The Great Pretender

by Susannah Cahalan

  In 2008 he appeared on a BBC reality show called How Mad Are You? where ten people—five “normal” and five who had been diagnosed with psychiatric conditions—lived in a house observed by a psychiatrist (Michael First), a psychologist, and a psychiatric nurse, and engaged in a variety of tasks, including performing stand-up comedy and cleaning out cow stalls. The panelists’ goal was to ferret out the mentally ill and correctly label them with only five days of observation. The panelists didn’t do such a hot job. They nailed the guy with obsessive-compulsive disorder after watching him struggle to clean up cow manure, but incorrectly diagnosed one volunteer with bipolar disorder (where no disorder existed) and one with a history of schizophrenia (there was no history). It’s worth recognizing how astonishingly deep Rosenhan’s thesis has cut: Despite all of psychiatry’s efforts to legitimize itself in the time since, the impossibility of distinguishing sanity from insanity had received the most mainstream of honors—its own reality show.

  First began. “Okay, I’m going to do it straight through as if we’re doing it for real because we are doing it for real.”

  He rattled off the first few questions and I answered them in quick succession: “How old are you?” “With whom do you live?” “How long have you been married?” “Where do you work?”

  I explained that I had been dating my husband for seven years, but that we had met when I was seventeen. I told him about our recent marriage. He asked about work so I summarized my history at the New York Post, where I had worked for even longer than I’d known my husband.

  “Have you ever had a period of time when you couldn’t work or go to school?”

  “Yes,” I said. “When I was sick.”

  “Tell me about the illness.”

  I walked him through the natural history of my illness, starting with the funk of depression, which morphed into mania, then to psychosis, and finally to catatonia before I was accurately diagnosed with autoimmune encephalitis. He asked questions along the way but kept me on the straightest road possible. He maintained an emotional distance—never a wow or that must have been hard or even a how did that make you feel?, all common reactions among others hearing this story. He moved right along, question after prewritten question.

  “Have you ever wished you were dead or would go to sleep and never wake up?” he asked.

  I thought of Rosenhan’s answer to this question posed during his intake interview at Haverford Hospital. I responded no.

  “Have you ever tried to kill yourself? Have you ever done anything to hurt yourself?”

  No, no.

  “Have you had any problems in the past month?”

  “Problems?” I asked.

  “Anything, like at work, home, other problems.”

  “Every day I have a problem.” I laughed. What kind of question was this?

  “Like everyday normal stuff?”

  “Yes.”

  “How has your mood been in the past month?”

  “Actually pretty good,” I said. “I’ve been meditating.”

  “Medicating?”

  “No, meditating.”

  Moving on.

  An odd dynamic was occurring—I said no to all the above, but despite myself I found that I wanted to please this doctor. I didn’t want to disappoint him with my normalcy.

  “In the past month, since the twentieth of March, was there a period of time when you felt depressed or down for most of the day nearly every day?” This was odd. I had just told him that my mood had been good thanks to that Headspace app. He was just reading off the page.

  “In the past month, since the twentieth of March, have you lost interest or pleasure in things you usually enjoyed?”

  It now felt like what I imagined a courtroom interrogation would be like—as if he was trying to catch me in a lie.

  He went on to ask the same questions but extended over the course of my life. During my illness, for example, I felt depressed but a yes wasn’t enough. He wanted to know exactly how long I felt blue, as if emotions have hard edges.

  “A week, that’s it?”

  “Oh, I don’t know. Maybe a month? It’s so hard for me to say.”

  “In the hospital were you depressed?”

  “I was so cognitively impaired. People said I was, but I don’t remember.”

  “How about the mania?” he continued. “How long did that last?”

  “Again, it was so mixed with depression it’s hard to say.” I’m trying desperately to make something concrete out of something that just isn’t. Emotions are not mathematical formulas, inserted as x + y = psychiatric diagnosis.

  “Just to recap. February 2009, three weeks most of the day every day you were depressed. Does that sound right?”

  “Sure.”

  He focused on the first two weeks of the depression and I played along, as if I, or frankly anyone else, could accurately respond to such prescribed questions about such an irrational, frightening time.

  “How long did the mania last total: a week and a half?”

  “It’s so hard to say…”

  “During that week-and-a-half period, how did you feel about yourself? More self-confident than usual?”

  “Sometimes. But one second I’d be the best and then the worst.”

  “But certainly for a significant amount of that time you did have that feeling.”

  “Sure.” It was astounding. Everything needed to be so concrete.

  More questions: “Sleep? Concentration? Spending more time thinking about sex? Pacing? Buying things you couldn’t afford?” And then my favorite one: “Did you make any risky or impulsive business decisions?” This after telling him that at the time I made thirty-eight thousand dollars a year. I laughed at this one. “Oh, all those risky business investments!”

  “Now I’m going to ask you about some unusual experiences,” he said, again reading. “During that time, did it seem like people were talking about you?”

  “Yes. Nurses were talking about me. I could read their mind.”

  “Did you have the feeling that some things on the radio or TV were especially for you?”

  “Yes,” I said. “I had a whole delusion about the television and my father.”

  “What about anyone going out of their way to give you a hard time or trying to hurt you?”

  The yeses kept coming: “Did you ever feel like you were especially important? Had special powers?”

  Of course: I vividly remembered my brief brush with godlike powers when I believed I could age people with my mind.

  “Were you ever convinced that something was wrong with your physical health even though doctors told you there wasn’t?”

  My obsession with bedbugs; my conviction that I was dying of melanoma.

  “Were you ever convinced that your boyfriend was being unfaithful?”

  The time I rummaged through his things in search of nonexistent clues to his imaginary affair.

  There were specific questions about people implanting thoughts in my head, about the porousness of human interactions, about unrequited love, that didn’t fit. At the end of our interview, Dr. First closed the book.

  “If I didn’t have the answer”—meaning autoimmune encephalitis—“I would have a different diagnosis. This would have been schizophreniform disorder.”

  Schizophreniform is when someone exhibits features of schizophrenia for less than six months, the minimum length of time required for a schizophrenia diagnosis. (Though this minimum time length was created under the Feighner criteria, which predates the creation of the DSM-III, I suspect it was included in the DSM at least in part thanks to Rosenhan’s study. If you needed to exhibit symptoms for six months, then the pseudopatients, who were supposed to only very recently have started to hear voices, would have at least been filtered through a less definitive diagnosis.)

  When I told him that the psychiatrists at the hospital offered two diagnoses, bipolar 1 and schizoaffective disorder, he reopened his book. “If you were depressed at the sam
e time you were psychotic… That would make sense… Actually, it wouldn’t have been schizoaffective because the amount of mood wasn’t as long as the psychosis. Was there a time when you were psychotic when your mood was normal?”

  I laughed here. “Can you be psychotic and your mood be normal? Is that even possible?”

  “Well, yes,” he said. “I think technically it really wouldn’t be schizoaffective. Technically it’s kind of mixed. It’s hard to say. That’s the problem. You really need to know with a reasonable amount of precision…”

  I couldn’t believe it. I had a more precise view of my illness than most—especially a psychiatric one—since I had spent a year writing and researching it and the past four years talking endlessly about it. I still couldn’t adequately answer his rigid questions.

  “At the time, the two diagnoses that would have been most reasonable were schizophreniform and schizoaffective disorder,” he said. “But it doesn’t matter because both of those diagnoses are wrong.” He closed the booklet. It was brave and honorable to be so candid about the limitations of his creation. He continued. “We see this all the time with people with psychotic symptoms that don’t respond to antipsychotics. Is it because they really have your condition? Or that some people with bona fide schizophrenia don’t respond? Or maybe what we’re calling schizophrenia is actually many different things.”

  He had dropped the formality of the interview, to my relief. “You can see how messed up this field is,” he said.

  A moment of awkwardness passed before I removed my wallet. “So how much do I owe you?”

  “Well, my typical price for this kind of thing is $550.”

  Five hundred and fifty bucks for him to give me a misdiagnosis. I couldn’t believe it. And I don’t think he could, either.

  “Do you take Amex?”

  PART FIVE

  The greatest obstacle to discovery is not ignorance—it is the illusion of knowledge.

  —Daniel Boorstin

  22

  THE FOOTNOTE

  The harder I fought to make sense of it, the more I realized that Rosenhan and his study were like quicksand: Whenever you felt that you were on solid ground, the support would fall away, leaving you deep in the dark muck and sinking fast.

  Thanks to Bill Underwood, I learned the first name of a fellow graduate student who also took part in the study: Harry. I scanned the 1973 Stanford psychology graduate student class and there he was, just a few spots above Bill: Harry Lando. I noticed immediately, however, that Harry’s name didn’t match the first name of any of six remaining unidentified pseudonyms—he wasn’t John or Bob or Carl—and his position as a graduate student didn’t match their bios, either. Was I wrong that the first names were kept the same? I searched “Harry Lando” on PubMed and found around a hundred studies on smoking cessation but nothing on Rosenhan. On WorldCat, I typed in “Lando” and found more smoking articles, but then I added “Rosenhan” and bingo—a hit for a study titled “On Being Sane in Insane Places: A Supplemental Report,” published in Professional Psychology in February 1976. The summary read:

  There he was. Another pseudopatient: He recommends stressing the positive aspects of existing institutions in future research. Out of the 1,066 results for Rosenhan on WorldCat, Harry Lando’s study was number 251 on page twenty-six. I had skimmed past it in my initial search, long before I’d begun looking for pseudopatients, and in all the digging since had not encountered even one source that had quoted it.

  I tracked down a hard copy of the study, which featured a black-and-white author photo of a young man with a thick head of hair, a big bushy mustache, and an angular face, and read the opening sentence: “I was the ninth pseudopatient in the Rosenhan study; and my data were not included in the original report.”

  Of course! The footnote! “Data from a ninth pseudopatient are not incorporated in the report because, although his sanity went undetected, he falsified aspects of his personal history, including his marital status and parental relationships. His experimental behaviors therefore were not identical to those of the other pseudopatients.” Harry Lando didn’t match any of the eight pseudopatients because he wasn’t one of them. He was the unknown ninth—the footnote who received little attention in rehashings of the study because it was used as pro forma acknowledgment that the data was so pristine, Rosenhan had thrown out a whole data set that didn’t uphold the study’s standards.

  However, knowing what I now knew, that logic sounded a bit sanctimonious—Rosenhan himself had done that exact thing, misleading doctors about his own symptoms and changing his medical records.

  Even more intriguing than the hypocrisy was the question: Why would Harry be advocating for the institutions instead of railing against them? He used words like “excellent facility” and “benign environment,” a drastic departure from the experiences of Rosenhan and Bill, the other two patients I’d found so far.

  I located Harry’s picture, his face a bit older and without the bushy mustache, on the School of Public Health’s website at the University of Minnesota, where he now works as a psychology professor with a focus on the epidemiology of smoking behaviors. I sent Harry an email. Three days later I found myself ear-to-ear with the second of Rosenhan’s mystery pseudopatients. By this point my level of enthusiasm, which, let’s be honest, is normally set somewhere around eight, was probably measuring on the Richter scale. If it’s possible to hear someone beam, that is how you would describe my rambling, rapid speech. We discussed Bill, whom Harry seemed delighted to know that I had already contacted; my own experience with autoimmune encephalitis, which he seemed interested in; and then we got down to business.

  Harry’s experience was, indeed, incongruous with Bill’s. He was also a very different guy. He’s the kind of person you might call an absentminded professor. One of his regrets as a kid, he said, was that he was not enough of a rebel, too much of a goody-goody.

  Harry’s career studying the mind was born from the most universal of urges: He had developed a crush on a junior professor who suggested that he take graduate-level courses while an undergraduate at George Washington University in Washington, DC. One of these high-level courses was taught by Dr. Thelma Hunt, the youngest person to be awarded a PhD at the university during a time when women didn’t often receive such honors at any age. Though her accomplishments were legion during her fifty-nine-year career (including establishing therapy programs and recruiting more women to the sciences), one of her most cited works was with Walter Freeman, Rosemary Kennedy’s doctor, the pioneer of the transorbital “ice-pick” lobotomy. They collaborated on Psychosurgery: Intelligence, Emotion and Social Behavior Following Prefrontal Lobotomy for Mental Disorders, which featured three hundred pages of case studies and photographs of post-lobotomy patients. Hunt supplied supplemental materials on cognitive and intelligence studies performed after the surgery, measuring a patient’s “self-regarding span,” or the amount of time a patient would talk about herself, pre-and post-operation. Patients before the surgery spoke about themselves for nine minutes, on average; post-op this dropped to four minutes for a standard lobotomy, two minutes for radical ones. I’m not sure what this tells us about what lobotomy does to the self—but it’s safe to say it’s not good.

  Harry didn’t remember much about Dr. Hunt’s class other than it was so dry that it put quite a few students to sleep (though it wasn’t boring enough to deter Harry from pursuing a higher degree in psychology). He applied to a PhD program at Stanford to study social learning theory with psychologist Al Bandura, well known for his “Bobo doll study” of aggressive behavior in preschool children. (Among the study’s findings was that when preschoolers at Stanford’s Bing Nursery School watched adults physically or verbally abuse a three-foot blow-up cartoon clown, they would mimic the assaults, an example of behavior modeling, showing that abusers are often made in early childhood. In some ways, it was in line with the question that many postwar social psychologists, like Milgram with his shock machine and
Zimbardo with his prison studies, were pursuing: Are you born bad or are you made that way?)

  Despite his research interests, Harry didn’t acclimate to Stanford the way Bill had. Harry, who was a few years into an unhappy marriage, found Stanford to be an unfriendly, stifling, overly competitive place. Like Bill and Maryon, he joined a few sit-ins protesting the Cambodian incursion and, later, a mass demonstration honoring the victims of the Kent State shooting, but mostly he felt lost. “I was, I would say, quite insecure. I wondered if I really belonged at Stanford,” he told me. “I wondered if they would discover my incompetence.” When I asked him if he maybe was depressed, he had to think it over. “I don’t think I would have met the criteria for clinical depression,” he said in his detached manner, “but certainly I was not a happy camper.”

  He even found the work unfulfilling. Bandura, though renowned for his Bobo doll experiments, was studying aversion therapy when Harry joined his research team. Harry soon learned that prepping participants for experiments that would likely torture them didn’t stoke his enthusiasm. He nearly quit when he had to clean up the mess made by one of the subjects, who, after inhaling dozens of cigarettes in a row for a study on smoking aversion, deposited the contents of his stomach into Al Bandura’s snake cage. Harry certainly hadn’t dreamed of a career cleaning up vomit; he wanted to tap into something greater than himself. In his free time, he read One Flew Over the Cuckoo’s Nest and I Never Promised You a Rose Garden, two books in heavy rotation on the campus at the time, along with the usual suspects like Goffman’s Asylums, Laing, Szasz, and Foucault.