A Level Psychology at Spalding Grammar School

"I've always been mad. I know I've been mad, like the most of us are. Very hard to explain why you're mad, even if you're not mad."

In 1973 the English rock band Pink Floyd released their most popular album, Dark Side Of The Moon. If you've heard it, you might recognise the snippet of dialogue above and understand why it introduces a study on sanity and insanity. But 1973 was a crazy year in many other ways: booming oil prices and deepening recession meant many in Britain were working a 3-day week, over in America President Nixon told the Watergate Hearings, "I am not a crook." War raged in Israel, Britain went to war with Iceland over fish and terrorist bombs went off in London, while US troops pulled out of Vietnam. Can you tell the sane from the insane?

David Rosenhan was Professor of Law & Psychology at Stanford University and had a strong interest in the legal definition of insanity. Being a bit of a maverick, he phoned round his friends asking if they were busy in October. Those who were free ended up spending the month in mental hospitals, trying to convince doctors they weren't mad. This was a field experiment (similar to Piliavin et al.) since it took place in real psychiatric hospitals. It's also similar in structure to the Loftus & Palmer study, since Rosenhan actually carried out TWO related experiments in this study.

Madness has been around a long time but PSYCHIATRY -the medical study of madness - is only about a hundred years old. A particularly interesting and troubling mental illness is SCHIZOPHRENIA. This condition was first described in 1887, but defined and named by Bleuler in 1911. The name means "shattered mind" and the symptoms include:

• Delusions - like believing you are Napoleon or that people are out to get you
• Hallucinations - such as "voices" in your head telling you to do things
• Disordered thinking - confusion, panic, memory loss, etc
• Emotional problems - inappropriate emotions (rage, depression, hilarity) or total lack of emotion and motivation
• Motor problems - twitches, tics, rocking backwards and forwards, etc

Strictly speaking, a person must suffer from more than one of these symptoms before being considered schizophrenic, because all sorts of perfectly sane people have odd ideas, strange moods, vivid imaginations, etc.

The case study by Thigpen & Cleckley shows how controversial diagnoses of insanity can be. In the early 1970s the "anti-psychiatry movement" led by thinkers like R.D. Laing claimed that psychiatry was a non-science and that psychiatric diagnoses were just an excuse to lock away troublesome people. David Rosenhan was inspired by one of R.D. Laing's lectures to carry out a test to find out whether psychiatrists really could tell whether someone was insane or not.

• Diagnosing someone with a problem they don't have is a FALSE POSITIVE, also called a TYPE 2 ERROR
• Missing a diagnosis of someone who really does have a problem is a FALSE NEGATIVE or TYPE 1 ERROR

Study 1

Rosenhan wanted to see if sane people who presented themselves to psychiatric hospitals would be diagnosed as insane.

Study 2

Next, Rosenhan wanted to see if hospitals would consider people with genuine mental health problems to be fakes

Rosenhan assembled an opportunity sample of 8 people, including himself - 5 men, 3 women, including a student, a psychologist, a doctor, a psychiatrist, a painter and a housewife. He called them PSEUDOPATIENTS because they would be pretending to be mental patients.

The pseudopatients applied to be let into 12 different psychiatric hospitals across America. These represented a broad range: modern and old, well-staffed or poorly funded, one of them was a private hospital.

The pseuopatients went to admissions interviews and told the truth about their life stories except for one thing: they claimed they were hearing voices. An important CONTROL was that each pseudopatient claimed to hear an unknown voice repeating the words EMPTY, HOLLOW and THUD.

(Rosenhan picked these words because they suggested an "existential crisis" - a feeling that life was pointless. It's important to remember that just hearing voices by itself is not a symptom of schizophrenia, nor is having an "existential crisis")

Once inside the hospital, the pseudopatients were given careful instructions:

• Stop claiming to hear voices and act perfectly normally
• Don't take any of the medications
• Take written notes of what happens - do this secretly but if found out, carry on taking notes openly
• Approach members of staff with this question: "Pardon me, could you tell me when I am likely to be discharged?"

The only Independent Variable was a comparison with a normal (non-psychiatric) hospital. Rosenhan sent a female student to the Stanford University health centre to ask staff pre-scripted questions. Their responses were compared with the treatment the pseudopatients got when they approached staff with questions.

Rosenhan also measured how long it took the pseudopatients to be discharged and recorded a lot of qualitative data about how they were treated while in the psychiatric hospitals.

All the pseudopatients were admitted, 7 with diagnoses of schizophrenia and one with manic-depression.

They were kept in the hospital for between 7 and 52 days - 19 days on average.

They were only discharged when they stopped claiming to be sane and admitted to being ill, but feeling better. All were discharged with "schizophrenia in remission" (a non-existent medical condition). Interestingly, other patients had no problem recognising that the pseudopatients were healthy ("You're not crazy, you're a journalist or something").

Asking staff questions resulted in getting ignored - staff neither paused nor made eye contact. Only 2% of staff stopped to chat. This can't be explained by the fact that hospitals are busy places or that hospital staff lack social skills, because in the control condition (university medical centre) every member of staff stopped to answer questions, making clear eye contact.

Hospital staff made Type 2 Errors, showing they mistook perfectly sane people for being insane.

Rosenhan argues that psychiatric diagnoses are "sticky labels". In other words, once you've been given a diagnosis of mental illness, it's really hard to persuade people you're sane. In particular, everything you do is treated as yet another example of your madness.

• Pseudopatients waklking the corridors out of boredom were diagnosed as suffering from "anxiety"
• Patients waiting for the canteen to open were described as suffering from "oral acquisitive behaviour", meaning an obsession with eating - again in reality, they just had nothing better to do
• When pseudopatients described their (perfectly normal) family backgrounds, the doctor's notes described them as "unstable" and "ambivalent" with "angry outbursts"

Rosenhan also claims the psychiatric hospitals produced powerlessness and depersonalisation.

• Staff would punish patients for small things and swear at them. They would do this with other patients watching, showing that patients didn't count as witnesses.
• There was no privacy, for example toilets had no doors and examinations were conducted with other people watching, staff could enter patients' rooms without permission and anyone could read patients' medical notes.

When the hospitals found out about the pseudopatients, they were outraged at being deceived in this way. One of them challenged Rosenhan to send more pseudopatients, confident that this time the forewarned doctors and nurses would spot them.

Rosenhan informed the hospital that, during the next 3 months, at least one pseudopatient would try to be admitted to the hospital.Each member of staff was asked to rate all the new admissions on a 10-point scale, where 1 = "definitely a pseudopatient" and 10 = "certainly a genuine patient".

Over the 3 month period, 193 patients were admitted for treatment.

• 41 were judged to be pseudopatients by at least one member of staff
• 23 were judged to be pseudopatients by at least one trained psychiatrist

This time the staff were making type 1 errors (calling a sick person healthy).

Rosenhan claims he has shown that the diagnostic procedure in psychiatric hospitals is unreliable (does not give consistent results).  In fact, he goes further, suggesting that diagnoses are invalid too and that we cannot tell the sane from the insane.

Hospitalising the mentally ill seems to create powerlessness and depersonalisation, which is very anti-therapeutic. The power of "sticky labels" makes it very hard for staff to view patients' behaviour clearly and objectively. Quite often, patients end up acting the way they have been labelled, because they're not allowed to do anything else - this is called the Self Fulfilling Prophecy (SFP). Rosenhan has two solutions:

1. Treat mental illness in new ways, in particular caring for the mentally ill in community settings rather than in impersonal institutions and using behaviour therapies that don't "label" the patients
2. Train mental health workers to be more sensitive to their patients as people, and to recognise how much of patients' behaviour is produced by the situation they are in