The Great Pretender

by Susannah Cahalan

  But there were some serious downsides to going undercover at Haverford, too, given exactly those conditions. Three years later, in 1972, a Haverford Hospital nurse named Linda Rafferty would sue the hospital, exposing a host of offenses, including “homosexual abuse by other patients;… sexual exploitation by outside workmen;… leaving blank prescription forms, signed in advance by physicians, in unlocked drawers for nurses to fill out on weekends; and chronic absenteeism on the part of the hospital’s medical staff.”

  Though Rafferty’s allegations were on the extreme end, it was a precarious time for all psychiatric hospitals, as they were in the midst of profound changes—none more transformative than the new drugs now flowing through patients’ bloodstreams. Chlorpromazine (marketed under the name Thorazine in America) seemed at the time to be psychiatry’s pivotal twentieth-century discovery. It hit the American market in 1954 and by the end of the next decade had infiltrated most psychiatric hospitals. Thorazine was, as historian Edward Shorter put it, “the first drug that worked” and, according to psychiatrist, psychopharmacologist, and vocal critic of the pharmaceutical industry David Healy, “widely cited as rivaling penicillin as a key breakthrough in modern medicine.”

  Chlorpromazine came from a happy accident: After a researcher tested the antihistamine out on rats and found that they were uninterested in climbing a rope to get their food, French naval surgeon Henri Laborit tested the drug on surgical patients and found that it had a dissociative, sedating effect. Open me up, who cares, seemed to be the vibe. Why not, his peers wondered, try this drug out on psychotic patients?

  The results were astounding, though not uncontroversial. In a remarkable number of patients, the most pronounced positive symptoms of schizophrenia—the hallucinations, paranoia, and aggression—faded away. Journalist Susan Sheehan describes the miracle of Thorazine in her 1982 book, Is There No Place on Earth for Me? “Thousands of patients who had been assaultive became docile. Many who had spent their days screaming subsided into talking to themselves. The décor of the wards could be improved: chairs replaced wooden benches, curtains were hung on windows. Razors and matches, once properly regarded as lethal, were given to patients who now were capable of shaving themselves and lighting their own cigarettes without injuring themselves or others or burning the hospital down.” Pharmaceutical companies added other related drugs with brand names like Compazine, Stelazine, and Haldol by 1969, the year Rosenhan went undercover. A year later, antipsychotics were minting money for the American pharmaceutical industry to the tune of $116.5 million (which today would be $780 million) a year.

  This started the modern, drug-dependent era of psychiatry. Psychiatrists might not have been able to find and identify the “seat of madness,” but now at least there was a way to treat it, wherever it was. Other breakthroughs soon fell in line: the discovery of antidepressants, lithium for bipolar disorder, and Miltown for anxiety. Though little was yet known about brain chemistry (depression was still viewed by many as “inward-directed anger,” obsessive-compulsive disorder as “arrested psychosexual development in an anal stage,” and schizophrenia as the result of overbearing mothers), psychiatry now had an armamentarium and a language—take that, oncology!—that gave it legitimacy as a true medical specialty. Later, as more insight into brain chemistry emerged, our terminology changed. We developed schizophrenia because of a “dopamine disorder.” We were depressed because of a “catecholamine disorder” (later a “serotonin imbalance”) and anxious because of a “5HT disorder.” It all appeared so comfortingly scientific, and the public embraced this new insight into our minds/brains. And with this insight came new ramifications for misdiagnosis: Different drugs treated different conditions (antipsychotics, like Thorazine, were diagnosed for people with schizophrenia; mood stabilizers, like lithium, for manic depression; and antidepressants for those with depression). Diagnostic mistakes suddenly meant something. There was now a premium on diagnosis—not only for doctors and patients, but for insurance and pharmaceutical companies, too.

  Despite the obvious progress, it wasn’t a smooth transition, however. Kesey documented the array of drugs—and the backlash to them—in One Flew Over the Cuckoo’s Nest: “Miss Ratched shall line us against the wall, where we’ll face the terrible maw of a muzzle-loading shotgun which she has loaded with Miltowns! Thorazines! Libriums! Stelazines! And with a wave of her sword, blooie! Tranquilize us all completely out of existence.” Though the general effectiveness of the medications was unmistakable—even if they were perhaps too effective, as shown by Kesey’s quotation—many psychiatrists insisted that they offered a skin-deep fix that did not address the all-debilitating deficits that had diffuse effects across a wide range of ordinary life situations.

  Once Jack Kremens had agreed to host undercover undergraduates at Haverford, despite all the risks, Rosenhan and his students discussed the specifics of the study. Would the staff be aware of their presence or not? Would they make up names or use their own? What addresses would they use? Most crucially: How would they get out once they got in?

  The first few decisions came easily. They would change their last names and keep their given names. The students would identify as such, but claim to be from different universities to protect their anonymity. (After all, how many potential employers would believe you if you said: Oh yes, I was institutionalized, but it was for a class…?)

  It may have started as a dare, but it quickly morphed into something more provocative—a teaching exercise. Though the superintendent knew about their mission, Rosenhan made certain that the rest of the staff remained in the dark. So they still needed to convince the hospital that they required help. What symptoms would get them in? This became the source of debate. Would the pseudopatients chew up the scenery pretending to be mad—wide eyes, dirty clothes, ranting and raving the way Nellie Bly had—or would they play it cool? What did madness look like anyway?

  “We were all keyed up,” Swarthmore student Harvey Shipley Miller recalled. “I certainly was. I’d never been inside [an institution]. This was exciting.”

  They came up with auditory hallucinations—hollow, empty, and thud—words that practically screamed of ennui, an existential crisis. Frankly, this should have raised an immediate red flag at the institution because, according to Rosenhan, there had been exactly zero cases of existential psychosis reported in the literature. Rosenhan joked in a letter to a friend, “They will probably write a paper about it!” In a very obvious way this choice thumbed a nose at the rube psychiatrist who most likely had never read much Kierkegaard—the Swarthmore version of an inside joke. At this point, according to his manuscript, Rosenhan had no plans to publish anything himself or collect serious data. Their one goal was to get into the hospital by any means necessary with as little risk to the students as possible.

  They studied the work of the few academics who had attempted similar coups before them, among them medical anthropologist William Caudill, who lived for two months in 1950 as a patient of a psychiatric hospital associated with Yale, writing up his traumatic experiences in the article “Social Structure and Interaction Processes at a Psychiatric Ward.” Caudill exaggerated his own issues at his intake interview, amplifying his marital troubles and intensifying his anger and alcohol issues, but he kept the rest of his biography intact. Still, Caudill claimed that even such minimal lying took a serious toll on him, generating deep inner turmoil about having to live as an impostor. It got so intense that Caudill warned against any replications. One of his supervisors who visited him in the hospital commented, “I believe he lost his objectivity as a participant observer, and almost became a participant, a patient.” Rosenhan made a note of this in his own writings and, unlike Caudill, vowed that the participants would “not alter our life histories in any way, nor describe pathology where none existed in our current lives, or exaggerate our real problems.”

  Rosenhan and his class read exposés by journalists from around the country who had, like Bly before them, revealed the barbari
ty occurring in our backyards. During World War II, three thousand conscientious objectors were assigned alternative service at state psychiatric hospitals around the country. Shocking photographs taken by one of the objectors were featured in Albert Maisel’s “Bedlam 1946,” published in Life magazine. Maisel’s article described brutal conditions inside Pennsylvania’s Philadelphia State Hospital at Byberry and Ohio’s Cleveland State Hospital—beatings so bad that people died—alongside those deeply disturbing photographs that looked uncomfortably close to images that had just emerged from liberated German death camps. In one, a patient sits on a wooden bench, arms mummified by a white straitjacket revealing legs riddled with untreated sores. In another, a group of men huddle, heads down, naked on a refuse-covered floor.

  This was a deranged version of Groundhog Day—the same atrocities repeated time and time again. Harold Orlansky compared American asylums to Nazi death camps in his “An American Death Camp,” published in 1948. Frederick Wiseman’s damning documentary Titicut Follies documented in stark black-and-white the forensic (for “the criminally insane”) hospital Bridgewater, where the patients were physically and verbally abused—all in front of a camera. Men wandered the hospital grounds naked; a man in solitary confinement banged his head and fists against the wall, spraying dark black spots of blood. An Eastern European psychiatrist interviewed a pedophile, asking questions like: “What are you interested in, big breasts or small breasts?” In one of the more unwatchable scenes, the same psychiatrist smokes while force-feeding a man using a rubber tube, the ashy end of his cigarette perilously close to the funnel. These were dramatic, appalling stories, but they lacked a key ingredient necessary for wide-scale change: They weren’t scientific. Ultimately, it would be Rosenhan’s own study that would slide in and fill that void—though he and his students had no idea of the power of this idea at the time.

  Rosenhan was most inspired by the work of sociologist Erving Goffman, who spent a year undercover as an assistant to the physical education instructor at St. Elizabeths Hospital in Washington, DC, all the while recording the inner workings of the deeply dysfunctional mini-city of six thousand patients. In Asylums, his famous text published in 1961 (a big year for landing punches, the same year Laing’s second book, Self and Others, and Szasz’s The Myth of Mental Illness hit the shelves), Goffman described the hospital as a “total institution,” much like prisons and concentration camps, that dehumanized and infantilized patients (really prisoners) and not only did not effectively treat but actually caused the symptoms of mental illness. Institutional life not only didn’t cure mental illness but actually contributed to chronicity, a condition that psychiatrist Russell Barton named “institutional neurosis” in 1959. Though Asylums was a groundbreaking work and remains highly respected within sociological and psychological circles, it did not reach the masses in the same way that Rosenhan’s paper would.

  To his students, Rosenhan assigned work that described psychiatric hospitals as “authoritarian,” “degrading,” and “illness-maintaining,” among other terms. Clearly, he did not expect to find a great deal of healing going on inside those walls.

  Perhaps this was why Rosenhan required that the students receive permission from their parents to participate in the study, even though the students were over eighteen years old. Parent responses were far from supportive. “Wasn’t it dangerous?” they asked. “How could one be sure that real patients would not harm the pseudopatients? What about staff? It had been said that occasionally staff are hurtful and worse to patients.” How would Rosenhan ensure that the pseudopatients would not be “molested or harmed” from “shock therapy, even lobotomies, not to speak of medications that might be poured or injected into them?” One mother flatly refused, explaining that she had been an employee at a psychiatric hospital and she would never trust her son in the care of one. Another summed it up with one sarcastic sentence: “I hereby give you permission for my son to participate in your insane experiment on insanity.”

  Rosenhan noted that the parents had all reached the same consensus: “Perhaps hospitals cure, but psychiatric hospitals don’t. They brutalize, torture: they are outside the pale; they make the sick sicker, and even the sturdiest, sick.”

  They make the sick sicker.

  Rosenhan contacted a friend, psychiatrist Martin Orne,1 for advice, who responded: “Go slowly, and perhaps not at all.”

  History made it clear. Psychiatric hospitals were far from therapeutic. David Rosenhan couldn’t subject his students to being committed to one of those hospitals without first seeing what they were up against.

  First, he would have to go in alone.

  8

  “I MIGHT NOT BE UNMASKED”

  Rosenhan pulled from his real-life experience to make a kind of bizarro-David, one with a new last name, address, and occupation. He took on his mother’s maiden name and became David Lurie, an out-of-work economist / advertising executive. This would be easy to fake since he had, in real life, pursued a master’s degree in mathematics. (He dropped this focus when he didn’t rank first in his class. Rosenhan didn’t do anything that he didn’t feel he was the best at, his son, Jack, has explained to me, so he decided to switch to psychology.) Beyond growing a beard (“lest I be recognized!”), he didn’t alter his physical image much, planning simply to wear shabbier items from his own wardrobe.

  He went ahead and arranged his visit at Haverford through Kremens, making sure no others on staff would be aware of his ruse. Yet, despite all his bravado, as zero hour approached he began to get cold feet. “Thinking and discussing are not like doing,” he wrote in his unpublished book. “I was frankly panicked. Would I actually get in? On the basis of such a simple symptom? I began to have serious doubts not only about my ability to get in, but even about my desire to be hospitalized.”

  His wife, Mollie, did little to alleviate her husband’s worries. And she was not one to keep quiet when things bothered her. They had met on the first day of Rosh Hashanah outside a synagogue in Lakewood, New Jersey, in 1958. The two young lovers got so lost in conversation that they didn’t even make it inside for services. When Mollie left Rosenhan’s side later that summer to return to the University of Chicago, they exchanged desperate letters. One by Rosenhan read: “Remember how I touched your arm and you touched it and wanted to be touched, so I touched your breast and [you] put your arms around me. I’m thinking I loved you without thinking you loved me back… I wanted to receive so greedily and tearfully. It hurts. My, it hurts terribly.” Two weeks after their first meeting, Rosenhan boarded a flight to Chicago and proposed. As independent as she was, Mollie desperately wanted a family, having been an only child raised in a crowded hotel. (Both of her parents were innkeepers who catered to wealthy Jews on summer vacation.) She and Rosenhan married and a few years later adopted two children—first Nina and then Jack.

  Mollie was the prickly one, the difficult one, the tough one—she was notoriously persnickety about her food and would haughtily return meals at restaurants, never too shy to make her grievances known. Or at least that’s how she appeared. Close friends described her as warm and caring with a delicious sense of humor. She was a feminist when that was still a dirty word, and she was a scholar, receiving her PhD in Russian history, teaching college classes, publishing on a wide array of feminist issues, and later co-founding the Stanford Center for Research on Women while also raising the couple’s two young children. One of her closest childhood friends shared with me a picture that seems to sum her up: Mollie as a teen on a trip to Israel, sitting in the bed of a truck, holding a semi-automatic rifle.

  Mollie appeared to be the force in the couple, but those who knew them well saw something else. Rosenhan knew how to sway her. Though she hated the thought of her husband going into a psychiatric hospital, it didn’t stop her from helping him prep for his role.

  On Wednesday, February 5, 1969, Rosenhan set the study in motion by cold-calling Haverford State Hospital to ask for help. The phone logs recorded a man wh
o had difficulty expressing himself “as his speech was retarded, and he was very emotional.” The idea of Rosenhan’s speech being “retarded,” or, in more modern parlance, delayed, is laughable knowing the natural and gifted speaker he was. Perhaps his nerves were getting the better of him; perhaps, out of fear that he would be exposed as a fake, he leaned into his acting role; or perhaps the operator expected to hear the voice of a “crazy person” so that’s what she heard. Either way, he needn’t have worried: The operator was concerned enough about his symptoms to advise that “David Lurie” consult with his wife about coming to the hospital the following afternoon. It was his first test, and he had passed with ease.

  Rosenhan had a hard time sleeping that night. By the morning, his dread had shifted into tingly jitters mixed with sudden clearheadedness of purpose. He put on an old raggedy button-down shirt, worn gray flannel slacks, a moth-eaten beige pullover, and tired Clarks that had long served as his weekend gardening shoes.

  If Rosenhan glanced at the New York Times that morning during breakfast, he might have noticed this story: Two court-martialed soldiers were held in a sanity inquiry for mutiny after taking part in a sit-in demonstration. A psychiatrist had testified that the soldiers, who allegedly led the mutiny, were sane—but that they both “suffered impairment of their ability to do what was right by society’s rules because both [have] sociopathic tendencies.” But did this make them crazy? The jury was still out.

  If sanity and insanity exist, how shall we know them?

  It was time for Rosenhan to commit himself to the mental hospital.