Key study: "On being sane in insane place" (Rosenhan, 1973)

Rosenhan’s famous study attempted to demonstrate the unreliable nature of psychiatric diagnosis in the 1970s and how poorly patients were treated in psychiatric hospitals. While his methods were a little suspect, the study seemed to make the point Rosenhan was hoping for.

Background Information

One of the most influential studies conducted investigating the difficulties in defining normality and abnormality, and the inherent repercussions for valid and reliable diagnoses of psychological disorders, was conducted by David Rosenhan. This research was published in 1973, a time when psychiatric hospitals were quite different to the way they are today.

Aims

Prior to this study, some researchers had conducted participant observations of psychiatric hospitals, but this was often for a short time and the hospital staff knew of their presence. Rosenhan wanted to take this research one step further and so he conducted a participant, naturalistic, covert observation. He was interested in investigating whether the 8 pseudopatients(people pretending to be patients) would be diagnosed based on their objective symptoms and behaviours, or if the nature of the environment would influence the interpretation of their behaviours by the professionals who were diagnosing them. Perhaps his aim can be best summarised by the question he poses in the opening to his article:

Psychiatric hospitals were once called “insane asylums,” “mental hospitals,” or more informally “nut houses” or “loony bins.” The classic image of an “insane” person is them wearing a straightjacket.

“If sanity and insanity exist, how shall we know them?”

Methodology and Results

Rosenhan was one of the pseudopatients, along with 7 others. They were an eclectic mix of people who used false names and occupations. There was a graduate student of psychology, three psychologists, a pediatrician, a psychiatrist, a painter and a housewife.

They sought admission into 12 different hospitals on the East and West coasts of the United States. The only symptom they were told to give the hospitals was that they had been hearing voices from a stranger’s voice that was the same gender as them, and the voices were unclear but they thought they said “thud”, “empty” and “hollow”. One reason why these words were chosen was because there is a suggestion that they are signaling some sort of crisis in the individual’s life, such as their life “is empty and hollow”. Once they were granted admission into the hospital, all the other details about their lives and their personal histories that they told the hospital staff were true.

Results

Of the 12 admissions to the hospitals, 11 were diagnosed with schizophrenia and one was diagnosed with manic-depressive psychosis. They remained in the hospitals for a range of 7 to 52 days, with an average of 19 days.

Scared Woman With Schizophrenia Sitting In The Corner At Room Wi

Schizophrenia is a mental disorder that has many varieties. It is mainly characterized by an inability to understand reality (e.g. not being able to determine what is real and what is not).

Once the pseudopatients were admitted to the hospital, they carried on behaving normally and told the staff their symptoms had stopped. They took notes and made other observations, at first hiding this in case the staff found out, but after they realized the staff weren’t paying attention to them, they took notes freely. This resulted in other patients in the hospital raising questions about the authenticity of the pseudopatients’ illnesses. In fact, during the first 3 admissions to hospitals, 35 of 118 patients expressed some concern regarding whether or not the pseudopatients were really ill. This raises an interesting question, like why can the diagnosed “mentally insane” recognize sanity, while the trained professionals cannot?

Follow-up study

After this original study was conducted, one hospital heard of the findings and challenged Rosenhan to send pseudopatients to their hospital with the belief that they would be able to spot the fakes from the genuine patients. Over a three month period, 193 patients were admitted for treatment and received a judgement based on the staffs’ beliefs if they were an actual patient or not. Of these 193, 41 were judged with high confidence by at last one member of the staff to be a pseudopatient, while 19 were suspected as being a pseudopatient by a psychiatrist and at least one other member of the staff. In fact, Rosenhan had not sent any pseudopatients during this time.

Conclusions

While they were on the hospital wards, the pseudopatients made notes about their experiences and in his article Rosenhan details the dehumanization that was experienced by the pseudopatients while they were in the care of the hospital staff. He believes that it is the power of the label (in this case schizophrenia) that influences the way the clinicians interpret their behaviour: “Once a person is diagnosed abnormal, all of his other behaviours are colored by that label”. For example, a perfectly normal description of one of the pseudopatient’s relationships with family members was interpreted by the clinician in a way that was consistent with his diagnosis of schizophrenia. Rosenhan’s study highlights ethical considerations regarding diagnosis, primarily those concerned with the power of labels and stigmatisation.

Critical thinking considerations

How does this study demonstrate difficulties in defining normality and abnormality?
How does this study demonstrate validity and reliability issues related to the diagnosis of psychological disorders?
How does this study demonstrate ethical considerations in diagnosis, such as the effects of labels and the potential for stigmatisation?
Are there limitations to this study? For example, why might we be limited in applying these findings to today’s psychiatric hospitals?

Interview with David Rosenhan…

References

Rosenhan, David L. “On Being Sane in Insane Places,” Science, Vol. 179 (Jan. 1973), 250-8. (Accessed from isites.harvard.edu). (Full “On Being Sane in Insane Places” article here)

ararat_lunatic_asylum_-_aradale_psychiatric_hospital

Ararat Lynatic Asylym – psychiatric hospitals were a lot less welcoming and pleasant in the past than they are today. (Image from wikipedia)

Psychiatric Hospitals

The following are some short clips to develop your schematic understanding of what psychiatric hospitals for mentally ill people used to be like. I also highly recommend reading and/or watching “One Flew Over the Cuckoo’s Nest” if you’re interested in this topic.