Detecting Insanity: The Rosenhan Study

1. Question:How do we detect insanity? Rosenhan Study For the spec: You need to be able to refer to this study within an evaluation of how abnormality can be hard to define.

2. Recap of definitions of abnormality Abnormality IS • Behaviour which deviates from the social norm • i.e. most people don’t behave that way • Behaviour which does not conform to social demands • i.e. most people don’t like that behaviour • Failure to Function Adequately • Deviation from Ideal Mental Health • Behaviour which is maladaptive or painful to the individual • i.e. it’s not normal to harm yourself • Statistical Infrequency - it’s rare !

3. Learning outcomes: • Consider problems with definingabnormal behaviour • to be able to describe and evaluate the reliability of the diagnosis of mental disorders • To be able to describe and evaluate the validity of the diagnosis of mental disorders • Describe the Rosenhan study in relation to the above issues

4. In order to diagnose and treat mental disorders, we need a system by which we can categorise them – put them in groups according to similarities (just as we do with physical illnesses). A classification system is simply a comprehensive list of categories, including detailed descriptions of the symptoms characteristic of each. • The Diagnostic and Statistical Manual of Mental Disorder (Edition 5), was last published in 2013. • The DSM is produced by the American Psychiatric Association. • It is the most widely used diagnostic tool in psychiatric institutions around the world

5. ICD - 10 • There is also the International Statistical Classification of Diseases (known as ICD). • It is produced by the World Health Organisation (WHO) and is currently in it’s 10th edition.

6. DSM-5 DSM-5 classifies mental disorders into major groups, including: • Depressive disorders • Anxiety disorders • Obsessive-compulsive and related disorders • Feeding and eating disorders

7. Phobias A phobia is an irrational fear of an object or situation. DSM-5 distinguishes three groups of phobias: • Specific phobia: phobia of an object, such as an animal or body part, or a situation such as flying or having an injection. • Social anxiety (social phobia): phobia of a social situation such as public speaking or using a public toilet. • Agoraphobia: phobia of being outside or in a public place.

8. Depression Depression is a mental disorder characterised by low mood and low energy levels. The categories of depression and depressive disorders in DSM-5 are: • Major depressive disorder: severe but often short-term depression. • Persistent depressive disorder: long-term or recurring depression, including sustained major depression and what used to be called dysthymia. • Disruptive mood dysregulation disorder: childhood temper tantrums. • Premenstrual dysphoric disorder: disruption to mood prior to and/or during menstruation.

9. Obsessive Compulsive Disorder – OCD OCD is characterised by obsessions (recurring thoughts, images, etc.) and/or compulsions (repetitive behaviours such as hand washing). Most people with a diagnosis of OCD have both obsessions and compulsions. Examples are: • Trichotillomania: compulsive hair pulling. • Hoarding disorder: the compulsive gathering of possessions and the inability to part with anything, regardless of its value. • Excoriation disorder: compulsive skin-picking.

10. Reliability and the diagnosis of mental disorders The DSM’s reliability rests on the question of whether one person’s set of symptoms would lead to a common diagnosis by different physicians If different doctors give different diagnosis for the same set of symptoms (e.g. for the same person), then the diagnosis are not reliable and the treatment may not work

11. D L Rosenhan (1973) On being sane in insane places! The Assylum

12. Rosenhan was interested in finding out if….. 1. The diagnoses of mental illness was reliable. In other words, he wanted to find out if the same symptoms would be consistently diagnosed as the same condition across different psychiatric institutions. 2. He also wanted to find out if diagnosis was valid. In other words, would psychiatrists in different hospitals be able to tell if a person was really mentally ill or not.

13. He recruited 8 brave volunteers……the ‘pseudo patients’ • These were all sane people! • one graduate student • three psychologists • one paediatrician • one painter • One Housewife • One Psychiatrist

14. What did they DO?The procedure…………………….. • telephoned 12 psychiatric hospitals for an urgent appointment (in five USA states) • arrived at admissions • gave false name and address • gave other ‘life’ details correctly

15. They all complained of hearing unclear voices … saying “empty, hollow, thud” They all said the voice was unfamiliar, but was same sex as themselves Simulated ‘existential crisis’ “Who am I, what’s it all for?”

16. What happened? ……….. • Allwere admitted to hospital • All but one were diagnosed as suffering from schizophrenia • Once admitted the ‘pseudo-patients’ stopped simulating ANY symptoms • Took part in ward activities

17. What happened on the wards? All pseudo-patients asked to be discharged immediately BUT - they all had to wait until they were diagnosed as ‘fit to be discharged’

18. 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” Their ‘normal’ behaviour was distorted to ‘fit in’ with their own theories of what they thought was wrong with the patients (obsession with eating)

19. The pseudo-patient’s observations… If they approached staff with simple request (NURSES & ATTENDANTS) • 88% ignored them ~ (walked away with head averted) • 10% made eye contact • 2% stopped for a chat (Total of 1283 attempts) • (PSYCHIATRISTS) • 71% ignored them ~ (walked away with head averted) • 23% made eye contact • 2% stopped for a chat • (Total of 185 attempts)

20. 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 all agreed to stay until they convinced the staff they were sane!!

21. 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!!

22. What did the pseudo patients make notes about …….? • Nurses stayed in ward offices 90% of time • Each ‘real patient’ spent less than 7 minutes per day with psychiatric staff

23. DID ANYONE SUSPECT they were not really mentally ill? 35 out of 118 real patients voiced their suspicions

24. On release ………………... The pseudo-patients were diagnosed as Schizophrenia “IN REMISSION”

25. RosenhanThe follow up study…………….. A teaching & research hospital were told of the first study and warned that … Over the next three months ONE OR MORE pseudo-patient would attempt to be admitted

26. What happened……….? 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 staff) • 23 rated as pseudo-patient (by psychiatrist) • 19 rated as pseudo-patient (by both)

27. How many of these SUSPECTS were pseudo-patients?……... NONE No pseudo-patients were sent Staff were rating their regular intake

28. What did Rosenhan conclude? Remember .. His question was … Is the diagnosis reliable ? Is the diagnosis valid ?

29. 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 unableto detect ‘insanity’

30. Rosenhan’s study highlights! ... • 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 The pseudo-patients described their stay in the hospitals as a negative experience This is not to say that REAL patients have similar experiences Real patients do not know the diagnosis is false & are NOTpretending (Remember Zimbardo)

31. Relevance of the study today? Questions YOU should be able to answer... How do we accurately detect insanity? Can we be confident in diagnosis? Methodology of Rosenhan…. • This was a participant observation, why? • Who were the OTHER participants? • Was this study ethical? If not why not? • Why might the reports of the pseudo-patients have been unreliable?

32. ‘One Flew Over The Cuckoo’s Nest’ is the story of a criminal, Randle. P. McMurphy, who transfers himself into a psychiatric hospital from a hard labour camp in order to get what he thinks will be an easy ride. He rebels against the Nurse overlooking the hospital who has taken away any confidence the inmates had by being loud, destructive and by attempting to ruin any routine she has built. As time goes on the inmates all grow fond of him while the staff do just the opposite. However, the only way he can get out is for the Nurse to decide he is ready to go, but by now they think he may well be crazy.