Download rosenhan-1973_ Being Sane in Insane Places

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Rosenhan (1973)
Study in detail: Rosenhan’s 1973 study ‘On being sane in insane places’
Aims
David Rosenhan was interested in the difficulty of defining abnormality. The aim of his study was to illustrate
experimentally the problems involved in determining normality and abnormality, in particular, the poor reliability of the
diagnostic classification system for mental disorder at the time (as well as general doubts over its validity); and the
negative consequences of being diagnosed as ‘abnormal’ and the effects of institutionalisation.
Procedure
The sample involve eight pseudo-patients (three women and five men), who were clinically sane, but were sent by
Rosenhan to a mental health institution (twelve hospitals in total were used, Rosenhan wanted different settings to
generalise the findings) with fake names and occupations, reporting one symptom: they were hearing voices – each
patient would report hearing one word repeatedly, either “empty”, “hollow” or “thud”. Apart from this one pseudosymptom and the fake names and jobs, each pseudo-patient did not change the rest of their behaviour.
The pseudo-patients called the hospitals to arrange appointments, and arrived at the admissions offices saying that they
were hearing this voice. It was unclear and always of the same sex as the patient. One of the pseudo-patients was
Rosenhan himself (where his research was conducted, the hospital administrator and chief psychologist knew about his
research, but the other seven patients were secret).
After being admitted, the pseudo-patients stopped simulating any symptoms immediately, and responded normally to all
instructions – except they did not swallow the medications they were given. They all reported they were fine and told
staff their symptoms had gone. Their tasks then were to:
 seek release from the psychiatric hospital by convincing the members of staff that they were sane, and all but one of
the pseudo-patients were very motivated to do this
 observe and record the experience of the institutionalised mentally disordered patient – each was to record notes
about patient life and how they were treated, based on their experience, and at first they recorded their experiences
covertly (although this was not specified as necessary by Rosenhan)
Findings
Admission
All of the pseudo-patients except for one were admitted to the wards with a diagnosis of schizophrenia in remission, but
all eight were admitted with some diagnosis to every hospital. None of the staff were doubtful of the pseudo-patients, in
fact Rosenhan stated that once given the label of ‘schizophrenia’ it seemed very hard to shake. He noted that more of the
actual patients on the ward, 35 of the 118 from the first three hospitalisations, were suspicious of the pseudo-patients,
suggesting things like “You’re not crazy, you’re a journalist or a professor” (due to the note-taking).
It should be noted that the hospitals were considered good or excellent and were not to blame for the failure to recognise
the patients’ sanity, and also that prior to admission, the pseudo-patients were not carefully observed: so it was not full
observation of their behaviour which led to the label of ‘schizophrenia’.
Release
The length of stay ranged from 7 days to 52 days (with an average stay of 19 days). All except the one had the diagnosis of
schizophrenia in remission (meaning schizophrenia, but being able to be discharged, so non-severe), supporting the view
that they had never been detected as sane. There were no records of any suspicion among the staff members.
Observations of pseudo-patients
 lack of monitoring – there was very little contact with doctors, and a strong sense of segregation between the staff
and the patients was noted
 powerlessness and depersonalisation – the pseudo-patients noted that powerlessness and depersonalisation was
produced in the institution through the lack of rights, constructive activity and privacy, plus there were frequent
verbal and even physical abuse from the attendants
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 distortion of behaviour – all normal behaviour become interpreted in the light of the schizophrenic label the pseudopatients were given, for example:
a note-taking – pseudo-patients were never asked why they were taking notes, but it was recorded by nurses as
“patient engages in writing behaviour” implying that it was a symptom of their disorder
b pacing the corridors – this was done out of boredom, and was noted by the nurses as a sign of nervousness,
again implying that this was a symptom of their supposed disorder
c waiting outside the cafeteria before lunchtime – this was interpreted as showing the “oral-acquisitive nature of
the syndrome” by a psychiatrist, rather than just waiting outside in preparation for lunch
 lack of normal interaction – for example, pseudo-patients courteously asked a staff member “Pardon me, doctor,
could you tell me when I will be presented at the staff meeting?” or “When am I likely to be discharged?” and they
found mostly a brief and not always relevant answer was given, on the move, without even a normal turn of the head
or any eye contact (psychiatrists were recorded as stopping to answer the questions a mere 4% of the time)
Follow-up
After Rosenhan published the results of his study, ‘On being sane in insane places’, to check the poor reliability of
diagnosis, and to see if the insane could be distinguished from the sane, a later study was conducted where a teaching
hospital, who had been informed of Rosenhan’s initial studies, was told to expect at least one more pseudo-patient over a
three month period. During that time, the teaching hospital rated 193 incoming patients for how likely they were
suspected to be pseudo-patients, and in total 41 patients were suspected of being pseudo-patients (19 of whom had
been suspected as so by both a psychiatrist and another staff member). Rosenhan had in fact sent no more pseudopatients, and so the 41 patients identified by the teaching hospital as fake were in fact real (as far as Rosenhan knew).
Analysis
Rosenhan claims that the study demonstrates that psychiatrists cannot reliably tell the difference between people who
are sane and those who are insane. The main experiment illustrated a failure to detect sanity, and the follow-up study
(above) demonstrated a failure to detect insanity.
Rosenhan explains that psychiatric labels tend to stick in a way that medical labels do not, and that everything a patient
does once admitted is interpreted in accordance with the diagnostic label once it has been applied. He suggested that
instead of labelling a person as insane, we should focus on the individual’s specific problems and behaviours.
The study demonstrates both the limitations of diagnostic classification and importantly the appalling conditions in many
psychiatric hospitals. This has stimulated much further research and has led to many institutions improving their
philosophy of care. Rosenhan, like other anti-psychiatrists, is arguing that mental illness is a social phenomenon. It is
simply a consequence of labelling. This is a very persuasive argument, although many people who suffer from a mental
illness might disagree and say that mental illness is a very real problem.
Evaluation
Strengths
 The hospitals used were varied (new and old, private and public, and different locations) allowing for generalisation,
and since twelve hospitals were used this strengthens the findings further again allowing for generalisation
 There was validity to the study in that the pseudo-patients behaved as themselves except for the voices which were
only mentioned in the admissions stage: this validity could be seen in that other patients questioned their diagnosis
 Using eight people in twelve hospitals meant that the study was replicated and, as the same results were found, this
gives the study reliability
Weaknesses
 The study involved telling the staff that they were hearing voices, which was a classic symptom of schizophrenia, so
perhaps it was hardly surprising they were diagnosed accordingly, similarly it might not be surprising that the teaching
hospital identified some people they thought to be pseudo-patients: the validity is compromised
 Since the study was carried out 30 years ago, methods of care and diagnosis has improved, and there is more
emphasis on care in the community, and so it might be wrong to say that there is still a problem with diagnosis
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