients and how much time the staff spent on the ward, interacting with the patients
  • In 4 hospitals, the pseudopatient approached staff with a scripted question: "Pardon me, Mr [or Dr or Mrs] X, could you tell me when I will be eligible for grounds privileges?” (or “ . . . when I will be presented at the staff meeting?” or “. . . when I am likely to be discharged?”). The member of staff's answer and body language were recorded.
Follow-on study: After the main study ended, Rosenhan contacted his own hospital and revealed the results. The hospital agreed to a second study, but this time they would be aware that new pseudopatients would be seeking admission over the next 3 months. Staff were issued with a questionnaire to rate each new patient on a 10-point scale: 9-10 meant high confidence that the patient was really ill but 1-2 meant a strong suspicion that this was a pseudopatient.
Results

All 12 hospitals diagnosed the pseudopatients as mentally ill. 11 hospitals diagnosed schizophrenia, 1 hospital (the private hospital) diagnosed manic-depression (bipolar disorder). The pseudopatients went to hospitals that had diagnosed them with schizophrenia.
None of the staff recognised that the pseudopatients were healthy. It took between 7 and 52 days for the pseudopatients to be discharged; the mean length of stay was 19 days.
Who was the person stuck in a mental hospital for 52 days? Why, that was Rosenhan himself! The irony!
The pseudopatients were discharged with a diagnoses of "schizophrenia - in remission" (meaning the person has schizophrenia but the symptoms appear to have stopped) in 7 cases; 1 pseudopatient was discharged with a diagnosis of "schizophrenia" on their medical record.
The pseudopatients observed many disturbing things while in the hospitals.
  • Staff abusing patients: The pseudopatients were well-behaved and none of them were harmed in any way, but they observed other patients being verbally or physically abused by staff. Rosenhan reports that patients were awakened in the morning by an attendant shouting "Come on you m---- f----s, out of bed!" and one patient was beaten for saying to an attendant "I like you".
  • Patients refusing medication: The pseudopatients disposed of their pills but when they went to flush them down the toilet, they often observed that other patients had done the same thing
  • Depersonalisation & powerlessness: The patients weren't treated as persons. There were no doors on toilet cubicles and staff would inspect their medical records and personal belongings without asking permission. Staff would not make eye contact with patients. Staff would discuss patients within earshot, as if the patients could not hear them. Attendants would abuse patients while other patients were watching, but not when doctors were present. 
Staff are credible witnesses. Patients are not - David Rosenhan
Rosenhan describes feeling as if he were invisible and offers one memorable example of this:
A nurse unbuttoned her uniform to adjust her brassiere in the presence of an entire ward of viewing men. One did not have the sense that she was being seductive. Rather, she didn’t notice us - David Rosenhan
Structured observations: Rosenhan carried out two structured observations during the study:
  • Although staff were not suspicious of the pseudopatients, other patients were. 35 out of 118 patients accused the pseudopatients of not being genuinely ill.
You’re not crazy. You’re a journalist, or a professor You’re checking up on the hospital - anonymous patient
  • The staff spent most of their time in a secure area with glass windows ("the cage") and little time on the ward. On average, staff spent only 11.3% of their time outside "the cage" and much of this was doing chores rather than interacting with patients. Doctors only came onto the ward on average 6.7 times per day. Rosenhan observes that the staff behaved as if mental illness were "catching" (contagious).
Follow-on study: Rosenhan sent NO pseudopatients in the follow-on study, so ALL the patients seeking admission were genuine. 193 patients arrived at the hospital: 41 were rated as pseudopatients by at least one member of staff, 23 were rated as pseudopatients by at least one psychiatrist and 19 were rated as pseudopatients by a psychiatrist AND a staff member.


Conclusions

Rosenhan draws bold conclusions from this study:
It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals - David Rosenhan
Rosenhan draws attention to the private hospital that diagnosed a pseudopatient with manic-depression. This is a more treatable disorder than schizophrenia. Rosenhan notes that wealthier people are more likely to get diagnosed with milder problems that have better therapeutic outcomes, which shows that your class background affects the way you are diagnosed.
Maddeningly, Rosenhan muddles up Type I and Type II errors in his writing: he calls the false negatives Type I errors and the false positives Type II errors. Maybe this is a Type III error?!?!? In any event, the Examiner should credit you with answering correctly whether you use the standard terminology (false positives = Type I) or Rosenhan's terminology (false positives = Type II).
Rosenhan is very concerned that the conditions in psychiatric hospitals do not help with therapy; in fact, they make patients worse. Rosenhan agrees with Goffman (1961) that conditions in psychiatric hospitals are psychologically mortifying - they make healthy behaviour and healthy thoughts more difficult.

DIAGNOSTIC LABELS

Rosenhan points out a number of things that support the idea of mental health diagnosis as a label:
  • During his own clinical interview, Rosenhan described his own family life with only the normal amount of friction and disappointment. The psychiatrist recorded "ambivalence" (conflict) and "affective instability" (unstable emotions). This is because the symptom of hearing voices made the psychiatrist suspect schizophrenia, so he found evidence of it in Rosenhan's background. This shows that the label of mental illness CREATES the diagnosis, rather than the other way round.
  • Other pseudopatients experienced similar things. 3 pseudopatients had their note-taking recorded on their medical record as "writing behaviour" as if it were a symptom of mental illness. One pseudopatient walked the corridors to relieve boredom, but a nurse interpreted this as his being "nervous".  A psychiatrist pointed out patients arriving early at the cafeteria as an example of "the oral-acquisitive nature of the syndrome" but in fact there is nothing to do in a hospital but wait for mealtimes.
Such labels, conferred by mental health professionals, are as influential on the patient as they are on his relatives and friends, and it should not surprise anyone that the diagnosis acts on all of them as a self-fulfilling prophecy. Eventually, the patient himself accepts the diagnosis ... and behaves accordingly - David Rosenhan
The SELF-FULFILLING PROPHECY is an important concept from the Labeling Theory, which you will study in more detail as part of Criminal Psychology. It occurs when people accept the label they have been given and it becomes true about them.
Rosenhan refers to mental health diagnoses as "labels" which are attached to patients. His study shows that these labels are often attached wrongly. He also claims that these labels, once attached, are very hard to change or remove.
A psychiatric label has a life and an influence of its own - David Rosenhan
Rosenhan refers to the "stickiness" of labels
The pseudopatients, who spent a lot of time with the other patients, noticed that they behaved in a sane way most of the time, with occasional episodes of abnormal behaviour.

Rosenhan describes how labels affected the staff. For example, outbursts of anger or frustration from patients were treated by the staff as symptoms of their illness, even when they were clearly provoked by the staff themselves being rude or the hospital procedures being burdensome.

The "bizarre setting" of the psychiatric hospital makes it hard for patients to behave normally or for staff to recognise normal behaviour when they see it. This adds to the power of labels.

Rosenhan wonders whether patients come to believe these labels.
Homer: This isn't fair! How can you tell who's sane and who's insane?
Doctor: Well, we have a very simple method. [stamps Homer's hand with a stamp that reads "INSANE"]  Whoever has that stamp on his hand is insane.

ANOTHER FOLLOW-ON STUDY
A FIELD EXPERIMENT

This follow-on research isn't described in Rosenhan's 1973 study, even though it's frequently described in textbooks and websites. You don't need this extra detail, but it does show how an observation can be turned into a field experiment by comparing two different environments.
In 4 hospitals, the pseudopatients approached hospital staff with a scripted question and recorded how they were treated.
Rosenhan repeated this by sending a female pseudopatient to the Stanford University health clinic (not a psychiatric hospital, but a normal medical centre) to ask members of staff in the corridors for directions on 14 occasions. Here are the results compared:
You can see how rare it was for staff to stop and respond in the psychiatric setting, but in a normal health setting this behaviour was completely typical.
This suggests that the behaviour of psychiatrists, nurses and attendants wasn't due to them being busy health professionals - because the busy health professionals at the normal health centre responded differently.

EVALUATING ROSENHAN AO3
GRAVE

Generalisability

Rosenhan made a point of using a range of psychiatric hospitals - private and state-run, old and new, well-funded and under-funded - from across the United States. Nevertheless, 12 is a small sample for a country as big as the USA and a few "bad apples" could have skewed the results of Rosenhan's observations.

There's been a lot of progress in mental health care since the 1970s (indeed, Rosenhan's study prompted many reforms), so perhaps the results are "time-locked" and cannot be generalised to psychiatric diagnosis and care today.

For example, Rosenhan's pseudopatients were diagnosed using DSM-II. Today's DSM-5 requires the patient to show TWO symptoms (not just one) and have the symptoms for at least 6 months.
On the other hand, the psychiatrists in 1973 weren't using DSM-II properly when they diagnosed the pseudopatients, so why should psychiatrists today use DSM-5 properly?
Reliability

Rosenhan trained his pseudopatients beforehand, but they didn't all follow the same standardised procedures.
  • Data from a 9th pseudopatient was not included in Rosenhan’s report because, among other things, he did not follow procedures.
  • The graduate student asked his wife to bring in his college homework to do, revealing he was a psychologist.
  • Another pseudopatient revealed that he was going to become a psychologist and one of his visitors was a college Psychology professor
  • One pseudopatient struck up a romantic relationship with a nurse.
Rosenhan explains this as the pseudopatients resisting the effects of depersonalisation and powerlessness. However, it also suggests they failed to follow instructions and act consistently.
Lauren Slater (2004) attempted to replicate Rosenhan’s study by presenting herself at 9 psychiatric emergency rooms. Her symptom was an isolated auditory hallucination (hearing the word ‘thud’). Slater was given a diagnosis of ‘Psychotic Depression’ and prescribed antipsychotics or antidepressants. (Slater had previously been diagnosed with depression). Spitzer, Lilienfeld & Miller (2005) challenged Slater’s findings by giving 74 emergency room psychiatrists her case description and asking about diagnosis and treatment. Only 3 psychiatrists diagnosed ‘Psychotic Depression’ and only a third recommended medication.
Application

This study had a huge impact on mental health care, not just in America but worldwide. It caused psychiatric hospitals to review their admission procedures and how they trained their staff to interact with patients. It started the move away from dependency on the "chemical straitjacket" of drugs to treat mental health. Today, the study is a compulsory part of training in psychiatric medicine and nursing.

Along with Robert Spitzer's criticisms, this study was a major influence on reforming the DSM. DSM-III (1980) defined mental illnesses much more carefully, with clear guidelines for including or excluding people from each classification. For example, in DSM-III, a hallucination needed to be repeated several times; in DSM-IV (1994) hearing voices needed to be experienced for over a month before a diagnosis of schizophrenia can be made and DSM-5 makes this 6 months.
Validity

Seymour Ketty (1974) criticised Rosenhan, saying that, because the pseudopatients were faking an unreal mental condition, it doesn't tell us anything about how people with genuine mental conditions are diagnosed.
If I were to drink a quart of blood and, concealing what I had done, had come to the emergency room of any hospital vomiting blood, the behaviour of the staff would be quite predictable. If they labelled and treated me as having a bleeding peptic ulcer, I doubt that I could argue convincingly that medical science did not know how to diagnose that condition - Seymour Kety
Kety’s point is that psychiatrist don't expect someone to carry out deception in order to be admitted to a psychiatric hospital. In other words, the study lacked ecological validity.
Rosenhan points out one reason why patients might lie to get into a psychiatric hospital, which is to avoid criminal prosecution (especially in a state which enforces the death penalty!).
The fact that 11 of the 12 diagnoses were consistent - schizophrenia - may prove diagnoses is reliable after all. If patients present the same symptoms, they receive the same diagnosis. This goes against Rosenhan's view that diagnosis is unreliable.

Robert Spitzer (1976) points out that the diagnosis ‘Schizophrenia - in Remission’ given to 7 of the discharged pseudopatients is very unusual. He examined records of discharged schizophrenic patients in his own hospital and 12 other American hospitals and found that ‘Schizophrenia - in Remission’ was used only for a handful of patients each year. Spitzer claims the psychiatrists’ discharge diagnosis was a recognition that the pseudopatients' behaviour was unusual, not proof that the psychiatrists couldn’t tell the sane from the insane.
Ethics

The hospital staff were deceived about the pseudopatients’ symptoms being real. The doctors and nurses in the hospitals could not consent to take part or exercise their right to withdraw from the study. The other patients in the study had no possibility of consenting or withdrawing and didn't enter psychiatric hospitals in order to be in psychology research
However, Rosenhan notified the management of the hospital he went to.
I was the first pseudopatient and my presence was known to the hospital administration and chief psychologist and, so far as I can tell, to them alone - David Rosenhan
If Rosenhan thought that the management of the hospital he went to could be trusted, why didn't he inform the hospitals the other pseudopatients went to?
Rosenhan did protect confidentiality - no staff or hospitals were named.
Rosenhan may be criticised for failing in a duty of care towards his own researchers - the pseudopatients. He put them in a harmful environment where they experienced tension and stress. None of them were physically abused but they witnessed physical abuse going on. They were instructed in how to avoid taking medication, but if they had been forced to take medication, it could have produced side-effects on them.

However, Rosenhan took a few precautions. In his own case, he notified the hospital manager and chief psychologist of what he was doing. For all the pseudopatients, he prepared lawyers who would intervene to get the pseudopatients out of hospitals if they requested it.
A different ethical issue with Rosenhan’s study is that it contributed to a crisis of public confidence in the American mental health system - which may have prevented people who genuinely needed help from seeking it.
However, Rosenhan wasn't the only critic of psychiatry at the time. Two years after Rosenhan, "One Flew Over The Cuckoo's Nest" (1975) dramatised many of the same problems in mental health care. It won the Best Film Oscar.
Start with an evaluation point and back it up with evidence.
Evaluation + evidence = "logical chain of reasoning"
Issues & Debates (like contributions) make great conclusions

EXEMPLAR ESSAY
AN 8-MARK ESSAY ON THE CLASSIC STUDY

Evaluate the classic study by Rosenhan (1973). (8 marks)
  • A 8-mark “evaluate” question awards 4 marks for AO1 (Describe) and 4 marks for AO3 (Evaluate).

Rosenhan's study is reliable because he followed a standardised procedure.His 8 pseudopatients were trained to behave the same way. They reported the same symptoms (hearing a voice that said 'hollow', 'empty' and 'thud') and concealed that they had any background in psychology or psychiatry. In the hospital, they stopped claiming to hear voices and took secret notes on what they observed.

However, Rosenhan's study wasn't entirely reliable because some pseudopatients ignored the procedures. A 9th pseudopatient had to be dropped from the study and even the ones that were included did things like tell staff they were studying Psychology, bring in the Psychology homework and strike up a romantic relationship with a nurse.

Rosenhan's findings must be valid because his observation was covert;the hospital staff didn't know they were being observed and even when they saw pseudopatients taking notes they treated it as "writing behaviour" and a symptom of mental illness.

Because the observation was unstructured it contains rich qualitative data, like Rosenhan's account of the nurse undressing in front of the patients which shows that they didn't count as 'real people' to the staff.

In conclusion, Rosenhan's study made a big contribution to reforming mental healthcare and the DSM. The other critics of mental health care at the time (such as R.D. Laing and films like "One Flew Over the Cuckoo's Nest") suggest Rosenhan was right to expose something wrong with the system.
  • Notice that for a 8-mark answer you don’t have to include everything about Rosenhan. I haven’t explored generalisability problems or the ethical issues. But it is a balanced answer - half description, half evaluation.

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