This is a Classic Study so everyone learns it and the Examiner will expect you to know it in detail. While the Exam could ask general questions about the procedure or evaluation, it could also ask specific questions, like, What did the pseudopatients say about their symptoms? or, What explanations did Rosenhan give for the failure of the hospital staff to diagnose the pseudopatients? or, What made this study ethical (or unethical)?

ROSENHAN (1973)
THE CLASSIC STUDY: THE PSEUDOPATIENT STUDY

This study was carried out by David Rosenhan. It is a famous naturalistic observation with aspects of a field experiment included. Rosenhan was a young academic who attended R.D. Laing's lectures on the anti-psychiatry movement: Laing argued that schizophrenia was "a theory not a fact" and rejected "the medical model of mental illness", especially the use of drugs. Rosenhan wanted to test the reliability of diagnosis for mental disorders.

This study is significant for students in other ways:
  • It shows how scientific research proceeds, because Rosenhan is testing and criticising established scientific theories and procedures concerning mental illness.
  • It illustrates problems with the reliability and validity of diagnosis of mental disorders while DSM-II was in use
  • It illustrates the power of the observational method, since it is a covert participant observation in a naturalistic setting

THE PSEUDOPATIENTS

After attending R.D. Laing's inspirational lecture, Rosenhan contacted a group of friends and colleagues to test Laing's criticisms of mental health diagnosis. The group would try to get admitted to mental hospitals, observe what they saw going on inside and see how long it took medical staff to realise they were healthy.

Rosenhan called this group PSEUDOPATIENTS (fake patients). There were 3 women and 5 men: a psychology graduate student in his 20s, three psychologists (including Rosenhan himself), a paediatrician, a psychiatrist, a painter, and a 'housewife'. Rosenhan trained them in how to address psychiatric health workers and how to avoid swallowing medication.

In order to be admitted, the pseudopatients had to attend a clinical interview at the hospital to be diagnosed. They told the truth about their backgrounds, except for the psychologists and the psychiatrists, who invented different careers. All of them reported the same symptoms: hearing an unfamiliar voice repeating the words 'empty', 'hollow' and 'thud'.
Such symptoms are alleged to arise from painful concerns about the perceived meaninglessness of one’s life. It is as if the hallucinating person were saying, “My life is empty and hollow” - David Rosenhan
Rosenhan also chose these symptoms because they didn't match up with the diagnostic classification of any mental illness at the time (using DSM-II).

DIAGNOSING SCHIZOPHRENIA

All of the 8 pseudopatients were admitted to mental hospitals with a diagnosis of schizophrenia. At the time of the study, DSM-II was in use. This manual described conditions like schizophrenia without clear criterion: it was described as a group of disorders that showed disturbances of thought, often leading to reality distortions, delusions and hallucinations. Schizophrenic behaviour was described as "highly deviant" with a reduced capacity for "empathy with others".

Although the pseudopatients reported one odd symptom (hearing voices), they described normal healthy lifestyles: they were not delusional or deviant and had no abnormal problems in their work or relationships. Even by the vague standards of DSM-II, they shouldn't have been diagnosed with schizophrenia, so this is a false positive.
7-minute video summing up the study

ROSENHAN'S STUDY
APRC

Aim

Rosenhan wanted to test the reliability of mental health diagnosis, to see if medical professionals could tell the sane from the insane in a clinical setting. He also wanted to investigate the effect of labeling on medical diagnosis.

In particular, Rosenhan investigated whether healthy pseudopatients would be given a diagnosis of mental illness and whether their imposture would be recognised by medical staff and other patients. Later, he investigated whether genuine patients would be identified as pseudopatients by suspicious staff.

IV & DV

This is an observation, not an experiment, so there is no IV or DV.

Sample
A common mistake students make is to write about the pseudopatients as if they were the participants in the study. The pseudopatients were the observers, not the participants (although Rosenhan does make some observations about the effect the study had on them).
The participants were the staff and patients in 12 psychiatric hospitals (mental asylums) in the United States.

The hospitals were in 5 different states, on the East and West coasts of the country.
Some were old and shabby, some were quite new. Some had good staff-patient ratios, others were quite understaffed. Only one was a strict private hospital - David Rosenhan
How could there be 12 hospitals if there were only 8 pseudopatients? Some of the pseudopatients applied to be admitted to more than one hospital. They then chose which hospital they would stay in.
Procedure

The pseudopatients went to clinical interviews and reported their symptoms.

Rosenhan approached the head of the hospital he went to and informed him of the deception, but the other pseudopatients weren't known to anyone on the staff. Rosenhan also briefed lawyers to get the pseudopatients out if anything went wrong.

When they were admitted to a hospital, they started behaving normally and stopped reporting hearing voices. They took a notepad and pen along with them to record what they heard and saw (unstructured observation). They tried to do this covertly, but if the staff detected them they carried on recording things overtly.
As soon as they were admitted, the pseudopatients requested to be discharged. They secretly disposed of any medication they were given (eg they flushed pills down the toilet) but otherwise they were friendly and polite and did everything that was asked of them - Rosenhan instructed them to be "paragons of cooperation".
Structured observations: Rosenhan carried out two structured observations during the study:
  • In 3 hospitals, a record was kept of how many patients voiced suspicions about the pseudopatients and how much time the staff spent on the ward, interacting with the patients
  • In 4 hospitals, the pseudopatient approached staff with a scripted question: "Pardon me, Mr [or Dr or Mrs] X, could you tell me when I will be eligible for grounds privileges?” (or “ . . . when I will be presented at the staff meeting?” or “. . . when I am likely to be discharged?”). The member of staff's answer and body language were recorded.
Follow-on study: After the main study ended, Rosenhan contacted his own hospital and revealed the results. The hospital agreed to a second study, but this time they would be aware that new pseudopatients would be seeking admission over the next 3 months. Staff were issued with a questionnaire to rate each new patient on a 10-point scale: 9-10 meant high confidence that the patient was really ill but 1-2 meant a strong suspicion that this was a pseudopatient.
Results

All 12 hospitals diagnosed the pseudopatients as mentally ill. 11 hospitals diagnosed schizophrenia, 1 hospital (the private hospital) diagnosed manic-depression (bipolar disorder). The pseudopatients went to hospitals that had diagnosed them with schizophrenia.
None of the staff recognised that the pseudopatients were healthy. It took between 7 and 52 days for the pseudopatients to be discharged; the mean length of stay was 19 days.
Who was the person stuck in a mental hospital for 52 days? Why, that was Rosenhan himself! The irony!
The pseudopatients were discharged with a diagnoses of "schizophrenia - in remission" (meaning the person has schizophrenia but the symptoms appear to have stopped) in 7 cases; 1 pseudopatient was discharged with a diagnosis of "schizophrenia" on their medical record.
The pseudopatients observed many disturbing things while in the hospitals.
  • Staff abusing patients: The pseudopatients were well-behaved and none of them were harmed in any way, but they observed other patients being verbally or physically abused by staff. Rosenhan reports that patients were awakened in the morning by an attendant shouting "Come on you m---- f----s, out of bed!" and one patient was beaten for saying to an attendant "I like you".
  • Patients refusing medication: The pseudopatients disposed of their pills but when they went to flush them down the toilet, they often observed that other patients had done the same thing
  • Depersonalisation & powerlessness: The patients weren't treated as persons. There were no doors on toilet cubicles and staff would inspect their medical records and personal belongings without asking permission. Staff would not make eye contact with patients. Staff would discuss patients within earshot, as if the patients could not hear them. Attendants would abuse patients while other patients were watching, but not when doctors were present. 
Staff are credible witnesses. Patients are not - David Rosenhan
Rosenhan describes feeling as if he were invisible and offers one memorable example of this:
A nurse unbuttoned her uniform to adjust her brassiere in the presence of an entire ward of viewing men. One did not have the sense that she was being seductive. Rather, she didn’t notice us - David Rosenhan
Structured observations: Rosenhan carried out two structured observations during the study:
  • Although staff were not suspicious of the pseudopatients, other patients were. 35 out of 118 patients accused the pseudopatients of not being genuinely ill.
You’re not crazy. You’re a journalist, or a professor You’re checking up on the hospital - anonymous patient
  • The staff spent most of their time in a secure area with glass windows ("the cage") and little time on the ward. On average, staff spent only 11.3% of their time outside "the cage" and much of this was doing chores rather than interacting with patients. Doctors only came onto the ward on average 6.7 times per day. Rosenhan observes that the staff behaved as if mental illness were "catching" (contagious).
Follow-on study: Rosenhan sent NO pseudopatients in the follow-on study, so ALL the patients seeking admission were genuine. 193 patients arrived at the hospital: 41 were rated as pseudopatients by at least one member of staff, 23 were rated as pseudopatients by at least one psychiatrist and 19 were rated as pseudopatients by a psychiatrist AND a staff member.


Conclusions

Rosenhan draws bold conclusions from this study:
It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals - David Rosenhan
Rosenhan draws attention to the private hospital that diagnosed a pseudopatient with manic-depression. This is a more treatable disorder than schizophrenia. Rosenhan notes that wealthier people are more likely to get diagnosed with milder problems that have better therapeutic outcomes, which shows that your class background affects the way you are diagnosed.
In particular, Rosenhan identifies a tendency toward false positives (Type I errors) in normal diagnoses, but Type II errors (false negatives) when "the stakes are high" (ie. when the hospital knows its diagnoses are being assessed).
Maddeningly, Rosenhan muddles up Type I and Type II errors in his writing: he calls the false negatives Type I errors and the false positives Type II errors. Maybe this is a Type III error?!?!? In any event, the Examiner should credit you with answering correctly whether you use the standard terminology (false positives = Type I) or Rosenhan's terminology (false positives = Type II).
Rosenhan is very concerned that the conditions in psychiatric hospitals do not help with therapy; in fact, they make patients worse. Rosenhan agrees with Goffman (1961) that conditions in psychiatric hospitals are psychologically mortifying - they make healthy behaviour and healthy thoughts more difficult.

DIAGNOSTIC LABELS

Rosenhan refers to mental health diagnoses as "labels" which are attached to patients. His study shows that these labels are often attached wrongly. He also claims that these labels, once attached, are very hard to change or remove.
A psychiatric label has a life and an influence of its own - David Rosenhan
Rosenhan refers to the "stickiness" of labels
Rosenhan points out a number of things that support the idea of mental health diagnosis as a label:
  • During his own clinical interview, Rosenhan described his own family life with only the normal amount of friction and disappointment. The psychiatrist recorded "ambivalence" (conflict) and "affective instability" (unstable emotions). This is because the symptom of hearing voices made the psychiatrist suspect schizophrenia, so he found evidence of it in Rosenhan's background. This shows that the label of mental illness CREATES the diagnosis, rather than the other way round.
  • Other pseudopatients experienced similar things. 3 pseudopatients had their note-taking recorded on their medical record as "writing behaviour" as if it were a symptom of mental illness. One pseudopatient walked the corridors to relieve boredom, but a nurse interpreted this as his being "nervous".  A psychiatrist pointed out patients arriving early at the cafeteria as an example of "the oral-acquisitive nature of the syndrome" but in fact there is nothing to do in a hospital but wait for mealtimes.
The pseudopatients, who spent a lot of time with the other patients, noticed that they behaved in a sane way most of the time, with occasional episodes of abnormal behaviour.

Rosenhan describes how labels affected the staff. For example, outbursts of anger or frustration from patients were treated by the staff as symptoms of their illness, even when they were clearly provoked by the staff themselves being rude or the hospital procedures being burdensome.

The "bizarre setting" of the psychiatric hospital makes it hard for patients to behave normally or for staff to recognise normal behaviour when they see it. This adds to the power of labels.

Rosenhan wonders whether patients come to believe these labels.
Homer: This isn't fair! How can you tell who's sane and who's insane?
Doctor: Well, we have a very simple method. [stamps Homer's hand with a stamp that reads "INSANE"]  Whoever has that stamp on his hand is insane.
Such labels, conferred by mental health professionals, are as influential on the patient as they are on his relatives and friends, and it should not surprise anyone that the diagnosis acts on all of them as a self-fulfilling prophecy. Eventually, the patient himself accepts the diagnosis ... and behaves accordingly - David Rosenhan
The SELF-FULFILLING PROPHECY is an important concept from the Labeling Theory, which you will study in more detail as part of Criminal Psychology. It occurs when people accept the label they have been given and it becomes true about them.

ANOTHER FOLLOW-ON STUDY
A FIELD EXPERIMENT

This follow-on research isn't described in Rosenhan's 1973 study, even though it's frequently described in textbooks and websites. You don't need this extra detail, but it does show how an observation can be turned into a field experiment by comparing two different environments.
In 4 hospitals, the pseudopatients approached hospital staff with a scripted question and recorded how they were treated.
Rosenhan repeated this by sending a female pseudopatient to the Stanford University health clinic (not a psychiatric hospital, but a normal medical centre) to ask members of staff in the corridors for directions on 14 occasions. Here are the results compared:
You can see how rare it was for staff to stop and respond in the psychiatric setting, but in a normal health setting this behaviour was completely typical.
This suggests that the behaviour of psychiatrists, nurses and attendants wasn't due to them being busy health professionals - because the busy health professionals at the normal health centre responded differently.

EVALUATING ROSENHAN AO3
GRAVE

Generalisability

Rosenhan made a point of using a range of psychiatric hospitals - private and state-run, old and new, well-funded and under-funded - from across the United States. Nevertheless, 12 is a small sample for a country as big as the USA and a few "bad apples" could have skewed the results of Rosenhan's observations.

There's been a lot of progress in mental health care since the 1970s (indeed, Rosenhan's study prompted many reforms), so perhaps the results are "time-locked" and cannot be generalised to psychiatric diagnosis and care today.

For example, Rosenhan's pseudopatients were diagnosed using DSM-II. Today's DSM-5 requires the patient to show TWO symptoms (not just one) and have the symptoms for at least 6 months.
On the other hand, the psychiatrists in 1973 weren't using DSM-II properly when they diagnosed the pseudopatients, so why should psychiatrists today use DSM-5 properly?
Reliability

Rosenhan trained his pseudopatients beforehand, but they didn't all follow the same standardised procedures.
  • Data from a 9th pseudopatient was not included in Rosenhan’s report because, among other things, he did not follow procedures.
  • The graduate student asked his wife to bring in his college homework to do, revealing he was a psychologist.
  • Another pseudopatient revealed that he was going to become a psychologist and one of his visitors was a college Psychology professor
  • One pseudopatient struck up a romantic relationship with a nurse.
Rosenhan explains this as the pseudopatients resisting the effects of depersonalisation and powerlessness. However, it also suggests they failed to follow instructions and act consistently.
Lauren Slater (2004) attempted to replicate Rosenhan’s study by presenting herself at 9 psychiatric emergency rooms. Her symptom was an isolated auditory hallucination (hearing the word ‘thud’). Slater was given a diagnosis of ‘Psychotic Depression’ and prescribed antipsychotics or antidepressants. (Slater had previously been diagnosed with depression). Spitzer, Lilienfeld & Miller (2005) challenged Slater’s findings by giving 74 emergency room psychiatrists her case description and asking about diagnosis and treatment. Only 3 psychiatrists diagnosed ‘Psychotic Depression’ and only a third recommended medication.
Application

This study had a huge impact on mental health care, not just in America but worldwide. It caused psychiatric hospitals to review their admission procedures and how they trained their staff to interact with patients. It started the move away from dependency on the "chemical straitjacket" of drugs to treat mental health. Today, the study is a compulsory part of training in psychiatric medicine and nursing.

Along with Robert Spitzer's criticisms, this study was a major influence on reforming the DSM. DSM-III (1980) defined mental illnesses much more carefully, with clear guidelines for including or excluding people from each classification. For example, in DSM-III, a hallucination needed to be repeated several times; in DSM-IV (1994) hearing voices needed to be experienced for over a month before a diagnosis of schizophrenia can be made and DSM-5 makes this 6 months.
Validity

Seymour Ketty (1974) criticised Rosenhan, saying that, because the pseudopatients were faking an unreal mental condition, it doesn't tell us anything about how people with genuine mental conditions are diagnosed.
If I were to drink a quart of blood and, concealing what I had done, had come to the emergency room of any hospital vomiting blood, the behaviour of the staff would be quite predictable. If they labelled and treated me as having a bleeding peptic ulcer, I doubt that I could argue convincingly that medical science did not know how to diagnose that condition - Seymour Kety
Kety’s point is that psychiatrist don't expect someone to carry out deception in order to be admitted to a psychiatric hospital. In other words, the study lacked ecological validity.
Rosenhan points out one reason why patients might lie to get into a psychiatric hospital, which is to avoid criminal prosecution (especially in a state which enforces the death penalty!).
The fact that 11 of the 12 diagnoses were consistent - schizophrenia - may prove diagnoses is reliable after all. If patients present the same symptoms, they receive the same diagnosis. This goes against Rosenhan's view that diagnosis is unreliable.

Robert Spitzer (1976) points out that the diagnosis ‘Schizophrenia - in Remission’ given to 7 of the discharged pseudopatients is very unusual. He examined records of discharged schizophrenic patients in his own hospital and 12 other American hospitals and found that ‘Schizophrenia - in Remission’ was used only for a handful of patients each year. Spitzer claims the psychiatrists’ discharge diagnosis was a recognition that the pseudopatients' behaviour was unusual, not proof that the psychiatrists couldn’t tell the sane from the insane.
Ethics

The hospital staff were deceived about the pseudopatients’ symptoms being real. The doctors and nurses in the hospitals could not consent to take part or exercise their right to withdraw from the study. The other patients in the study had no possibility of consenting or withdrawing and didn't enter psychiatric hospitals in order to be in psychology research
However, Rosenhan notified the management of the hospital he went to.
I was the first pseudopatient and my presence was known to the hospital administration and chief psychologist and, so far as I can tell, to them alone - David Rosenhan
If Rosenhan thought that the management of the hospital he went to could be trusted, why didn't he inform the hospitals the other pseudopatients went to?
Rosenhan did protect confidentiality - no staff or hospitals were named.
A different ethical issue with Rosenhan’s study is that it contributed to a crisis of public confidence in the American mental health system - which may have prevented people who genuinely needed help from seeking it.
However, Rosenhan wasn't the only critic of psychiatry at the time. Two years after Rosenhan, "One Flew Over The Cuckoo's Nest" (1975) dramatised many of the same problems in mental health care. It won the Best Film Oscar.
Rosenhan may be criticised for failing in a duty of care towards his own researchers - the pseudopatients. He put them in a harmful environment where they experienced tension and stress. None of them were physically abused but they witnessed physical abuse going on. They were instructed in how to avoid taking medication, but if they had been forced to take medication, it could have produced side-effects on them.

However, Rosenhan took a few precautions. In his own case, he notified the hospital manager and chief psychologist of what he was doing. For all the pseudopatients, he prepared lawyers who would intervene to get the pseudopatients out of hospitals if they requested it.
Start with an evaluation point and back it up with evidence.
Evaluation + evidence = "logical chain of reasoning"
Issues & Debates (like contributions) make great conclusions

EXEMPLAR ESSAY
AN 8-MARK ESSAY ON THE CLASSIC STUDY

Evaluate the classic study by Rosenhan (1973). (8 marks)
  • A 8-mark “evaluate” question awards 4 marks for AO1 (Describe) and 4 marks for AO3 (Evaluate).

Rosenhan's study is reliable because he followed a standardised procedure. His 8 pseudopatients were trained to behave the same way. They reported the same symptoms (hearing a voice that said 'hollow', 'empty' and 'thud') and concealed that they had any background in psychology or psychiatry. In the hospital, they stopped claiming to hear voices and took secret notes on what they observed.

However, Rosenhan's study wasn't entirely reliable because some pseudopatients ignored the procedures. A 9th pseudopatient had to be dropped from the study and even the ones that were included did things like tell staff they were studying Psychology, bring in the Psychology homework and strike up a romantic relationship with a nurse.

Rosenhan's findings must be valid because his observation was covert; the hospital staff didn't know they were being observed and even when they saw pseudopatients taking notes they treated it as "writing behaviour" and a symptom of mental illness.

Because the observation was unstructured it contains rich qualitative data, like Rosenhan's account of the nurse undressing in front of the patients which shows that they didn't count as 'real people' to the staff.

In conclusion, Rosenhan's study made a big contribution to reforming mental healthcare and the DSM. The other critics of mental health care at the time (such as R.D. Laing and films like "One Flew Over the Cuckoo's Nest") suggest Rosenhan was right to expose something wrong with the system.
  • Notice that for a 8-mark answer you don’t have to include everything about Rosenhan. I haven’t explored generalisability problems or the ethical issues. But it is a balanced answer - half description, half evaluation.