The Great Pretender

by Susannah Cahalan

  Like all of us, Rosenhan didn’t or couldn’t share some things even in his private writing. Through his son, Jack, I learned that Rosenhan’s younger brother struggled with manic depression (now called bipolar disorder). Rosenhan’s family home was a rigidly Orthodox one, and as his younger brother came of age he grew even more conservative—becoming Ultra-Orthodox, the opposite of David, who may have studied the Torah as a hobby but approached Judaism with a scholar’s eye more than as a true believer. His brother’s extremism capsized other aspects of his life. He had difficulties with money, for example, and during manic phases when off his medications would often call Rosenhan to discuss his finances, issues with his growing family, and his various paranoid fixations that this or that person was out to get him.

  “My dad was constantly on the phone with his brother dealing with that and trying to help with that,” Jack said. “I would hear my father being upset and just saying when he’s on his lithium he’s fine, but when he’s not he has these manic episodes and these grandiose ideas. Eventually [because of] one of those ideas he moved his entire family to Israel.” Jack believed that these experiences with his brother shaped Rosenhan’s interest in psychology—especially abnormal psychology—and contributed to his zeal for reform, but Rosenhan never discussed this family issue publicly.

  On the late-winter morning of February 9, 1969, Rosenhan and Mollie climbed into their VW hatchback, leaving five-year-old Jack and seven-year-old Nina, both of whom were blissfully unaware of their father’s plans, with a babysitter. A new worry had cropped up, overriding even the fear of exposure: “a fear that I might not be unmasked.” Rosenhan handled the stick shift as his thoughts raced: “Do I need shirts, ties, and underwear, or will I be wearing pajamas all day? Or will it be government-issued clothes? Do I need a heavy sweater for the cold days? Will I be going out at all? The children were in school. Will I be permitted to call them? Do they even have phones on the ward? Will they allow me to smoke, and could I bring my lighter?”

  The Rosenhans drove through the Philadelphia Main Line. Stately mansions with pristine lawns lined the way. A semicircular gray stone wall provided the only indicator that they were entering Haverford State Hospital’s manicured grounds. They drove to the five-story red-brick admissions building, aka Building Four.

  No wonder people called it the Haverford Hilton. Built just seven years before Rosenhan’s visit, in 1962, Haverford Hospital was an outlier in Pennsylvania in that it was new—few states were allocating funds to building psychiatric hospitals. A psychiatrist who worked there described a large recreation building with a gym, billiards room, pool, barbershop, beauty salon, and soda fountain. There was a four-hundred-seat auditorium, bowling alley, library, and fully equipped surgical unit with X-ray equipment, an operating room, and a high-speed sterilizer (cutting-edge at the time).

  It was “the Queen Ship,” a shining example of the next generation of psychiatric hospitals. Back when Haverford State was being built, a project designed to address the overcrowding in nearby Norristown State Hospital, the construction was delayed five years as neighbors protested the placement of a mental hospital (no matter how groundbreaking) so close to their expensive properties. In response, Superintendent Jack Kremens went door-to-door, introducing himself to convince the community that the hospital would not be a danger or an eyesore, but a welcome addition to the community. He not only got approval but even managed to sign up a few neighbors as volunteers. After it was built, Kremens proudly called it his own “showpiece of radical design,” the first of its kind in the world, he told reporters.

  Kremens was being hyperbolic, however. It was really the second of its kind. Five of Haverford Hospital’s buildings, which catered to long-term hospitalizations, were modeled off the revolutionary work of British psychiatrist Humphry Osmond.

  Osmond, a “guru of the 1960s psychedelic movement” who is credited with bringing LSD to the mainstream of scientific research, was among the first to study similarities between the effects of psychedelics and psychosis. During Osmond’s psychiatric residency, he chanced upon a paper written by chemist Albert Hofmann, who had described the effects of the new chemical compound lysergic acid diethylamide (LSD) in 1943 after ingesting trace amounts of it, resulting in a whopper of a bike ride. Osmond recognized Hofmann’s symptoms—depersonalization, hallucinations, and paranoia—in the presentations of schizophrenia he’d seen in his residency. He speculated that maybe LSD affected the brain similarly to the way schizophrenia did—a new theory of the neurobiological cause of mental illness during a time when psychoanalysis still dominated the field. Armed with this brain chemical theory, Osmond conducted a series of experiments dosing psychiatric patients (and—why not?—himself) with LSD and mescaline. He also administered the drugs to alcoholics, other addicts, and treatment-resistant psychopaths with successful results.

  Osmond’s acid trips also piqued his interest in the environment’s influence on the experience of madness, leading to the realization that the way buildings are structured can aggravate or temper positive and negative hallucinations. He argued that most hospitals should be torn down. “They’re ugly monuments to medical error and public indifference,” he told Maclean’s magazine in 1957. In his redesign, he made the wards circular to promote greater social interaction, while also adding access to solitary spaces that would allow patients the dignity of privacy.

  Osmond gave LSD—which he said allowed one to “enter the illness and see with a madman’s eyes, hear with his ears, and feel with his skin”—to architect Kiyoshi Izumi, with whom he was working on a design for a Canadian psychiatric hospital. To see with a madman’s eyes was a precondition, Osmond felt, to work with or build for him, because, as he wrote in his famous 1957 paper “Function as the Basis of Psychiatric Ward Design”: “It would be heartless to house legless men in a building which would only be entered by ladders or very steep gradients,” in the same way that it would be heartless to erect a depressing or ominous structure for people who had perceptual or emotional issues.

  While under the influence of LSD, architect Izumi traveled to traditionally designed hospitals and found serious flaws for anyone dealing with issues of perception. The patterned tiles that covered the walls confused the eyes. The lack of calendars and clocks created a foreboding timelessness. The recessed closets were so dark that they seemed to gape like open mouths. The raised hospital beds were too high for patients to comfortably sit and touch the floor with their feet—something that seemed to be comforting during psychosis. The long corridors were intimidating.

  Osmond agreed, calling the old hospitals “illusion-producing machines par excellence, and very expensive ones at that. If your perception is a little unstable, you may see your old father peering at you from the walls.” Osmond and Izumi built their ideal mental hospital in Canada, a design that Kremens’s Haverford copied. Though Haverford didn’t use Osmond’s cheese wedge design (creating a double-Y-shaped structure with private rooms, shared sitting rooms, and shared bathrooms instead), the hospital incorporated many of Osmond’s theories. Pleasant, uplifting colors replaced patterned tile. The beds were lowered closer to the floor. The furniture was supposed to look like it had come from the patients’ own homes. Patients now came first—at least in terms of their immediate surroundings. That is, if you were lucky enough to live in one of Osmond’s buildings.

  Rosenhan wasn’t.

  When Rosenhan walked into the admitting room, he noticed that the furniture seemed “used here but not loved.” State-issued. Drab. “Not a picture nor an object nor a poster softened its state-owned décor. Clearly purchased at the lowest bid for the minimum specifications… it was owned by an anonymous State,” he wrote. This was a part of the hospital apparently untouched by Osmond’s theories. Rosenhan introduced himself to the receptionist in an almost giddy state, high from the alien sensation of using a name that wasn’t his own. When she asked for his driver’s license he nearly gave himself away but quickly recovered, sayi
ng he’d left it at home. The receptionist moved on to the next question on the form without comment.

  Case Number: #5213

  Patient name: “Lurie, David”

  Address: 42 State Road, Media, PA

  Next of kin—name, relationship: Mrs. Mollie Lurie (wife)

  Age on admission: 39

  Birthdate: 11/2/29

  Race: W

  Sex: M

  Religion: Jewish

  Marital Status: Married

  Occupation: Advertising writer

  Employer: Unemployed

  Previous hospitalizations: None

  And then they waited.

  And waited.

  This stoked Rosenhan’s irritation. He thought about how Mollie would not get home in time to relieve the babysitter and there was no pay phone in sight to call. What if I had really been a patient? he thought.

  Then, at a quarter to four, nearly two hours after his appointment, the admitting psychiatrist, Dr. Bartlett, called Rosenhan into his office.

  9

  COMMITTED

  Case #5213 sat on Dr. Bartlett’s desk as a reminder that he had left a patient waiting for nearly two hours. That was not unusual. Dr. Bartlett had lost the battle over time management at the hospital years ago.

  Dr. Bartlett, hardly ever without a cigarette, read the form: This was David Lurie’s first hospitalization.

  Lurie walked in. Dr. Bartlett took a beat to assess him physically. He would later describe him as a short and balding man with an academic air, an intellectual type, like a cartoon version of a poet or a struggling professor, with his glasses, beard, beaten-up penny loafers, and weathered khakis.

  Dr. Bartlett opened with some basic questions: Name? Age? Date? Location? Bartlett noted that the patient responded slowly. He was clearly uncomfortable, nervous even, but he was oriented.

  “I’ve been hearing voices,” Lurie said. Bartlett observed that Lurie grimaced and twitched. The aural hallucinations, Lurie said, started four months ago: “It’s empty.” “Nothing inside.” “It’s hollow, it makes an empty noise.”

  The interview continued for half an hour. Lurie spoke of an inability to choose a path in college, even though he was a successful student. “He has tended to get lost in unproductive creative fantasies and possibly used his intellect to rationalize his failures and lack of progress, professionally and socially,” Dr. Bartlett wrote. Lurie also talked about job problems. He shared his shame about borrowing money from his wife’s mother, which he said was “embarrassing.”

  Two pages of richly detailed typewritten notes ended with this conclusion: “This man who is unusually intelligent has had a long history of not directing himself very well, or of fulfilling his potential… He is very frightened and depressed.”

  Dr. Bartlett’s diagnosis: schizophrenia, schizoaffective type, defined as a “category for patients showing a mixture of schizophrenic symptoms and pronounced elation or depression.”

  Dr. Bartlett did not need to commit Rosenhan. There were excellent outpatient buildings on the grounds that he could have recommended. But Dr. Bartlett saw “David Lurie,” a very sick man who needed serious help, and wanted Mollie to commit her husband to the facility, effectively handing over many of his civil rights and allowing the hospital to hold him for as long as thirty days. If Rosenhan wanted to leave, he would have to petition the hospital.

  Mollie balked. She told the doctor that she needed to see her husband alone before signing anything.

  The two huddled in a back corner of the waiting room, whispering. Should they call Jack Kremens? What exactly did voluntary commitment mean? Would David have to miss some classes if the hospital refused to release him before his leave was up? How about the kids, who knew nothing about any of this—only that their father was going to take a short trip? How would they react to his unexplained absence? According to Rosenhan’s diary, Mollie phoned an unnamed psychologist friend to get her opinion. The psychologist exploded: “You both are crazy. Him for doing it, and you for letting him.”

  Mollie charged back into Bartlett’s office. There must be another way, she pressed. But Bartlett insisted: The hospital allowed only commitments, not voluntary admissions. Lurie must be committed. It was standard procedure. There was no other way of getting into the hospital. Dr. Bartlett argued that it was “really for the patient’s own good” and that this was “merely a technicality, nothing to get upset about. That’s the way we do things here, and it doesn’t really matter.”

  “Like hell it didn’t matter!” Rosenhan fumed. He was particularly upset that Superintendent Kremens had not forewarned them about this procedure. Perhaps, if you’re not the one going through them, matters like these might seem merely bureaucratic. But when your own rights—your ability to leave, to refuse medications, to eat and sleep when you want—are on the line, it’s a different story.

  Rosenhan described a visibly shaken Mollie managing to keep it together long enough to sign. She stopped short at one document that gave the hospital permission to administer electric shock therapy, but permission was mandatory for him to be committed. Dr. Bartlett assured Mollie that “we do not administer any type of insulin or electric shock without consulting the family first.” But this did little to ease the threat. She decided she would not sign this document. Rosenhan grabbed her hand. He needed her. She would be able to visit him every day. Rosenhan did not explain how he did it, but eventually, she signed.

  And so began Rosenhan’s odyssey into lunacy.

  10

  NINE DAYS INSIDE A MADHOUSE

  DAY ONE

  Nurses’ Note: 2/6: Thirty-nine year old. Adm to 3 South this PM. History done. First psych admission.

  First, the nurse confiscated Rosenhan’s belongings—a bag with extra clothes, a toothbrush, and his tape recorder. When she saw this last item, she confiscated it because it was “illegal” and would “disturb the other patients.” The nurse left him with his pen (luckily) and five dollars, which she explained was the most that a patient could have. She then told him to strip while keeping the door ajar. Even if this was a safety procedure, she showed no respect for his modesty, as if the moment the system deemed him mentally ill he was no longer entitled to basic human decencies. She took his temperature, his pulse, and his blood pressure—all normal—and measured his height and weight without a word. Even though she was doing all these tests on his body, she acted as if he weren’t there at all.

  The nurse led Rosenhan into an elevator and up two floors. The elevator opened onto a set of locked, heavy doors. She opened the door with one of her many keys—which clacked as she walked, a sounding bell to guard her against being mistaken for one of them—him. Rosenhan stared down the shadowy corridor. He had expected the stereotypical noise of Bedlam to greet him, but all he heard was the metallic banging of the nurse’s keys, those symbols of freedom. “Opening the locked door of this unit, you felt as if you were entering a dark foreboding cave where danger lurked,” one Haverford psychiatrist wrote in a memoir about his time working on men’s 3-South, Rosenhan’s new home. “I was often in fear of physical harm.”

  Rosenhan walked past the brightly illuminated, glassed-in nursing station—aka “the cage,” locked at all times—where the nurses could observe the dayroom without having to interact with the patients.

  He may have noticed the smell—a sickly sweet aroma of coffee, cigarette smoke, ammonia, and incontinence common to most hospital dayrooms. A patient ran up and enveloped him in an aggressive bear hug. Once the nurse helped extricate him from the embrace, she deposited Rosenhan at a table; his presence—fresh blood!—unsettled the ecosystem, sending the room into a frenzy.

  “Son of a bitch!”

  “Cocksucker!”

  “I only hit him with my open hand!”

  These are some of the snippets of dialogue Rosenhan managed to write down as he waited. Most patients were diagnosed, like Rosenhan, with schizophrenia. Some, catatonic, sat staring blankly like the men in the hallway;
others paced, muttering to themselves, shaking their fists, or crying out. One psychiatric resident, upon seeing the scene at 3-S, asked, “What the hell have I gotten myself into?”

  Rosenhan sat frozen for two hours, his hunger and urge to urinate growing as the feeling of vulnerability immobilized him, something he would later refer to as “the freeze.” He realized that he was entirely defenseless. His mind ran in circles: Where to wash up or to shower? What does one do here? How does one spend one’s time? Is there a phone? Can I call my wife and children? When will I see the doctor? When will I get my clothes back?

  “For all my sanity and experience, for all that I knew better than others what I was getting into, I was dazed into helplessness,” he later wrote.

  Someone—likely an attendant—handed Rosenhan a plate of cold, gelatinous stew, a cup of warm milk, and an orange. Rosenhan stared at it in disgust, not realizing that an orange was a rare delicacy inside these walls. Anything edible birthed outside the asylum was a prize.

  DAY TWO

  Nurses’ Note: 2/7/69 Patient offers no special cps [complaints] during the night. Apparently slept well.

  A blaring fire alarm sounded at 6:30 AM.

  “C’MON, YOU MOTHERFUCKERS, LET’S GO.”

  These words greeted Rosenhan his first morning.

  He’d had a terrible night’s sleep. The sounds of the ward kept Rosenhan in a constant state of fight or flight. Sleep finally came late in the morning, but lasted only until he was jostled awake by a vivid dream of being unmasked. Now in the light of day he had the chance to examine his surroundings. He noticed the spokes of the steel beds, the undressed windows, the bare beige walls with metal night tables standing on beige tile floors, the strange bodies in their identical beds.