Chapter 8 Psychopathology

Who’s Crazy Here, Anyway? Rosenhan, D. L. (1973)

Defining Abnormality

• This definition is crucial in determining whether or not someone is mentally ill.

• The line that defines normal behavior from abnormal is not clear, however, it can be seen as lying on a continuum with normal, or effective psychological functioning, at an end and abnormal, or mental illness, at the other end.

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Criteria For Using The Continuum

1. Bizarreness of the behavior

2. Persistence of the behavior

3. Social deviance

4. Subjective distress

5. Psychological handicap

6. Effect on functioning

Questions

• Symptoms and characteristics of mental illness involve judgments from mental health professionals…So…

• Two questions remain: can they really determine between mentally ill and mentally healthy people? And what are the consequences of mistakes?

• These are the two questions David Rosenhan addresses in his study.

Theoretical Propositions

• Rosenhan questioned if the features that direct one to psychological diagnosis is in the patients or in the situations in which the observers find the patients.

• Rosenhan believed that mental health professionals training should be sufficient enough to distinguish between the sane and insane.

Theoretical Propositions Cont.

• Rosenhan proposed a way to test the professionals ability to “correctly categorize” people of normal or abnormal behavior.

• He had normal people obtain entry into psychiatric facilities to see if they can be detected as psychologically healthy.

• The “pseudopatients” behaved normally and if they weren’t found to be normal, it proved that diagnosis of mental illness is tied more to the situation than to the patient.

Method

• 8 subjects were used as the pseudopatients. 3 of them were women and 5 were men, including Rosenhan himself.

• Their mission to was to present themselves in 12 psychological hospitals, in 5 states on both coasts of the United States.

Method Cont.

• All pseudopatients followed the same instructions.

• When at the appointment they complained of hearing voices that said “empty,” “hollow,” and “thud.”

• The subjects acted normal and gave truthful information when questioned by an interviewer.

Method Cont.

• All the subjects were admitted to various hospitals and all except one were diagnosed with schizophrenia.

• Secondly, when they were inside the hospital the pseudopatients showed no symptoms and behaved normally.

Method Cont.

• The subjects did not know when they were going to be released. It was basically up to them to convince the hospital staff that they were healthy enough to be released.

• The subjects acted as “model patients” and accepted all medicine (which was flushed down the toilet).

Results

• Hospital stay for the pseudopatients ranged from 7 to 52 days. The average stay was 19 days.

• A key result of this study was that the pseudopatients were not discovered by any of the hospital staff.

Results Cont.

• Although the hospital staff could not discover the truth about the pseudopatients, they couldn’t fool the other patients!

• Three of the pseudopatients actually had encounters with patients that thought otherwise.

• The other patients said, “you’re a reporter,” and simply “you’re not crazy.”

Results Cont.

• Associations between the staff and the patients were minimal and somewhat strange.

• At some point during their stay all the pseudopatients had to try and speak to various staff members, asking normal questions.

• 71% of the psychiatrists moved on without responding. Only 4% actually stopped to talk to the patients.

Results Cont.

• Throughout their stay, no one mentioned a lack in the medication they received.

• Another account was recalled by one of the pseudopatients. He says that a nurse unbuttoned her shirt and fixed her bra right in front of a room filled with male patients.

• She wasn’t being provocative, she just did not see the patients as real people.

Discussion

• Rosenhan’s study clearly showed that normal people cannot be determined from mentally ill in a hospital setting.

• He feels this is because once patients are admitted into a hospital, they are judged as if they must be crazy.

• Rosenhan refers to this as stickiness of the diagnostic label.

Discussion Cont.

• Stickiness of the diagnostic label can be seen in Rosenhan’s study as soon as the patients were labeled as a schizophrenic.

• The staff then distinguishes all of the patients behavior as a result of that label.

Discussion Cont.

• Another aspect of the stickiness of the diagnostic label is that a patients history is also interpreted by that label.

• See next slide for example.

Discussion Cont.

• The patient described his relationship with his wife as close and warm. He has occasional angry outbursts and the children were rarely spanked.

• The doctor interpreted this as the man trying to control his emotions with angry outbursts and in the child’s case, with spanking.

Significance of Findings

• Rosenhan’s study showed 2 significant factors.

• First, it showed that sane couldn’t be distinguished from insane in a hospital setting.

• Secondly the danger of a diagnostic label. The label can become self-confirming.

Significance of Findings Cont.

• After this study, greater care in diagnostic settings grew. Along with awareness of applying labels to patients.

• These two problems started to decline with the decrease in patients confined to mental hospitals.

• This decrease was mainly due to the discovery of antipsychotic medications, which reduce symptoms in patients enough to allow them to live outside of a hospital.

Questions and Criticisms

• One hospital setting doubted that what Rosenhan found could happen in their place.

• Rosenhan tested them by telling them he would send pseudopatients, within the next three months, for admittance into their hospital.

• The staff was told to rate each patient from 0-10 as to the liking that they are the pseudopatient.

Questions and Criticism Cont.

• When the three months were over, 193 patients were admitted. Of those, 41 had high ratings for being the pseudopatient among staff members and psychiatrists had high ratings for 23 of the patients.

• Rosenhan actually didn’t send anyone to the hospital during the three months.

• This showed that diagnosing “sane people as insane can be reversed when stakes are high.”

Questions and Criticisms Cont.

• Rosenhan duplicated the same study many times during 1973 and 1975.

• Everytime he found the same results. However, some researchers argue about the results that Rosenhan found.

• One researcher, Spitzer, argued that Rosenhan’s study actually did not disprove psychological diagnostic systems.

Questions and Criticisms Cont.

• Spitzer also feels that one can lie their way into a hospital because after all, who would want to actually stay there.

• He also argued that even though the pseudopatients acted normally once inside, such “variations in symptoms is common” and it does not mean that the staff was incapable in figuring them out.

Follow Up Study

• A study by Boisvert and Faust in 1999 showed the increased awareness of diagnostic labels that has taken place since 1973.

• Subjects were presented with different scenarios based on an employer that was said to behave in violent manners towards his boss.

• Scenarios varied in amount of stress and in some cases were told he had been diagnosed with schizophrenia.

Follow Up Study Cont.

• Boisvert and Faust thought that the subjects who were told about the diagnose would blame his violent behavior on the schizophrenia label.

• For the subjects who were not told about the diagnose, they would blame the behavior on the environmental stress.

Follow Up Results

• The researchers found the exact opposite!

• The subjects blamed the violent behavior less on stress regardless of the label.

• The researchers found the same results when tested among practicing mental health clinicians and college students.