Research in psychology: Rosenhan (1973)

Rosenhan wanted to test the validity of psychiatric diagnoses as well as determine the negative consequences of institutionalization.

He conducted a field study where eight healthy people tried to gain admission to 12 different psychiatric hospitals. They complained that they had been hearing voices. The voices were unfamiliar, of the same sex and said single words like “empty” or “thud”. These were the only symptoms they reported. Once they were admitted to the hospital, they immediately stopped reporting symptoms and act “normally.”

Seven of the pseudo-patients were diagnosed as suffering from schizophrenia.

After the individuals had been admitted to psychiatric wards, they all said they felt fine, and that they were no longer experiencing the symptoms. It took an average of 19 days before they were discharged. For all of the pseudo-patients, they were discharged with a diagnosis of  “schizophrenia in remission”, implying that the schizophrenia might come back.

During hospitalization the pseudo-patients experienced very little contact with doctors and what they considered to be “a lack of normal interaction” with the staff, feeling that the replies from the nursing staff were lacking eye-contact and a personal connection. In addition, the staff interpreted the patients' normal behaviour – for example, note-taking – as abnormal.

Rosenhan concluded that “It is clear that we cannot distinguish the sane from the insane in psychiatric hospitals. The hospital itself imposes a special environment in which the meaning of behavior can easily be misunderstood. The consequences to patients hospitalized in such an environment – the powerlessness, depersonalization, segregation, mortification, and self-labeling – seem undoubtedly counter-therapeutic.”

The study played a key role in raising awareness about the way that diagnosis is carried out and the treatment that patients receive in mental hospitals.  Rosenhan showed that when people come into a hospital, it is assumed that there is a problem that needs treatment.  Then, once a diagnosis is made, health professionals may notice behaviours that they believe are in line with the diagnosis – what is called confirmation bias.

The study was highly influential in promoting change in hospital practice, protecting the rights of the patients.  In addition, today diagnostic manuals are much more complex and psychiatrists are encouraged to practice data triangulation in diagnosis. But was does Rosenhan’s study really teach us about the validity of diagnosis?

When discussing the validity of diagnosis, this study has several limitations:

• The study is unethical because no consent was given by the people working in the hospitals. In addition, deception was used by the confederates. Rosenhan did not debrief the hospitals on his findings or allow them to withdraw from the study. Some consider the outcome of the study important enough to justify the lack of consent.
• There is no way to verify the validity of the claims made by the “patients.” Rosenhan wrote that the nurses saw note-taking as an “aspect of their pathological behaviour.” However, the nurses’ notes simply said: “engages in writing behaviour.” This is an example of researcher bias.
• Only a single disorder was studied – schizophrenia. It is not possible to say from this single study that diagnostic systems are therefore invalid.

Research in psychology: Lobbestael, Leurgans & Arntz (2011)

Lobbestael, Leurgans & Arntz (2011)  investigated the reliability of diagnosis using the DSM IV with a sample of 151 participants, consisting of both patients and non-patients.  The original clinical interviews, often lasting up to two hours, were audio-taped. The interviews were then assessed by a second psychiatrist who did not know the diagnosis made by the first psychiatrist.

The results showed that generally there was higher reliability for personality disorders over other disorders. There was a 71 percent rate of reliability in the diagnosis of major depression, whereas there was an 84 percent rate of reliability of personality disorders. The high rate of consistency in diagnosis indicates that a diagnostic manual like the DSM IV, in this case, ensures that clinicians are more in agreement on a diagnosis.  But even if the diagnosis is reliable, that does not necessarily mean that it is valid.

A strength of this study is that the researchers used a single-blind procedure - the second psychiatrist did not know the diagnosis made by the first psychiatrist.  Also, by using only audiotapes, non-verbal behaviour or the appearance of the patient did not affect the diagnosis process.  However, this can also be seen as a limitation. It is difficult to know the extent to which non-verbal behaviour may have played a role in the first diagnosis.  Therefore, the second diagnosis may be too controlled and could have missed important non-verbal data which may have changed the diagnosis.