Rosenhan

Background

Medical model critisism

• The psychiatric practice in the 1950s onwards was to look at mental illness as being treatable in exactly the same way as physical illness, with hospitalisation and treatment.
  
  
• Abnormal behaviour was classified by the "Diagnostic and Statistical Manual of Mental Disorder" (DSM)
  
  
• Rosenhan and others were fierce critics of this approach and this study was an attempt to show that psychiatric classification was unreliable. 

Rosenhan

Aim

• To test the hypothesis that psychiatrists cannot reliably tell the difference between people who are sane and those who are insane.

Rosenhan

Sample + Pseudo-patients

• The first part of the study involved eight sane people (a psychology graduate student in his 20s, three psychologists, a paediatrician, a psychiatrist, a painter, and a 'housewife'). There were three women and five men.
  
  
• They attempted to gain admission to 12 different hospitals, in five different states in the USA. these hospitals are the 'sample'.

Rosenhan

Results: Exp 1

• All of the pseudo patients disliked the experience and wished to be discharged immediately.
   
• None of the pseudo patients was detected and all but one were admitted with a diagnosis of schizophrenia and were eventually discharged with a diagnosis of 'schizophrenia in remission' This diagnosis was made without one clear symptom of this disorder. They remained in hospital for 7 to 52 days (average 19 days), Visitors to the pseudo patients observed ‘no serious behavioural consequences'. 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’.
   
• The pseudo patients’ normal behaviours were often seen as aspects of their supposed illness. For example, nursing records for three of the pseudo patients showed that their writing was seen as an aspect of their pathological behaviour. 'Patient engages in writing behaviour'. Rosenhan notes that there is an enormous overlap in the behaviours of the sane and the insane. But in the context of a psychiatric hospital, these everyday human experiences and behaviours were interpreted as pathological.
   
• Another example of where behaviour was misinterpreted by staff as stemming from within the patient, rather than the environment, was when a psychiatrist pointed to a group of patients waiting outside the cafeteria half an hour before lunchtime. To a group of registrars (trainee psychiatrists) he suggested that such behaviour was characteristic of an oral-acquisitive syndrome. However, a more likely explanation would be that the patients had little to do, and one of the few things to anticipate in a psychiatric hospital is a meal.

Rosenhan

Method: Exp 1

• The main study is an example of a field experiment.
  
  IV = the made up symptoms of the pseudo patients
  
  DV = the psychiatrists' admission and diagnostic label of the pseudo patient.
  
  The study also involved participant observation, since, once admitted, the pseudo-patients kept written records of how the ward as a whole operated, as well as how they personally were treated.
  
  
• These pseudo-patients telephoned the hospital for an appointment, and arrived at the admissions office complaining that they had been hearing voices. They said the voice, which was unfamiliar and the same sex as themselves, was often unclear but it said 'empty', 'hollow', 'thud'. These symptoms were partly chosen because they were similar to existential symptoms (Who am I? What is it all for?) which arise from concerns about how meaningless your life is. They were also chosen because there is no mention of existential psychosis in the literature.
   
• The pseudo patients gave a false name and job (to protect their future health and employment records), but all other details they gave were true including general ups and downs of life, relationships, events of life history and so on.
   
• After they had been admitted to the psychiatric ward, the pseudo patients stopped simulating any symptoms of abnormality.
   
• The pseudo patients took part in ward activities, speaking to patients and staff as they might ordinarily. When asked how they were feeling by staff they were fine and no longer experienced symptoms. Each pseudo patient had been told they would have to get out by their own devices by convincing staff they were sane.
   
• The pseudo patients spent time writing notes about their observations. Initially this was done secretly although as it became clear that no one was bothered the note taking was done more openly.

Rosenhan

Method Exp 2

• In the secondary study, the staff of a teaching and research hospital, which was aware of the first study, was falsely informed that during the next three months one or more pseudo patients would attempt to be admitted into their hospital. Staff members were asked to rate on a 10-point scale each new patient as to the likelihood of them being a pseudo patient.
   
• This false information was the manipulated independent variable, and the dependent variable was the number of patients which staff subsequently suspected of being pseudo patients.

Rosenhan

Results: Exp 2

• The table shows that many patients of the hospitals regular intake were judged to be pseudo patients. For example, around ten per cent of their regular intake were judged by one psychiatrist and another staff member to be pseudo patients.
  
  
• Table 2: Judgement of all admissions patients as to the likelihood that they are pseudo patients

[image]

Rosenhan

Results: Depersonalisation and Powerlessness

Human rights, Pills, Patient contact time

• Powerlessness and depersonalisation were evident in the ways in which the patients were deprived of many human rights such as freedom of movement and privacy. Personal hygiene was monitored and many of the toilets did not have doors.
  Some of the ward orderlies would be brutal to patients in full view of other patients but would stop as soon as another staff member approached. This indicated that staff were credible witnesses but patients were not.
  
  
• 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. Often, when the pseudo patients visited the toilets to dispose of their tablets they found the medication of other patients that had already been placed there. As long as the patients were co-operative, then their behaviour went unnoticed.
  
  
• The records the pseudo patients had made about the amount of time the nurses stayed in the ward offices was about 90% of the time.
  Amount of time spent with psychiatrists, psychologists, registrars and so forth was, on average, under seven minutes per day.

Rosenhan

Conclusions

• The main experiment illustrated a failure to detect sanity, and the secondary study demonstrated a failure to detect insanity.
   
• Rosenhan explains that psychiatric labels tend to stick in a way that medical labels do not and that everything a patient does is interpreted in accordance with the diagnostic label once it has been applied.
   
• He suggested that instead of labelling a person as insane we should focus on the individual’s specific problems and behaviours.

Thigpen & Cleckley

Background

MPD

• Multiple Personality Disorder (MPD) is defined in DSM-III as a dissociative disorder in which two or more distinct personalities coexist within one and the same individual. It is an example of a neurotic disorder.

Thigpen & Cleckley

Aim

• The aim of this article was to provide an account of the psychotherapeutic treatment of a 25-year-old woman who was referred to Thigpen and Cleckley because of 'severe and blinding headaches'.

Thigpen & Cleckley

Method

• The psychiatrists used a case study method. This consisted of interviews with the patient and her family, hypnosis, observation, EEG tests and a number of psychometric and projective tests including, memory tests, ink blot tests and intelligence tests.

Thigpen & Cleckley

Results

Beginning Referal, Letter, Eve Black Emergence

Eve Black Description, Awareness of Personalities, Eve Black's Mischief + Behaviour
Psychometric Tests
Regressive/Supressive
Seeming Resolution
Jane's Appearance, Jane in General
 

• Eve white is refered to therapy for 'severe and blinding headaches' she also complained of 'blackouts' after the headaches. although her family were not aware of any loss of conciousness.
  
  
• Eve revealed emotional difficulties stemming from marital problems and personal frustrations in several interviews. Eve was also seen to be a very withdrawn and quiet person.
  
  
• The therapists where also puzzled by the fact that Eve seemed to have no memory of a recent trip.
  
  
• Several days after Eve's therapy, a letter appeared concerning her therapy, the letter appeared unfinished, with a paragraph at the bottom not in Eve's usual handwriting, but in small, childish script.
  
  
• On her next visit, Eve denied sending the letter but admitted to writing it then destroying it without sending it, Eve became quite distressed by the letter.
  
  
• Eve asked if hearing voices made her insane, and admitted to hearing someone speaking to her. During this conversation, Eve put her head in her hands as if in great pain, after a moment of silence, she dropped her hands, gave a 'quick, reckless smile' and said "Hi there, Doc!" 
   
• To the therapist it seemed that the usually conventional and retiring Eve White had changed into a carefree person. She also seemed to have a very different physical presence in terms of manner, gestures, and eye movements. When asked her name she immediately replied that she was Eve Black.
  
  
• The therapist noted that this new person ‘had a childish daredevil air, an erotically mischievous glance, a face marvellously free from the habitual signs of care, seriousness and underlying distress’. Her voice and language structure were also different, she appeared to be an entirely different woman.
  
  
• Over the next 14 months, 11 hours of interviews were carried out with the Eves, After the first few, Eve Black could be called out under hypnosis, then eventually it became easier for Eve Black to 'pop out' and she was more able to do it in Eve White's normal life, causing considerable difficulty for Eve White.
  
  
• Eve Black admitted to being seperate from Eve White since early childhood.
  
  
• When Eve Black was 'out', Eve White was not aware of what was happening, in contrast, when Eve White was out, Eve Black was aware of what was going on.
  
  
  
• Eve Black told the therapists about a number of incidents in childhood where she engaged in acts of mischief or disobedience, which Eve White was unaware of and was punished for. Some of these incidents were later backed up in interviews with her parents and her husband.
   
• According to the therapists, Eve Black’s behaviour was ‘characterised by irresponsibility and a shallowly hedonistic desire for excitement and pleasure’. She succeeded in concealing her identity not only from Eve White, but also from her parents and husband. Eve Black denied marriage to the man, who she despised, and denied any relationship to Eve White’s daughter except that of an unconcerned bystander. To her husband, daughter and parents her unpleasant behaviour, harshness and occasional acts of violence were explained in terms of ‘unaccountable fits of temper in a woman who was habitually gentle and considerate’.
   
• During Eve Black’s longer periods ‘out’ she avoided her family and close friends, and sought the company of strangers and she was also able to remain unrecognised when it suited her by imitating Eve White.
   
• Both personalities were given a series of psychometric (i.e. IQ and memory tests) and projective tests (i.e. Rorschach and drawings of human figures) by an independent expert with the following results:
   
• IQ test results: Eve White obtained an IQ of 110 and Eve Black 104.
   
• Memory Test results: Eve White had a superior memory function than Eve Black
   
• Rorschach test (ink blot test) and drawings of human figures results: The profile of Eve Black was far healthier than Eve White. Eve Black though was regressive whilst Eve White was repressive showing obsessive-compulsive traits, rigidity and an inability to deal with her hostility.
  
  
• Eve Black appeared to have little compassion for Eve White, despised her husband and denied a marriage to him, and had no more attatchment to Eve White's daughter than that of an unconcerned stranger.
  
  
• As Eve white's treatment progressed, she became more able to surpress Eve Black, leading to a situation in which Eve Black had to barter for time 'out'. After 8 months, Eve White's blackouts were begining to cease, she was performing well in her job as a telephone operator and appeared to have reached some acceptable conclusion to her marital issues.
  
  
• However, as treatment progressed further, the blackouts and headaches begun to re-emerge. Eve Black denied responsibility and said she too was unaware of what was happening during these times.
  During this time Eve White's mental state was deteriorating and confinement was considered.
  The therapists began to search through childhood memories under hypnosis and during one such episode Eve White appeared to relax into a sleepy state. ‘After two minutes, her eyes opened, blankly staring about the room trying to orient herself. When her eyes finally met those of the therapist, slowly, with an unknown husky voice and immeasurable poise, she said, ‘Who are you?’
  
  
• The therapists believed that another personality had emerged who called herself Jane. The other personality, they argued, was more responsible than Eve Black and more confident and interesting than Eve White.
   
• After Jane appeared the three personalities were given electroencephalogram tests (EEG). It was possible to make a clear distinction between the readings of Eve Black and the other two personalities. Although it was not possible make a clear distinction between Eve White and Jane’s EEG.
   
• Having been able to work with the three personalities for several months the therapists concluded that if Jane could take possession of the personalities the patient would regain full health and find her way to a happy life. Jane had awareness of both Eves’ thoughts and behaviour but did not have complete access to their memories prior to her appearance. Jane had learnt to take over many of Eve White’s tasks at home and work to help Eve White and showed compassion to Eve White’s daughter. However, although the therapists could work with Jane to determine whether Eve Black had been lying, Jane had not found a way to displace Eve Black, or to communicate through her.
   
• It was decided the Jane was the person most likely to bring a solution to the troubled mind, and that her growing dominance over the other personalities to be an appropriate resolution.
 

Thigpen & Cleckley

Conclusions

• Thigpen and Cleckley were convinced that they had witnessed an example of multiple personality.
   
• Although Thigpen and Cleckley do not point to the cause of MPD, the received wisdom is that MPD is usually a response to child abuse - a way for the individual to protect him or herself.

Griffiths

Aim + 4 Hypotheses

• The aim of this study was to investigate cognitive bias involved in gambling behaviour.
   
• There were three main hypotheses:
   
• There would be no difference between regular and non regular fruit machine gamblers on objective measures of skill.
   
• Regular gamblers would produce more irrational verbalisations than non-regular gamblers
   
• Regular gamblers would be more skill orientated than non-regular gamblers on subjective measures of self-report
   
• A further hypothesis was also added that thinking aloud participants would take longer to complete the task than non-thinking aloud participants.

Griffiths

Sample

• The sample consisted of 60 participants. The mean age of the participants was 23.4 years and 44 were males and 16 were females. All of the participants had played fruit machines at least once in their lives.
   
• Most of the participants were recruited via a small poster advertisement circulated around a university and college campus. A number of the regular players were recruited via a regular gambler known to Griffiths.
   
• The regular gamblers consisted of 29 males and 1 female and the mean age was 21.6 years.
   
• The non regular gamblers consisted of 15 males and 15 females and the mean age was 25.5 years.
   
• ‘Regular gamblers’ were defined as those who gambled on fruit machines at least once a week.
   
• ‘Non-regular gamblers’ were defined as those who gambled on fruit machines once a month or less.

Griffiths

Method

• This study is using a quasi experimental approach. The main independent variable is whether participants are regular or non-regular gamblers.
   
• The dependent variables are objective measurements of skill on the fruit machine, the content analysis of utterances from the thinking aloud method and the subjective measures of skill perception from the post-experimental semi-structured interview.
   
• A further independent variable was created by a half of both the regular and non-regular gamblers being randomly assigned to the ‘thinking aloud’ condition.
  
  
• Each participant was tested individually at an arcade in the UK. All of the participants were asked to gamble on a fruit machine called ‘Fruitskill’ which played at 10 pence a go.
   
• Each participant was given £3 to gamble on the fruit machine which gave them 30 ‘free’ gambles.
   
• All of the participants were asked to try and stay on the machine for a minimum of 60 plays – which means that had to break even and win back £3 from the money they had put in.
   
• If they managed to achieve 60 gambles with the initial £3 stake they were given the choice of either keeping any of the winnings or carry on gambling.
   
• To measure the participants objective skill levels, Griffiths recorded the gamblers behaviour.
   
• Skill was defined as ‘the ability of the individual to affect the outcome of the gambling positively (e.g. more gambles with initial money staked and/or more winnings with initial money staked)”.
   
• The experimenter stood nearby recording the total time in minutes each participant was on the fruit machine, the total number of gambles, the amount of winnings and the result of every gamble.
   
• The following table contains the 7 objective behaviours that were used to assess the skill levels of the participants.
  
  
• [image]
  
  
• Irrational verbalisations were defined as “those which were incompatible or contrary to reason (e.g. personification of the machine, use of heuristics)”. 
  
  
• The participants assigned to the thinking aloud condition had their verbalisations recorded using a lapel microphone connected to a portable tape recorder. The experimenter transcribed all of the verbalisations made during the gambling session within 24 hours so that he could remember the context of the verbalisations.
  
  
• A post experimental semi-structured interview was also carried out to measure the participants’ subjective opinions of their skill levels.
   
• A number of questions relating to skill were asked. For example participants were asked “Is there any skill involved in playing a fruit machine? And “How skilful do you think you are compared with the average player?” What skill (if any) is involved in playing fruit machines?

Griffiths

Results

Objective measures
Thinking aloud

Semi-structured Interview 

• There were no overall differences in the objective measures, save two.
  
  Non-regular gamblers made on average 6 gambles per minute
  Reguar gamblers made on average 8 gambles per minute
  
  And
  
  Regular gamblers who thought aloud had a lower win rate in plays and so won less regularly.
  
  
• Verbalisations were recored for 30 gamblers, only 4 of these were classified as irrational, the rest were rational.
  Irrational verbs. included personification of the machine and explaining away loses
  Rational verbalisations were swearing and references to winning. 
  14% of regular gamblers made irrational verbalisations
  2.5% of regular gamblers made rational verbalisations
  
  
• Based on the findings of the post-experimental semi-structured interview it was found that regular gamblers were more skill orientated than non-regular gamblers.
  For example when asked the question “Is there any skill involved in playing a fruit machine?” most regular gamblers said ‘equal chance and skill’ whereas most non regular gamblers said ‘mostly chance’.
  In response to the question “How skilful do you think you are compared with the average person?” regular gamblers claimed that they were at least of average skill, but more usually ‘above average skill’ or ‘totally skilled’. Non regular gamblers an the whole viewed themselves as ‘below average skill” or “totally unskilled”

Griffiths

Conclusions

• Objective measures support the null hypothesis that there is no difference in skill between regular and non-regular gamblers.
  Gamblers are said to be playing WITH money, not FOR money, using gambling as a source of entertainment, not a method of making money.
  There is also some evidence to support the hypothesis that thinking aloud caused participants to gamble slower.
   
• Thinking aloud results support the hypothesis that regular gamblers will make more irrational verbalisations due to cognitive bias.
  
  
•  Findings in the semi-structured interview showed that regular gamblers relied more on cognitive biases that gave them the impression of skill. In reality machines were designed to work purely by chance.