TOPIC H: Clinical Psychology

Classic study

Rosenhan (1973) On being sane in insane places

Aim(s)

To investigate whether the sane could be distinguished from the insane, and whether
degrees of insanity can be distinguished from each other. To investigate whether normal
people can get admitted to psychiatric hospitals and to see if they are discovered to be
sane once admitted. To investigate how patients are treated in psychiatric hospitals.

Procedure

The study is an example of a field experiment using an independent groups design (each
hospital takes part once). The independent variable was the schizophrenic symptoms
that the pseudo patients presented with, and the dependent variable was admission (or
not) and diagnostic label (or not) given to the pseudo patient.

The study also involved participant observation. Once admitted, the pseudo-patients kept
written records of how the ward operated, as well as how they themselves were treated.

Sample: a volunteer sample of eight sane people was selected. It included a psychology
graduate student in his 20s, three psychologists, a paediatrician, a psychiatrist, a
painter, and a 'housewife'. There was a total of three women and five men.

Hospital sampling: 12 different hospitals, in five different states across the USA. The
hospitals were varied, including old and new, research orientated and not, understaffed
and not understaffed, and private and state funded.

The pseudo patients gave a false name and job to the hospitals, but all other details they
gave about their lives were true including general ups and downs, relationships with
spouse/children/parents, school life, work life, and general frustrations and joys. They
had no prior history of psychiatric problems, therefor their histories and behaviours had
no indicator of pathological behaviour in any way. The hospital staff did not know the
pseudo patients were present in the hospital except in the case of Rosenhan, when he
himself was a pseudo patient, who had informed the hospital Chief Psychologist and
Administrator.

They initially telephoned the hospital for an appointment, and when at the admissions
office they complained that they had been hearing voices. There was a standardised
response that pseudo patients gave when asked about the voices. They said the voice
was often unclear, but it seemed to say 'empty', 'hollow', and 'thud'. The voice was
unfamiliar to them, but it was the same sex.

Upon being admitted to the psychiatric ward with a diagnosis of schizophrenia in all but
one case, the pseudo patients immediately stopped simulating any symptoms of
abnormality. Rosenhan does note that some of the pseudo patients were mildly nervous
and anxious in the beginning, although this was brief. They were also concerned about
being found out to be frauds and that this would be embarrassing. Each pseudo patient
had been told they would have to get released from the hospital by convincing staff they
were sane.

The pseudo patients took part in ward activities, and spoke to patients and staff as they
would ordinarily. There was little to do on the ward, so the pseudo patients attempted to
engage others in conversation. They spent time writing their observations. At the

4 Pearson Edexcel International Advanced Level Psychology. Summary of Studies Unit 4. Issue 1. November 2016
beginning this was done secretly although it became evident that no one was particularly
interested in their note taking, so this was done more openly in places like the day room.

The pseudo patient ‘normal’ behaviours were often seen as part of their illness. For
example, nursing records for three of the pseudo patients stated 'Patient engages in
writing behaviour', highlighting that their writing was interpreted as pathological
behaviour. The pseudo patients were given medication for their illness (this was not
taken by the pseudo patients).

When asked by the ward staff how they were feeling, they said they were fine and no
longer experienced symptoms. All of the pseudo patients disliked the experience and
wished to be discharged immediately, motivating them to ‘prove’ their sanity. Therefore,
their behaviour was fully cooperative and this is supported by the nursing notes from
ward staff, which were found to have stated “exhibited no abnormal indications”
(obtained after the study was complete).

Results

None of the pseudo patients were detected.

Each was eventually discharged with a diagnosis of 'schizophrenia in remission', this

They remained in hospital for 7 to 52 days (average 19 days).

Although they were not detected by the staff, many of the other patients suspected their
sanity (35 out of the 118 patients voiced their suspicions). Some patients voiced their
suspicions very vigorously for example ‘’You’re not crazy. You’re a journalist, or a
professor. You’re checking up on the hospital’’.

It was estimated that the pseudo patients were given a total of 2,100 medication tablets,
though only two were swallowed. The rest were either pocketed or flushed down the
toilet.

Nurses stayed in the ward offices was about 90 per cent of the time.

The amount of time pseudo patients spent with psychiatrists, psychologists, registrars
and so forth was an average of under seven minutes per day.

Conclusions

The study revealed that the environment has a major impact on the process of diagnosis,
and in the hospital environment staff could not tell the mentally disordered from the
mentally healthy. Behaviour, such as the note taking, was interpreted within a context
of insane and reinforced the diagnosis of the pseudo patients. Rosenhan suggested that
this, along with significant examples in the observation notes of the pseudo patients,
would indicate that the behaviours of individuals were interpreted through the
environment and context of a schizophrenia diagnosis. A different meaning is most likely
to have been attributed to the ‘writing behaviour’ had the person been seen to be sane.

Rosenhan noted that experience for the pseudo patients was one of depersonalisation
and powerlessness, evident in how they were deprived of many human rights such as
freedom of movement and privacy. Medical records were open to all staff members
regardless of status. Personal hygiene was monitored and many of the toilets did not
have doors.

When the pseudo patients visited the toilets to dispose of their medication they found the
medication of other patients also there. It would seem that as long as the patients were

Pearson Edexcel International Advanced Level Psychology. Summary of Studies Unit 4. Issue 1. November 2016 5
co-operative, then their behaviour went unnoticed. An example of this is a discussion
about a patient, where staff were pointing at him and talking in the presence of other
patients as if they were not there.

There was evidence in some hospitals of abusive behaviours towards patients in full view
of other patients, but this would stop as soon as another staff member approached. This
indicated that staff were credible witnesses but patients were not.

The diagnosis of ‘schizophrenia in remission’ is not indicative of the pseudo patient

Rosenhan suggests that, in general, doctors are more likely to err on the side of caution
and call a healthy person sick rather than a stick person healthy. However, psychiatric
diagnoses can carry stigma, making the implications of inaccurate diagnoses serious.
Once labelled with a condition like schizophrenia, find it very difficult to escape the label
and be judged as sane.

Study 2

Aim

To investigate whether the tendency to diagnose the sane as insane could be reversed.

Procedure

Staff at a teaching hospital (who disbelieved the results of Rosenhan’s study) were
informed that over the next 3 months one or more pseudo patients would make an
attempt to gain admission to the hospital.

Each staff member had to rate each patient presenting for diagnosis or who had been
admitted on the likelihood that they were the pseudo patient.

Rosenhan did not send any pseudo patients to the hospital.

Results

193 patients received judgements from staff who had sustained contact with them.

41 patients were judged, with high confidence, to be pseudo patients by at least one
staff member.

23 patients were suspected of being pseudo patients by at least one psychiatrist.

19 patients were judged to be possible pseudo patients by at least one psychiatrist and
one member of staff.

Conclusions

This indicates that the tendency to diagnose insane over sane could be reversed if there
is something at stake, in this case the reputation or status of the staff and psychiatrists
and their hospital. Rosenhan noted that there was not any way to actually know if those
patients where judgements were made were actually sane or insane.

6 Pearson Edexcel International Advanced Level Psychology. Summary of Studies Unit 4. Issue 1. November 2016