Rosenhan DL (1973) On being sane in insane
places. Science 179, 250-8.
What could I be asked?
1. Summarise the aims and context of Rosenhan’s (1973) study. (12)
2. Outline the procedures of Rosenhan’s (1973) study. (12)
3. Describe the findings and conclusions of Rosenhan’s (1973) study. (12)
4. Evaluate the methodology of Rosenhan’s (1973) study. (12)
5. With reference to alternative evidence, critically assess Rosenhan’s
(1973) study. (12)
What do I need to know about the study?
aims and context
procedure
findings and
conclusion
• Why was this study carried out? What had happened
in society recently? Had there been related research
already carried out? What were they trying to find
out?
• What type of study was this? What did they actually
do? Where was it carried out? Who took part? How did
they measure outcomes?
• What did they find out? What conclusions did they
draw from this?
evaluation of the
methodology used
• What were strengths and weaknesses of the way this
study was carried out? Think about sampling issues,
reliability, ethics, ecological validity etc.
assessment using
alternative evidence
• What do other studies suggest about this study? Do
they support, contradict it, or perhaps suggest there is
something important the researchers didn't think of?
Context & aims
Definition
Validity is ..…………………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………….
Reliability is ……………………………………………………………………………………………………………………….
…………………………………………………………………………………………………………………………………………..
Context
Rosenhan begins his paper with the question 'If sanity and insanity exist how shall we know
them?'. People have wrestled with the notion of mental illness since long before the birth of
psychology. Rosenhan is clear that he is not questioning the existence of mental disorder. As
he puts it; 'Anxiety and depression exist. Psychological suffering exists. But normality and
abnormality, sanity and insanity and the diagnoses that flow from them may be less
substantive than many believe them to be.' In other words Rosenhan is suggesting that
although mental disorder exists we are not particularly good at recognising it.
Exercise: identify some ways in which we might decide that someone has a mental health
problem.
…..................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
Since the early 20th Century psychological abnormality had been dealt with by means of
medical diagnoses. It has been customary to diagnose mental illness from a patient’s
symptoms in the same way that physical illness is diagnosed. In 1952 the American
Psychiatric Association published its own system, the DSM (Diagnostic & Statistical Manual
of Mental Disorder). This is now in its 4th edition. Although it is standard practice to make a
diagnosis using one of these systems, there have always been concerns about their
reliability and validity. All systems assume that we can diagnose a mental health problem
like a physical health problem.
Rosenhan suggested that one test of the validity of psychiatric diagnosis was whether
doctors and other health professionals could recognise that in fact some of their patients
had no symptoms at all. This could be tested by using pseudopatients – mentally healthy
people who could gain entry to the psychiatric system by faking a symptom then who acted
normally. Rosenhan believed that if the mental health system was capable of valid
diagnosis, professionals would soon spot pseudopatients.
Contextual Research
An earlier study by Temerlin (1968) used a confederate to test the validity and reliability of
diagnoses. Psychiatrists were shown a videotape of a confederate who played a mentally
healthy mathematician. Prior to viewing the tape a prestigious doctor informed the
psychiatrists that they were about to view an interesting case, because the man looked
neurotic but was actually psychotic. Participants then selected their diagnosis from a list,
including psychotic, neurotic and mentally healthy. 60% of psychiatrists selected psychotic.
This suggests that diagnoses can be invalid as the man was diagnosed with a psychosis when
he showed behaviour consistent with a state of good mental health.
There are some issues with this study; rather than testing labelling effects, Temerlin may
have been testing conformity, which would not affect doctors confidentially diagnosing
patients. Rosenhan wanted to run an experiment which tested the validity of diagnoses
made using the DSM, in an more ecologically valid setting.
Aim
This was a pseudopatient study looking at the success
of the mental health system to spot pseudopatients at
the point of diagnosis and during hospitalisation. The
first specific aim was to see whether they would be
identified as 'sane' when they presented themselves for
diagnosis. The second specific aim was to record their
experiences as psychiatric in-patients.
Method
Sample
Size:
Experiment 1Experiment 2-
This was a
study because
it was held in the natural environment.
The IV (Independent Variable) was …
Sampling method:
Experiment 1-
The DV (Dependant Variable) was…
Experiment 2How were they recruited?
Setting:
Experiment 1Experiment 2Sample characteristics:
Experiment 1-
Exercise: suggest why it was important to
use a range of hospitals.
.......................................................................
…………………………………………………....................
Experiment 2-
…………………………………………………....................
…………………………………………………....................
Procedure
The pseudopatients
Eight pseudopatients took part in the study.
Five were men and three women. Three were psychologists, one a psychology student and
one a psychiatrist. The others were not mental health experts; one was a paediatrician (a
medical doctor specialising in treating children), another a housewife and the other a
painter and decorator. All used false names so that they would not have a diagnosis on their
own medical records after the study. The mental health professionals also gave false
information about their occupation so that they would not receive any special treatment.
Faking the symptom
Each pseudopatient called a hospital then attended an appointment where they reported
hearing voices. In each case the voice was the same sex as the pseudopatient and unfamiliar
to them. The voices were sometimes unclear but the words ‘empty,’ ‘hollow’ and ‘thud’
could be made out. Apart from the voices they gave accurate descriptions of their mental
state.
Exercise: why was it important for all patients to fake the same symptom?
…..................................................................................................................................................
....................................................................................................................................................
Being an inpatient
Once admitted to the hospital psychiatric wards they acted normally with staff and patients.
They accepted (but did not take) medication from staff. When asked they reported no
further symptoms. In three hospitals the pseudopatients recorded the number of patients
who expressed doubts that they were genuine. In four hospitals they attempted to ask
doctors and nurses questions and recorded their responses.
Exercise: What were they testing as inpatients? ……………………………………………………………………
………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………….
A follow-up study
A follow-up to the main study took place at another hospital whose staff had expressed
doubt that they would be fooled by pseudopatients. They were informed that one or more
pseudopatients would present themselves over the next three months. Staff rated all new
patients on a 1-10 scale for how likely each new admission was to be a pseudopatient. In
fact no pseudopatients approached them in this time; the idea was to record how many real
patients were falsely judged to be pseudopatients.
Findings
Headline figures
In 100% of cases the pseudopatient was immediately admitted to hospital. The length of stay
ranged from 7-52 days (average 19 days). 11 patients were diagnosed with schizophrenia and
one with manic depression. Whilst in hospital no doctors or nurses questioned the
genuineness of the pseudopatients. However, of the 118 patients in the three hospitals where
patient responses were recorded 35 (30%) challenged the pseudopatients.
Exercise: In the four hospitals staff responses to questions were recorded. Outline the
findings shown in the above table.
….....................................................................................................................................................
.......................................................................................................................................................
Plot this data into a graph.
Qualitative data
Qualitative data was available in the form of notes taken by the pseudopatients and hospital
staff. These illustrate how staff interpreted the behaviour of the pseudopatients in line with
their beliefs that they were mentally disordered. One nurse recorded daily that her
pseudopatient ‘engaged in writing behaviour,’ seeing this as a compulsive behaviour (in fact
the pseudopatient was keeping notes). Another interpreted the bored pacing of a
Recap
Recap
pseudopatient as nervousness. One patient mentioned how in childhood he was closer
to
his mother but more recently had got on better with his father. In his notes this was
presented as follows: ‘…manifests a long history of considerable ambivalence in close
Recap
relationships, which begins in early childhood. A warm relationship with his mother cools in
adolescence. A distant relationship with his father is described as becoming very intense.’
How does this make family life sound? …..................................................................................
……………………………………………………………………………………………………………………………………………….
Is there any real evidence for this? Yes [ ] No [ ]
Now check your understanding by summarising the study in the boxes below:
The follow-up study
Further data came from the follow-up study. Over the three months of the study 193
genuine patients and no pseudopatients were admitted. 41 were judged with a high level of
confidence to be a pseudopatient by at least one member of staff. In 23 cases at least one
psychiatrist and in 19 cases a psychiatrist and another staff member believed they were
dealing with a pseudopatient.
Conclusion
The major conclusion of the study was that even experienced mental health professionals
[delete one] could/couldn’t reliably distinguish between real and false patients.
Recap
Faking a single symptom on a single occasion [delete one] was/was not sufficient to receive a
psychiatric diagnosis. Furthermore, once in the mental health system, patients’ normal
behaviour was interpreted as symptoms of their disorder. This provides further evidence to
suggest that the validity of psychiatric diagnosis was [delete one] good/poor. Rosenhan did not
use his data to criticise the competence or conduct of doctors or nurses. Instead he blamed the
poor results on the ‘system’ of diagnosis.
Recap
Aim
•
•
Procedure
•
•
Findings
•
•
Conlcusions
•
•
Alternative Evidence
Temerlin (1968)
Temerlin (1968) used a confederate to test the validity and reliability of diagnoses.
Psychiatrists were shown a videotape of a confederate who played a mentally healthy
mathematician. Prior to viewing the tape a prestigious doctor informed the psychiatrists
that they were about to view an interesting case, because the man looked neurotic but was
actually psychotic. Participants then selected their diagnosis from a list, including psychotic,
neurotic and mentally healthy. 60% of psychiatrists selected psychotic. This suggests that
diagnoses can be invalid as the man was diagnosed with a psychosis when he showed
behaviour consistent with a state of good mental health.
This
Rosenhan’s findings that Psychiatric diagnoses are invalid.
Temerlin however, lacked ecological validity, which highlights the strength of Rosenahn’s
field study. Temerlin’s study also highlights the importance of
in
Rosenhan, which assured that measures were testing diagnoses made using the DSM, rather
than any extraneous variables such as conforming to colleague’s opinions.
Slater (2003)
Slater (2004) claims to have presented herself to nine hospital emergency rooms with the
same symptom as Rosenhan's pseudopatients. In most case she reports receiving a
diagnosis of psychotic depression. However, according to Moran (2006) a number of experts
have challenged the truthfulness of Slater's claims, so the credibility of her evidence is
unclear.
Slater’s replication shows strong
findings are
for Rosenhan, suggesting that his
, in that a diagnosis of mental illness was wrongfully made.
However, Slater presented the same symptoms and was given a different diagnosis, which
questions the reliability of diagnoses. This may be due to changes in the DSM, which have
tightened criteria for many mental illnesses, particularly for a diagnosis of schizophrenia.
This demonstrates that Rosenhan’s study was
in improving the
diagnostic system. Slater also highlights the importance of
, such as
standardised measures and criteria, which Rosenhan implemented.
Changes to the DSM/ ICD
There have been important changes to systems of psychiatric diagnosis since Rosenhan’s
study. At the time the standard system was the 2nd edition of the DSM (DSM-II). We are
now on the 4th edition with revisions (DSMIV-TR). One of the major reasons for continuing
to work on newer versions of systems like this is to improve the validity of diagnosis. One
way that newer versions have tightened up on diagnosis is in specifying that symptoms must
occur with particular frequency or over a particular period. For example in the DSM-IV
system, hearing voices must now take place for over a month before they could be used as a
basis for diagnosing schizophrenia. Diagnostic systems are also tested for validity by
measuring the concurrence (agreement) between two different manuals, for example the
ICD (European diagnostic manual) and DSM. This is called concurrent validity, and tests
show it is quite high, at 70%.
Changes in the diagnostic criteria demonstrate the
of Rosenhan’s study.
By tightening the criteria for schizophrenia, Rosenhan’s patients could not be diagnosed
with schizophrenia today, as they did not experience symptoms for over a month.
What can we conclude from alternative evidence?
Later research strongly
Rosenhan’s finding that psychiatric diagnoses are
fairly reliable, but lack validity. Temerlin also supports Rosenhan’s other findings of labelling
effects. However, Rosenhan’s results may not
to a modern sample because of
changes in the DSM partially inspired by his study.
Modern replications of Rosenhan lack validity because
they have not been carried out with such strict controls.