The Great Pretender

by Susannah Cahalan

  By the late 1980s, a little over a decade after its publication, nearly 80 percent of all intro-to-psychology textbooks included Rosenhan’s study. Most histories of psychiatry devote at least a section to it—even in the pocket-size Psychiatry: A Very Short Introduction (a kind of “psychiatry for dummies”), which is only 133 pages long, the Rosenhan study takes up nearly a whole page on “psychiatric gullibility.” To this day, “On Being Sane in Insane Places” is taught in a majority of psych 101 classes, an outright coup for a study four decades old. Its power was in its scientific certainty. Journalists, writers, even psychiatrists had infiltrated the world of the mentally ill before Rosenhan and exposed the horrors there—but none had done so with such rigor, with such a broad sample set, with such extensive citations, in such an attention-grabbing way, at just the right time in just the right publication. These researchers were not “a bunch of harum-scarum sensationalists,” one newspaper reporter wrote, but a varied group gathered by Rosenhan, a highly credentialed man who boasted dual professorship in law and psychology at Stanford University. Rosenhan’s study, published in one of the world’s most prestigious academic journals, quantified the medications, the number of minutes per day the staff spent with the patients, even the quality of those interactions. Unlike Nellie Bly and others before and after, David Rosenhan’s data was, at last, unimpeachable.

  Eight people—Rosenhan himself and seven others, a varied group that included three women, five men, a graduate student, three psychologists, two doctors, a painter, and a housewife—volunteered to go undercover in twelve institutions in five states on the East and West Coasts and present with the same limited symptoms: They would tell the doctors that they heard voices that said, “thud, empty, hollow.” (One potential pseudopatient who had not conformed to Rosenhan’s rigorous data collection methods was, as explained in a footnote, pulled from the study.) With this standardized structure, the study tested whether or not the institutions admitted the otherwise sane individuals. Based on those symptoms alone, the psychiatric institutions diagnosed all the “pseudopatients” with serious mental illnesses—schizophrenia in all cases but one, in which the diagnosis was manic depression. The length of hospitalization ranged from seven to fifty-two days, with an average of nineteen days. During their hospitalizations, twenty-one hundred pills—serious psychopharmaceuticals—were prescribed and administered to these healthy individuals. (The pseudopatients were trained to “cheek” or pocket the pills so they could be spit out in the toilet or thrown away rather than ingested.)

  Beyond a few biographical adjustments for privacy reasons, the pseudopatients used their own life stories. Once inside their designated institution, it was up to them to get themselves out. “Each was told that he would have to get out by his own devices, essentially by convincing the staff that he was sane,” Rosenhan wrote. Just as Nellie Bly had done nearly a century earlier, they dropped their hallucinations as soon as they were admitted and behaved “normally,” or as normally as the bizarre conditions allowed. Yet, from the moment of admittance, clinicians viewed all behaviors through the prism of the pseudopatients’ presumed mental illness. No pseudopatient was unmasked by the staff, yet 30 percent of fellow patients in the first three hospitalizations noticed something was awry, commenting, in one case, “You’re not crazy. You’re a journalist or a professor. You’re checking up on the hospital.” Nurses’ reports noted that “patient engages in writing behavior” when the pseudopatient was observed calmly documenting the activities of the ward for his or her undercover research. “Having once been labeled schizophrenic, there is nothing the pseudopatient can do to overcome the tag. The tag profoundly colors others’ perceptions of him and his behavior,” Rosenhan wrote.

  “How many people, one wonders, are sane but not recognized as such in our psychiatric institutions?” asked Rosenhan. “How many patients might be ‘sane’ outside the psychiatric hospital but seem insane in it—not because craziness resides in them, as it were, but because they are responding to a bizarre setting?” Or, as the nurse’s comment about “writing behavior” revealed, simply exhibiting normal behaviors that are misinterpreted as abnormal under the label of mental illness. It was unusual for a paper as narrative as this to end up in Science, one of the most widely read peer-reviewed academic journals in the world, endowed with seed money from Thomas Edison and later Alexander Graham Bell. (Science’s most famous papers include the first time the entire human genome was sequenced, early descriptions of the AIDS virus, a paper on gravitational lensing by Albert Einstein, and one on spiral nebulae by astronomer Edwin Hubble.) That it was published in such a revered general science academic journal gave the study a life that no one—probably not even David Rosenhan himself—could have seen coming.

  Arriving on the scene when it did, Rosenhan’s “On Being Sane in Insane Places” ended up falling right in line with other, more theoretical rebukes that had been building from inside the ranks of psychiatry from people who asserted that mental illness didn’t even exist. The pendulum had swung once more, this time into a third position, moving from the idea that mental illness resided in the brain as a tangible disease, like cancer, to the theory that it emerged from unresolved conflict in the mind’s psyche, to the new conviction that the “illness” itself lay entirely in the eye of the beholder. Intentionally or not, Rosenhan’s study ultimately built on this idea, arguing that the healthy volunteers were deemed insane because they were in an insane asylum, not because of any objective, external truths that psychiatry could point to for a diagnosis. Rosenhan provided the key element missing from anti-psychiatry’s arguments—proof of its convictions.

  The timing of the study couldn’t have been more fraught for psychiatry. These were the early rumblings of psychiatry’s worry years. Sobering studies cast psychiatry in a less-than-effective light. In 1971, a large-scale US/UK study showed that there was little consensus across the Pond about schizophrenia. American psychiatrists worked with a broader concept of the disorder and overwhelmingly diagnosed people with it, while British doctors were more likely to diagnose patients with manic depression, now known as bipolar disorder. Two psychiatrists on the same side of the Atlantic, studies showed, agreed on diagnosis less than 50 percent of the time—worse than blackjack odds. American psychiatrist Aaron T. Beck, who would later father the field of cognitive behavioral therapy, published two pieces on the lack of reliability in psychiatric diagnosis, concluding in his 1962 paper that psychiatrists agreed only 54 percent of the time when diagnosing the same psychiatric patient.

  Meanwhile, psychiatric hospitals closed at a rapid clip across the country. By the time California governor Ronald Reagan took office in 1967, state hospitals had released half of all their patient population. Under Reagan’s leadership, California passed several acts that hastened the demise of the institutions across the state—and the rest of the country followed. Yet even as the hospitals were being closed, psychiatry’s reach was spreading wide outside the asylum, like ground ivy, into Hollywood, government, education, child-rearing, politics, and big business, enjoying a sudden social cachet while turning its back on the people who needed help the most—the seriously mentally ill.

  Society at large, it seemed, was ready to push back against this overextension. In the wake of his study, David Rosenhan became an academic celebrity, a media darling whose research was extensively covered in the nationwide press. It launched scores of articles, some of them outright hostile, everywhere from the New York Times to the Journal of Abnormal Psychology, as people debated the limits of psychiatry as a medical specialty. (Various Reddit pages dedicated to the study still spring up with thousands of commenters weighing in, embracing the idea that there exists a respected academic paper they can brandish to jab back at a medical specialty that, to their minds, has ignored, exploited, or abused them.) There was even a rash of pseudopatient copycats in the 1970s—including one college student at Jacksonville State Hospital who was unmasked as a faker by the staff in 1973. He was the
second pseudopatient outed there in a period of six months.

  The study brought Rosenhan renown as a respected expert in diagnosis, precisely because of his critique of it. (This happened despite the fact that he had spent only six months in a hospital setting early in his career, when he researched—but never treated—people with serious mental illness.) He testified in a Navy hearing about the schizophrenia diagnosis and involuntary commitment of a skipper, worked as a psychology consultant to the Veterans Administration, and became a mascot for the limitations of psychiatry at countless academic conferences. Lawyers cited Rosenhan’s study as proof that a psychiatrist as an expert witness was an oxymoron—claiming that in the courtroom such testimony was as legitimate as “flipping coins.”

  When Dr. Deborah Levy introduced me to the study, I didn’t yet know how the tentacles of this one almost fifty-year-old paper extended in so many wild directions that it was cited to further movements as disparate as the biocentric model of mental illness, deinstitutionalization, anti-psychiatry, and the push for mental health patient rights. Nor did I know that it would alter my perspective on something that I thought I had all figured out. Reading the study for the first time, I—like many before me—simply recognized so much of my own experience in Rosenhan’s words. I had seen how doctors’ labels altered the way they saw me: During my hospitalization, one psychiatrist described my plain white shirt and black leggings as “revealing,” for instance, and used it as proof that I was hypersexual, a symptom that supported her bipolar diagnosis. It’s hard to ignore the judgment that comes with those kinds of labels. Yet the minute the doctors discovered my issues were neurological—after I had spent weeks living with a psychiatric diagnosis—the quality of care improved. Sympathy and understanding replaced the largely distant attitude that had defined my treatment, as if a mental illness were my fault, whereas a physical illness was something unearned, something “real.” It was the same way the psychiatrists treated the pseudopatients when the cause of their presumed distress could only be “mental.”

  “It is not known why powerful impressions of personality traits, such as ‘crazy’ or ‘insane,’ arise,” Rosenhan wrote. “A broken leg is something one recovers from, but mental illness allegedly endures forever. A broken leg does not threaten the observer, but a crazy schizophrenic? There is by now a host of evidence that attitudes toward the mentally ill are characterized by fear, hostility, aloofness, suspicion, and dread. The mentally ill are society’s lepers.”

  I identified with the extreme loss of self that all eight pseudopatients experienced during their hospitalizations—and bristled at the blame directed at the pseudopatients, as if they didn’t deserve sympathy or care. “At times, depersonalization reached such proportions that pseudopatients had the sense that they were invisible, or at least unworthy of account,” Rosenhan wrote. I recognized their outrage over the blatant hubris of the doctors who in the face of uncertainty doubled down with an unquestionable infallibility. “Rather than acknowledge that we are just embarking on understanding, we continue to label patients ‘schizophrenic,’ ‘manic-depressive,’ and ‘insane,’ as if in those words we had captured the essence of understanding. The facts of the matter are that… we cannot distinguish insanity from sanity,” Rosenhan wrote.

  In my first reading of “On Being Sane in Insane Places,” in a quiet Boston hotel room, the first of hundreds of readings to come, I saw immediately why so much of the general public had hailed it—and why psychiatry writ large despised it. I recognized the validation Rosenhan’s work gave to that father who had emailed me. I pinpointed so much of my own disappointment and frustration as a former patient myself. And I could feel, viscerally, the undercurrent of rage that travels through his paper that I feel, too, when I picture the face of my mirror image, that anonymous young woman, trapped in a psychiatric diagnosis, who would never be the same.

  “You are a modern-day pseudopatient,” Dr. Levy said to me over our dinner that night, meaning that I was also misidentified as a psychiatric patient.

  I took it a different way: It was a challenge, a call to learn more and understand how this study, and the dramatic questions Rosenhan raised almost fifty years ago, could help the untold others whom our health care system still leaves behind.

  5

  A RIDDLE WRAPPED IN A MYSTERY INSIDE AN ENIGMA

  I had so many questions for David Rosenhan: about his experiences, about the pseudopatients, about the creation of and the challenges in implementing the study. But he had died in 2012, in those same months when I was preparing for the release of my own Brain on Fire. I searched eagerly for more of his work, but with the exception of one companion piece, where Rosenhan clarified some of the points made in his original study, and a short personal reference to the study in an introduction to his abnormal psychology textbook, he never again published on the topic. He had even secured a book deal, I learned, but ended up never delivering the manuscript and was later sued by the publisher for it. He had walked away from this subject that so desperately needed a champion. What had happened to silence him?

  Unfortunately, I would not learn the answer easily. Google searches and basic digging led me nowhere in understanding more about the creation of “On Being Sane in Insane Places.” A news clip search revealed no further details. It seemed there was little else to find beyond the original premise—eight anonymous pseudopatients, twelve hospitals, “thud, empty, hollow.” None of the pseudopatients had gone public, their names never released. Nor had anyone revealed the identities of the hospitals they infiltrated. Rosenhan had remained tight-lipped his whole life about the identities of the hospitals (with one exception—he did reassure the superintendent of Delaware State Hospital that despite rumors, he had not sent pseudopatients there). He was determined to protect their privacy, he wrote, because he didn’t blame the individual doctors and hospitals themselves so much as the system overall. Given how groundbreaking the study was, it was startling that such a large part of it remained a mystery almost five decades later.

  Secrecy or no, the study had clearly touched a nerve, and not in the same way it had for me. In the April issue of Science, following the January publication of “On Being Sane in Insane Places,” furious letters to the editor filled twelve whole pages. “Through the publicity attracted by his methods,” one Yale psychiatrist wrote to Science, “Rosenhan may have provided society with one more excuse for pursuing the current trend of vilifying psychiatric treatment and neglecting its potential beneficiaries.” Another wrote: “It can only be productive of unwarranted fear and mistrust in those who need psychiatric help, and make the work of those who are trying to deliver and teach about quality care that much harder.” They were, understandably, standing their ground—but that same ground was now shifting beneath them.

  The debate Rosenhan had touched off continued to rage for decades. In 2004, author and psychologist Lauren Slater claimed that she replicated the study. Her work prompted a round of scorching critiques from many of the same members of the psychiatric community who had ripped Rosenhan’s study more than thirty years earlier. I marveled at how psychiatry could be so defensive, when so many others had acknowledged the problems before Rosenhan arrived to document them with hard data. Why attack the messenger?

  Finally, I stumbled upon a link that got me a little closer to that messenger: A BBC radio report that aired before David Rosenhan’s death revealed that Rosenhan’s personal files were with his close friend and colleague Lee Ross, a seminal Stanford social psychologist. I soon found myself in a rental car, hopelessly lost on my way to Stanford University’s Department of Psychology in Jordan Hall.

  “I’m so sorry I am late,” I hear myself say to Lee Ross on the audio recording I made of our meeting. I can hear in my voice how painfully aware I am of the stature of the man I’m interviewing. Lee Ross has written well over a hundred research papers, authored three and edited five influential academic books (when I visited him, he was in the midst of co-writing The Wisest On
e in the Room, a book that pushes readers to apply the best of social psychology research to their own lives), and founded the Stanford Center on International Conflict and Negotiation with, among others, psychologist Amos Tversky (a subject of Michael Lewis’s recent The Undoing Project).

  Lee also coined the term fundamental attribution error, which theorizes that people are more likely to credit other people’s faults to internal factors (she’s late because she’s a directionally challenged idiot with no time management skills) but credit external factors when we think of ourselves (I’m late because Stanford’s campus is needlessly confusing, and it’s impossible to find a parking spot). His research interests range from shortcomings in intuitive judgment and decision making, to sources of interpersonal and intergroup misunderstandings, to “naive realism”—a way of viewing the world that refuses to acknowledge that everyone experiences realities differently. He documented the shortcomings of the “intuitive psychologist” in one of his early papers, which showed how researchers’ biases color the interpretations of their data. He studied belief perseverance, or the tendency of people to dig in when presented evidence contrary to their convictions. He also coined the term false consensus effect to describe how people often overestimate how common their beliefs are—particularly dangerous in those who hold extremist views.

  In other words, if I had to narrow Lee’s interest down to a few words, it would be the fallibility of belief. And he was close friends with David Rosenhan, the man whose past I had come to mine.

  Lee Ross is a kind man but, according to a colleague, “doesn’t suffer fools.” He speaks slowly. His wildly engaging eyes, his gentle voice, and his congenial way of angling his head in your direction as you try to make a point, seeming to peer right inside you, made me nervous.