Note: I just wanted to say that some of the terms used to describe the patients at the hospitals can be perceived to some as offensive and degrading, i.e 'insane' and 'abnormal'; although for the purposes of the content of this study it is necessary to use these terms. However, do be careful in the way you state or contextualise these terms as you don't want to come across as offensive in any way. I feel very strongly about people with mental illnesses and therefore believe that they should be mentioned with respect, dignity and not joked about, as it is a very delicate topic. Rant over, I'm sure you will take this on board. I hope you find this page informative and useful. :)
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Revision suggestions: Watch 'One flew over the cuckoos nest', as this will give you an insight into how being in a hospital affects the way people judge/label you and the experience of being in a psychiatric hospital.
Background:
Substantial change- when your behaviour suddenly changes dramatically due to your environment, but it does not mean you have became abnormal. As soon as the situation changes you go back to your previous behaviour. As a result we cannot define or assess someone for abnormality at one point in time. It is relevant to assess their behaviour over a period of time. We need to consider the situation they are in and whether there is a reason for the way they are behaving. Rosenhan wanted to investigate whether the diagnosis given to patients came from symptoms being displayed by the patients themselves or whether their behaviours were being described as abnormal because they were in a psychiatric setting.
The strength of classifying mental health problems into identifiable grps is that COMMUNICATION between Dr's/Psychiatrists is easier as they can be confident they are talking about the SAME illness. The problem with mental disorders is that the symptoms are more subjective and less objective.
Key words:
Overall Aim of the whole study: to investigate whether psychiatric diagnosis was valid and reliable and would the context of being labelled as 'abnormal/diagnosed with a mental condition affect staff's ability to distinguish between 'sane' and 'insane' people within a psychiatric institution.
Research method: Field
Sample:
Experimental Design: Independent grps design (each hospital only takes part in the study once)
Background:
Substantial change- when your behaviour suddenly changes dramatically due to your environment, but it does not mean you have became abnormal. As soon as the situation changes you go back to your previous behaviour. As a result we cannot define or assess someone for abnormality at one point in time. It is relevant to assess their behaviour over a period of time. We need to consider the situation they are in and whether there is a reason for the way they are behaving. Rosenhan wanted to investigate whether the diagnosis given to patients came from symptoms being displayed by the patients themselves or whether their behaviours were being described as abnormal because they were in a psychiatric setting.
The strength of classifying mental health problems into identifiable grps is that COMMUNICATION between Dr's/Psychiatrists is easier as they can be confident they are talking about the SAME illness. The problem with mental disorders is that the symptoms are more subjective and less objective.
Key words:
- Abnormality= It could be defined in many ways depending on the situation, but it is overall behaviour that does not content to the majority of people and what are considered the norms of life. For e.g someone singing in class randomly would be seen as abnormal, but singing on a stage would be considered normal and not a cause for concern. Therefore it is hard to define, as if we are to say someone is mentally ill and needs treatment, we need to know exactly what the abnormality is in order to get a valid diagnosis (if necessary) and access the right level of treatment and care.
- DSM= Diagnostic and Statistical Manual of Mental Disorders, a classification system which lists all the currently accepted diagnosis of mental disorders and used by psychiatrists in their work.
- Idiographic= relating to the study of individuals.
- Nomothetic= relate to laws and systems, able to generalise
- Self-fulfilling prophecy= by being diagnosed with something, you directly or indirectly causes itself to become true.
- 'Sane'= psychological normality (being mentally healthy)
- 'Insane'= psychological abnormality (being mentally ill)
- Schizophrenia= mental disorder where the person has disturbed behaviour, emotion and experiences, such as having auditory and visual hallucinations, blunted emotion (lack of emotional response) and delusions (a belief held with strong conviction despite there being strong evidence against it).
- Pseudo ps= a researcher posing as a patient, 'pseudo' means false.
- Labelling theory= how the self-identity and behaviour of individuals may be determined or influenced by the terms used to describe or classify them. It is associated with the concepts of self-fulfilling prophecy and stereotyping.
- Stickiness of lables= Once labelled as mentally ill, people will view a person as if they are still ill, even if all symptoms have disappeared.
- Manic depression= when a person experiences cycles of low mood, followed by extremely high mood.
- Situational variables= where something outside the person affects their behaviour, (e.g the situation they are in-being in a psychiatric hospital with a diagnosis to their name) rather than by something within them.
- Remission= when a persons illness is not cured, but is not currently showing any symptoms.
- Covert observation- when the people around you are unaware that you are observing them.
- Powerlessness= Lacking strength or power; helpless and feeble, Lacking legal or other types of authority.
- Depersonalisation= an abnormal state of consciousness in which the ps feels unreal and detached from themself and the world.
- Ps observation= Method of observation where the researcher is also a ps in the environment being studied.
- Unique= Characteristic of a particular condition.
- Pseudonym= false name.
- The patients find it hard to be seen as sane once they have been diagnosed as they have been labelled and it is hard to remove. Also once diagnosed, all activities of the patients will be associated with being a symptom of the condition they are diagnosed with.
Overall Aim of the whole study: to investigate whether psychiatric diagnosis was valid and reliable and would the context of being labelled as 'abnormal/diagnosed with a mental condition affect staff's ability to distinguish between 'sane' and 'insane' people within a psychiatric institution.
Research method: Field
Sample:
- Staff at 12 different psychiatric hospitals in US, (some were old, some new, some with high staff patient ratio, some with low staff patient ratio)
- Staff did not know that the research was taking place
- the real patients at the hospitals
- 8 pseudo ps (including Rosenhan himself, 3 F, 5 M) who only used fake names and occupations
Experimental Design: Independent grps design (each hospital only takes part in the study once)
1st INVESTIGATION
Aim: Rosenhan wanted to see if sane individuals who presented themselves to a psychiatric hospital would be diagnosed as insane and therefore admitted. DV:
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2nd INVESTIGATION
Aim: To investigate the experience of psychiatric hospitalisation. At the time of the study there was growing concern over the ability of psychiatrists to accurately diagnose and treat mental disorders. Rosenhan therefore decided to test whether psychiatrists could differentiate between the sane and the insane by seeing if pseudopatients would be diagnosed as insane. DV:
QUAL DATA:
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Conclusions:
Evaluation:
Research Method:
+ = carefully selected symptoms are clever as they can be associated with any mental disorder
+ = symptoms were not art of any previous diagnosis system
+ = Ps observation- obtains v.detailed qual data, high in ecol valid.
- = not standardised in ps experience, so not able to replicable exactly.
- = less control, not standardised, each pseudo ps going through different experiences as in different hospitals
Research Design:
+ = creative, Rosenhan used this to test the reliability of identifying both sane and insane people
Sample:
- = descriptions selected by Roenhan from the 8 pseudo ps are only those that support his hypothesis.
- = small sample- only 8 used
- = biased- 6 had psychological backgrounds, biased towards those who had an understanding of psychological issues
Type of data:
+ = both qual and quant data
+ = quant data (no of admitted and discharged) provides harder evidence for qual findings (experiences)
- = quant data on own= reductionist, no reasons why the pseudo ps have been admitted, only that they were admitted
- =subjective- based on interpretation of researcher
Reliability:
+ = hospitals more representative as a range of hospitals were used (variety of old, new, with high or low staff patient ratios), making the findings generalisable
- = not consistent as pseudo ps in different hospitals, so not standardised experiences
Validity:
+ = process of being admitted as insane and not discharged until diagnosed as in remission in this context is arguably as close to an ecologically valid study as possible
+ = rich valid data from note taking
+/- = bias could be usefully employed in making insightful notes within hospitals, but may have an impact on their own behaviour within the wards
+ = High ecol valid as:
Usefulness:
+ = using ps observation enabled an insight into the experience of being in a psychiatric hospital
+ = applications of highlighting an awareness of the long term impact of psychodiagnstic labels and how to improve practive in mental health institutions
+ = highlights the difficulty of applying a medical model of diagnosis to mental health and has been the focus of much debate about what can be regarded as normal and abnormal behaviour.
+ = when realised hospitals were abusing patients, much better guidelines were put into place to ensure patient safety and humanisation is kept
- = process of diagnosing and treating mentally ill people in US hospitals may not be applicable to other countries as not all countries use the same diagnostic symptoms
Ethical Issues:
+ = confidentiality upheld
- = deception- (said hearing voices, but weren't) to pretend to be mentally ill may be found offensive to other people, but it was necessary to evaluate the diagnostic system objectively (if the hospital had been told they were going to investigate the hospital they would have got DCs and SDB which is not objective or realistic of how life really is for the patients)
- = no informed consent from staff and patients- didn't know they were going to be observed
- = protection of ps- distressed patient that someone has invaded in what you thought were a safe place
- = privacy invaded- research was in a private place, not in a public place
Improvements & Implications:
1a) Sample:
Increase sample of pseudo ps from 8 to 50, make sure they are from different backgrounds. Use volunteer sampling technique. A condition would be that the ps didn't have a psychological background.Check if they are mentally able to be in a mental illnesses hospital.
Visit hospitals in 10 other countries e.g one could be China. In each country there would be 8 hospitals chosen with 8 pseudo ps that each go to a different hospital. When all the pseudo ps had been discharges in remission all the pseudo ps would meet up to compare results.
Questionnaire to Dr's about why pseudo ps were given their diagnosis. Each questionnaire would include general questions about the Dr's age, gender, ethnicity, what their occupation is and the main question we would be interested in. This would be: 'If someone was to come into the hospital saying they had been hearing unfamiliar and unclear voices, what if any condition would you diagnose them with and why?'
Get informed consent from hospital staff and patients
Exam Q and A
In Rosenhan’s study, ‘On being sane in Insane Places’, health professionals in the first experiment made a Type 2 error (a false positive) in their diagnosis of the pseudo patients. Describe the Type 2 error in this study.
• Doctors classified the healthy pseudopatients as sick / insane.
• Doctors made a false positive diagnosis by identifying healthy pseudopatients as sick /insane people
. Wrong interpretation of normal behaviour e.g. oral acquisitive syndrome.
(They did this as it was safer to diagnose a sane person than not diagnose a potentially insane person.
Why does Rosenhan argue that it is worse to make a Type 2 error when diagnosing mental illness than physical illness?
- It raises important issues about the method of diagnosis and biases in perception due to the patients being able to detect the pseudo ps sanity but the staff could not. The psychiatric diagnosis is not always valid- due to the fact that pseudo ps were not detected and each given a psychiatric diagnosis. Rosenhan said: 'we cannot distinguish between sane and insane in psychiatric hospitals'. Therefore any method of diagnosis that makes errors like this cannot be v.reliable.
- Situational factors can affect diagnosis: - Patients behaviour was interpreted in the context of the illness.
- Psychiatrists/ Dr's fail to detect the pseudo ps sanity as they are strongly biased to say that a healthy person is sick, than a sick person is healthy. It is more dangerous to misdiagnose illness than health. (Basically they are cautious and prefer to diagnose someone if they have the slightest belief that they may be ill, even if it is more likely that they are healthy.) However a misdiagnosis of being mentally ill has many negative effects- self-fulfilling prophecy can occur where the individual adopts the behavioural symptoms of the condition they have been diagnosed with. So this is a major concern that needs to be addressed.
- The fact that in the follow up study at least 2 members of staff (including a psychiatrist) judged 10% of their regular patients at the hospital as being pseudo ps. This shows that the diagnosis cannot be reliable as there were only 8 pseudo ps in total, compared to the hundreds of real patients. It implied that the psychiatrists were not confident with their diagnosis.
- Patients are powerless and dehumanised.
- Findings highlight the role of labelling in psychiatric assessment.
- The label continues beyond discharge from hospital; when they are showing no more symptoms of their illness at the time (i.e they are considered to be 'in remission' -insane still, instead of sane.
- Rosenhan uses 'the stickiness of psychodiagnostic lables' to describe how it the lable of being 'schizophrenic' means there is nothing the pseudo ps can do to override the 'tag'. In effect they cannot change other peoples perceptions of them and their behaviour one they have been 'branded' if you like with a diagnosis.
Evaluation:
Research Method:
+ = carefully selected symptoms are clever as they can be associated with any mental disorder
+ = symptoms were not art of any previous diagnosis system
+ = Ps observation- obtains v.detailed qual data, high in ecol valid.
- = not standardised in ps experience, so not able to replicable exactly.
- = less control, not standardised, each pseudo ps going through different experiences as in different hospitals
Research Design:
+ = creative, Rosenhan used this to test the reliability of identifying both sane and insane people
Sample:
- = descriptions selected by Roenhan from the 8 pseudo ps are only those that support his hypothesis.
- = small sample- only 8 used
- = biased- 6 had psychological backgrounds, biased towards those who had an understanding of psychological issues
Type of data:
+ = both qual and quant data
+ = quant data (no of admitted and discharged) provides harder evidence for qual findings (experiences)
- = quant data on own= reductionist, no reasons why the pseudo ps have been admitted, only that they were admitted
- =subjective- based on interpretation of researcher
Reliability:
+ = hospitals more representative as a range of hospitals were used (variety of old, new, with high or low staff patient ratios), making the findings generalisable
- = not consistent as pseudo ps in different hospitals, so not standardised experiences
Validity:
+ = process of being admitted as insane and not discharged until diagnosed as in remission in this context is arguably as close to an ecologically valid study as possible
+ = rich valid data from note taking
+/- = bias could be usefully employed in making insightful notes within hospitals, but may have an impact on their own behaviour within the wards
+ = High ecol valid as:
- Because the study was carried out in 12 real psychiatric hospitals/ wards (located in five different states on the East and West coasts of America)
- Because the participants were the staff at the 12 (psychiatric) hospitals who were unaware they were being observed so behaved as they did normally.
- Can be argued that the pseudo ps aren't really insane, their experiences don't reflect those of regular patients.
- Because the pseudopatients were not genuine. Although they tried to behave normally this may have been difficult in the strange hospital environments.
- *Because the pseudopatients spent a lot of their time writing down their observations about the ward, staff and patients – an activity not normally indulged in by genuine patients.
Usefulness:
+ = using ps observation enabled an insight into the experience of being in a psychiatric hospital
+ = applications of highlighting an awareness of the long term impact of psychodiagnstic labels and how to improve practive in mental health institutions
+ = highlights the difficulty of applying a medical model of diagnosis to mental health and has been the focus of much debate about what can be regarded as normal and abnormal behaviour.
+ = when realised hospitals were abusing patients, much better guidelines were put into place to ensure patient safety and humanisation is kept
- = process of diagnosing and treating mentally ill people in US hospitals may not be applicable to other countries as not all countries use the same diagnostic symptoms
Ethical Issues:
+ = confidentiality upheld
- = deception- (said hearing voices, but weren't) to pretend to be mentally ill may be found offensive to other people, but it was necessary to evaluate the diagnostic system objectively (if the hospital had been told they were going to investigate the hospital they would have got DCs and SDB which is not objective or realistic of how life really is for the patients)
- = no informed consent from staff and patients- didn't know they were going to be observed
- = protection of ps- distressed patient that someone has invaded in what you thought were a safe place
- = privacy invaded- research was in a private place, not in a public place
Improvements & Implications:
1a) Sample:
Increase sample of pseudo ps from 8 to 50, make sure they are from different backgrounds. Use volunteer sampling technique. A condition would be that the ps didn't have a psychological background.Check if they are mentally able to be in a mental illnesses hospital.
- + = no more sampling bias
- + = more hospitals can be visited
- + = target population will be represented better
- - = people may not be mentally able to take part-may not be able to leave the hospital if they cannot convince the staff that they are mentally stable
Visit hospitals in 10 other countries e.g one could be China. In each country there would be 8 hospitals chosen with 8 pseudo ps that each go to a different hospital. When all the pseudo ps had been discharges in remission all the pseudo ps would meet up to compare results.
- + = not ethnocentric
- + = more representative of the population of people with mental illnesses, so more generalisable
- + = useful in showing diagnostic system in other countries
- + = larger sample also obtained
- - = may not be easy to get admitted to hospitals in other countries or be discharged
- - = hard to find pseudo ps
- - = expensive and time-consuming
Questionnaire to Dr's about why pseudo ps were given their diagnosis. Each questionnaire would include general questions about the Dr's age, gender, ethnicity, what their occupation is and the main question we would be interested in. This would be: 'If someone was to come into the hospital saying they had been hearing unfamiliar and unclear voices, what if any condition would you diagnose them with and why?'
- + = Useful to know whether there are symptoms that the Dr's go by to diagnose patients or whether there is not a diagnostic system in place
- + = would get qual data that is valid to a certain extent as it provides a more wholesome view of the diagnostic system as you would get the reasons behind their diagnosis of the pseudo ps
- - = can get DCs and SDB,which decrease validity
Get informed consent from hospital staff and patients
- + = no deception, no invasion of privacy unless got consent, better reputation of the study as more ethical
- - = DCs, the staff would treat the patients differently to make them look like they treat the patients well (SDB) when the aim is to find out the real experience of the patients in the hospital on a day to day basis, not when the hospital are at their best behaviour.
Exam Q and A
In Rosenhan’s study, ‘On being sane in Insane Places’, health professionals in the first experiment made a Type 2 error (a false positive) in their diagnosis of the pseudo patients. Describe the Type 2 error in this study.
• Doctors classified the healthy pseudopatients as sick / insane.
• Doctors made a false positive diagnosis by identifying healthy pseudopatients as sick /insane people
. Wrong interpretation of normal behaviour e.g. oral acquisitive syndrome.
(They did this as it was safer to diagnose a sane person than not diagnose a potentially insane person.
Why does Rosenhan argue that it is worse to make a Type 2 error when diagnosing mental illness than physical illness?
- Because psychiatric diagnoses carry personal, legal and social stigmas which are difficult/impossible to get rid of.