It bothered me that Rosenhan had told Maryon he had procured writs of habeas corpus when he hadn’t. I didn’t like how blithely Rosenhan had sent Bill in and how little he had prepped him, which resulted in Bill ingesting a large dose of Thorazine. Had Rosenhan learned nothing from the six other pseudopatients he had trained before Bill? Similarly bothersome, Rosenhan didn’t fully vet Agnews, which was in a state of disarray as it prepared to close its doors—a dangerous and unfair time to send someone inside for the experiment. The uniquely chaotic transition occurring then at Agnews should have disqualified it because the results would hardly be generalizable.
Rosenhan had taken great efforts to ensure his own safety when he went undercover, alerting the superintendent and even requesting a tour of the hospital prior to his stay. But for his student, there is no indication that these precautions were taken. Wasn’t it his duty as a researcher, as a teacher, and most of all as a human, to make sure that Bill was properly equipped for a traumatic and possibly dangerous experience? It didn’t sound like the Rosenhan I had come to know through his writing and my research. This didn’t just make me question Rosenhan’s character, it also undermined the study. It was key that Rosenhan had limited the amount of variability in the presentation of their symptoms (voices that said “thud, empty, hollow”) to make the data mean something. Not preparing his pseudopatients adequately harmed the study’s validity.
Still—there was no guarantee that Bill remembered everything accurately, which could account for some of the inconsistencies—so I revisited the CRITICISM folder, located in Rosenhan’s private files, hoping that some insight would jump out at me from the chorus of hostile voices:
“Seriously flawed by methodological inadequacies.”—Paul R. Fleischmann, Department of Psychiatry, Yale University
“It appears that the pseudopatient gathered pseudo data for a pseudo research study…”—Otto F. Thaler, Department of Psychiatry, School of Medicine, University of Rochester
“If I were to drink a quart of blood and, concealing what I had done, come to the emergency room of any hospital vomiting blood, the behavior of the staff would be quite predictable. If they labeled and treated me as having a bleeding ulcer, I doubt that I could argue convincingly that medical science does not know how to diagnose the condition.”—Seymour Kety, McLean psychiatrist, who studied the genetics of schizophrenia
“To point out that Rosenhan’s conclusion is unwarranted on the basis of his, ah, data is perhaps belaboring the obvious… Why did Science publish this?”—J. Vance Israel, Medical College of Georgia
Why did Science publish this? I had pondered this same question earlier in my research, and had asked Science if they could provide any information about the review process prior to the study’s publication. Rosenhan couldn’t have just mailed in a copy of his article and twiddled his thumbs as the prestigious journal made his career. He would have had to take part in a peer review process; someone on the editorial board would have inquired about his data, about the pseudopatients, about the hospitals. That’s how it works—certainly how it’s supposed to work.
Unfortunately, Science wasn’t going to give up these answers. A representative said that she would not divulge any details about the process because it was confidential; the journal protected its reviewers. I recruited the help of sociologist Andrew Scull to reach out on my behalf as an academic, but they declined his request for a different reason: They said that they don’t keep records that far back. In a letter to a colleague who wanted to publish his own follow-up pseudopatient research, Rosenhan said that he picked Science “mainly because they have a very quick review system. It usually takes no more than two months to hear from them, and four or five months for the article to be in print.” Psychologist Ben Harris has another theory why Rosenhan submitted his study to Science. He thinks that because it is a generalist journal (meaning that it has a wide range of interests beyond just psychiatry, unlike a more specialized journal like Molecular Psychiatry), he may have found a back door into academic fame. “Submitting to Science [may have been] a trick that [could have] bypassed review by top people in the field of clinical psychology,” Harris said.
Because of the stature of the journal in which it was published, none of the intense critiques from inside the field seemed to land—not really. Psychiatrists were like hungry panthers pouncing on a prey that had strayed too far from its pack, a prey (a psychologist, which was even worse) that had preened and boasted and received more attention than most of them ever would. The lay public, who were already primed to be suspicious of the field thanks in part to the mounting anti-psychiatry movement, were hardly inclined to be sympathetic to disgruntled psychiatrists with their reputations on the line. The more the psychiatrists had gnashed their teeth, the stronger the study’s power had grown.
Still, one criticism seemed to unmoor Rosenhan. I know this because he kept five copies of this critique in his files, despite, I remind you, keeping none of the pseudopatient notes. The article “On Pseudoscience in Science” was written by Robert Spitzer, the man who helped remove the term homosexuality from the DSM-II. The piece is delicious in its biting bitchiness. It’s the drollest piece of academic literature I’ve ever read. It’s mean. It’s funny. And man does it pack a hell of a wallop.
“Some foods taste delicious but leave a bad aftertaste,” Spitzer began. “So it is with Rosenhan’s study, which by virtue of the prestige and wide distribution of Science, the journal in which it appeared, provoked a furor in the scientific community.” He called the paper “pseudoscience presented as science” and wrote that its conclusion “leads to a diagnosis of ‘logic in remission.’” Spitzer then tore into every aspect of the Rosenhan paper—“one hardly knows where to begin”—from his research methods, which he called “unscientific,” to his use of the terms “sanity and insanity,” which are legal concepts,1 not psychiatric diagnoses. (Rosenhan defended his use of the terms in a letter to Vermont psychiatrist Alexander Nies in 1973: “Sane comes closest to what we mean when we say ‘normal’ (just imagine the fuss over that word).”
Spitzer argued that the designation “in remission,” a term rarely used but applied to all eight of the pseudopatients (though, it seems, not to Bill), actually showed that the doctors were aware that these pseudopatients were different from the rest. He called Rosenhan out for failing to disclose his data and his sources. Spitzer implied that Rosenhan was willfully withholding information from readers. “Until now, I have assumed that the pseudopatients presented only one symptom of psychiatric disorder. Actually we know very little about how the pseudopatients presented themselves. What did the pseudopatients say in the study reported in Science, when asked, as they must have been, what effect the hallucinations were having on their lives and why they were seeking admission to the hospital?” Spitzer asked.
Rosenhan took particular umbrage at Spitzer’s assertion that Rosenhan refused to share his and his pseudopatients’ medical records. I know this thanks to another folder titled SPITZER, ROBERT, which held a series of heated private letters between the two men.
Rosenhan and Spitzer began corresponding a year after “On Being Sane in Insane Places” was published, when Spitzer, while in the middle of writing his critique, was helping to arrange a symposium on Rosenhan’s study sponsored by the Journal of Abnormal Psychology.
The first letter opened “Dear Dave,” which struck me as odd because Rosenhan didn’t often go by Dave. It was a false familiarity that feels more like an elbow to the rib than a handshake. Spitzer began by cordially asking Rosenhan for a list of references that cited Rosenhan’s study. A close reading of Rosenhan’s response, however, reveals an undercurrent of rage. I imagine Rosenhan sitting among piles of papers on his desk, his forefinger at his temple, reading this missive, his face growing redder and redder; while I imagine Spitzer gleefully typing up his pages, smiling to himself as he thought of a zinger, maybe even editing his words to sharpen the shiv so that it pierced right into the hea
rt of the paper’s shortcomings.
Spitzer himself had been long obsessed with hard data and classification. There were stories that as a boy attending sleepaway camp, he designed a rating scale to track the hotness of his fellow female campers. By his teens, he had developed an active interest in psychoanalysis, specifically Reichian psychology and its orgone box therapy,2 a sham treatment fad popular in the 1940s and 1950s that claimed to use universe energy to ease psychic illness (and also espoused a belief in extraterrestrials). Spitzer subjected the orgone box to a series of experiments and found that the box was just that, a box, and had no effect whatsoever on the person inside it. This study was completed before Spitzer could legally drink alcohol.
A quieter motivation came from a strain of deep unhappiness that shadowed his family. Spitzer’s grandfather had pitched his own wheelchair out of a window after being struck by a neurological illness. His mother struggled with depression, the illness culminating after his older sister passed away from encephalitis when Spitzer was just four years old. Despite appearances to the contrary, Spitzer, a passionate, forceful, and animated man, inherited the family darkness. He struggled with depression and feelings of worthlessness and would spend his career comfortable with the solidity of numbers and hard facts.
Spitzer was, above all else, “a truth seeker,” his wife, Janet Williams, told me, and Rosenhan’s study piqued his intellectual interest.
In their correspondences, the two men traded passive aggressive attacks, shaded with affability—each ended his missive with “Yours Sincerely” (Rosenhan) or “Sincerely yours” (Spitzer)—back and forth. Spitzer repeatedly asked for access to the other pseudopatient materials and Rosenhan sidestepped him, explaining that the files contain sensitive information. When Spitzer wouldn’t remove a statement that Rosenhan “refuses to identify” the hospitals, Rosenhan got defensive: “[This] implies that I have something to conceal. You know that is not the case. Because my study has been misinterpreted to suggest that psychiatrists and hospitals generally, are incompetent, I am obliged to protect these sources,” wrote Rosenhan. (After publication, Rosenhan began to pull back on some of his harsh criticism by soft-pedaling some of his paper’s conclusions. “Let me make clear,” he wrote in a response letter to his critics published in Science, “that the theory that underlies this effort, and the report itself, do not support the vilification of psychiatric care.”)
And then Rosenhan launched his own attack: “In the same vein, I offer some observations about your own paper. Both the title and the abstract contain the phrase ‘pseudoscience in science’. That phrase is needlessly pejorative. What is pseudoscience other than findings that one disagrees with? Does science, in your view, have a particular method, or guarantee particular findings? Especially as you agree with a number of the findings, there must be other ways of indicating that you disagree with some methods and interpretations without treading such thin ice. ‘Logic in remission’, also in the title and the abstract, is a personal remark. Your argument can be strengthened considerably by dealing with the paper—its logic, in your view, is faulty—rather than its author.”
Spitzer returned with some critiques of his own and thumbed his nose at Rosenhan’s statistical interpretation of data. “Perhaps all that we can hope for is that our letters to each other get progressively shorter,” Spitzer quipped.
From here on, Rosenhan’s writing is the angriest I’ve ever seen; he’s practically spitting. He recruited Loren Mosher (founder of Soteria House) for his advice and even asked Haverford Hospital superintendent Jack Kremens to reach out to Spitzer on his behalf to convince him not to publish his critique. His argument was that the hospital would suffer a needless stain on its reputation. And he added: “You now have it from myself and the superintendent of the hospital (who arranged my hospitalization) that my stay there was part of a teaching exercise and had nothing directly to do with research.”
Wait, wait, wait.
Haverford Hospital had nothing to do with his research? A mere teaching exercise? Sure, it may have started that way, but Rosenhan couldn’t reasonably argue that he did not include his Haverford stay in “On Being Sane in Insane Places.” Most, if not all, of the in-depth scenes in the study are about Rosenhan’s hospitalization. When a patient comes up to a pseudopatient and says, “You’re not crazy. You’re a journalist or a professor. You’re checking up on the hospital,” it is taken verbatim from Rosenhan’s notes on the ward. Rosenhan was the one who watched as a nurse adjusted her bra in front of patients. He even quoted directly from the medical record written by Dr. Bartlett, the doctor who committed him. How could he possibly say that Haverford was just a test run?
That was an outright lie. And Rosenhan knew it.
Rosenhan knew it, and Spitzer knew it, too. The truth seeker had managed to gain access to Rosenhan’s medical records, the same pages I myself had tracked down. The pages I now held in my hands.
19
“ALL OTHER QUESTIONS FOLLOW FROM THAT”
In therapy, the aha moment is the stage of realization when sudden clarity hits and feelings that you have suppressed come to the fore and begin clicking into place. Robert Spitzer offered this to me from a distance of four decades.
I dug into the medical records. On cursory reading, the records support Rosenhan’s paper: There was his pseudonym David Lurie; there were the accurate numbers of days he spent hospitalized (though I had noticed that sometimes he exaggerated this figure depending on the audience); and there were his diagnoses, “schizophrenia, schizoaffective type,” and later, “paranoid schizophrenia, in remission.” It conformed to his published paper. It checked out.
Except it didn’t, as Spitzer had found.
One of the foundational principles of “On Being Sane in Insane Places” was that all of the pseudopatients presented with one symptom, voices that said “thud, empty, hollow.” The only other amendments were meant to add a layer of protection for the participants, changing names, jobs, addresses, but “no further alterations of person, history, or circumstances were made,” Rosenhan wrote.
But this is immediately contradicted by the text of the intake interview, written by Dr. Bartlett, the man who first diagnosed Rosenhan and insisted that Mollie commit him. If Dr. Bartlett’s notes are to be believed, Rosenhan’s alleged symptoms went far beyond “thud, empty, hollow.”
This is what Dr. Bartlett recorded:
The first part checks out—again we see the key words thud, hollow, empty. But then Rosenhan goes off script. Bartlett wrote that Lurie was so disturbed by the voices that he had to put copper over his ears—an almost clichéd example of the “tinfoil hat delusion” commonly reported by people suffering from serious mental illness.
“He has felt that he is ‘sensitive to radio signals and hear[s] what people are thinking.’”
Hallucinations and disturbances in thought patterns, especially the belief in the ability to hear or control other people’s thoughts, is considered a key symptom of schizophrenia, one of Kurt Schneider’s “first rank symptoms for schizophrenia.” In Massachusetts General Hospital’s Handbook of General Hospital Psychiatry, “thought broadcasting,” or the belief that others can hear your thoughts or the thoughts of others, is a classic symptom for a quick and easy identification of psychosis in an emergency room setting. It was the sort of symptom I had displayed myself during my encephalitis when I believed I could read the nurses’ thoughts about me, or that I could age people with my mind.
On deeper examination, the red flags continued to wave. There is a philosophy of the psychotic experience underlying Rosenhan’s paper that feels authentic. According to Clara Kean, who wrote about her experience with schizophrenia in two articles for Schizophrenia Bulletin, psychosis involves an “existential permeability,” a belief that there is a softening of the space between the self and others. She described the experience as the “dissolution of ego boundaries,” when “what is originated from the self and what is not are confused.” I recognize Cl
ara’s words in my own experience. When I was psychotic, I became more attuned to my surroundings (even if this attention was distorted, confused, misdirected) while also experiencing a loss of self that felt dangerous, more frightening than any other symptom I experienced. Whether intentionally or not, Rosenhan touched on something real, something that a good psychiatrist would identify as a fairly typical, though traumatic as hell, part of being psychotically ill.
Rosenhan’s timeline as reported to the doctor is also much longer than recorded in his paper. Bartlett wrote that Rosenhan started hearing voices more than three months before his admission, and that the hallucinations, in the form of amorphous sounds, started at least six months prior to that. According to another psychiatrist, Rosenhan “dated his illness to ten years ago [emphasis mine] when he gave up his job in economics.”
All of these factors created a “much clearer picture of schizophrenia, even by today’s standards,” according to Dr. Michael Meade, the chairman of psychiatry at Santa Clara Valley Health and Hospital System. (Dr. Meade added that it was unlikely David Lurie would have received a schizophrenia diagnosis today, however—the age of onset was too unusual, for example; he would likely have received the no-man’s-land diagnosis of “psychotic disorder, not otherwise specified.”) Still, the symptoms did conspire to create a realistic portrait of a man suffering from some kind of illness—not merely an “existential psychosis,” as Rosenhan said he intended.
The Great Pretender Page 18
