He also openly flirted with the young nurse who had coaxed him out of his shell in those early days. “It’s hard to concentrate on therapy when you’re wearing a skirt like that,” he said of her mini-skirt.
She laughed it off, as if they were in a bar, not a psych hospital. Sometimes she would invite him into the nurses’ office to relax. John, the military vet who had expressed anger about the war protesters, didn’t like the preferential treatment Harry seemed to receive and, one night when he’d had a bit too much to drink on a day-leave from the hospital, said as much. Deep into his cups, John belligerently motioned to Harry inside the station.
“Get out!” John ordered.
“I’m not going to do that,” Harry responded, surprised by the power of his new voice. John did not scare him. He was sad, sick, and jealous. (When he later recounted the story, Rosenhan was horrified. “Didn’t your dad ever teach you, never confront a drunk?” But Harry had read the situation correctly. John was grumpy but not violent.) As John walked away, Harry relished his newfound confidence. He was changing here—in a positive way.
Two weeks or so in, Harry decided he needed a break. Though he had adapted, he was drained of mental and physical energy. Even in the middle of the night, he was still pretending to be a sleeping patient, and it messed with his head. He decided to push for an early release. As he expected, most of the patients supported his overnight pass. (On this ward, patients helped decide who should receive day and night passes, which contributed to the communal, supportive environment.) The one exception? John, the veteran, who said, “He’s got more problems than a lot of the rest of us.” The nurses agreed and, to Harry’s horror, rejected his pass request.
“I could not convince them that I could handle it. And that was the most surreal experience. Here I am, I’m in a psychiatric institution and I can’t convince them that it’s safe to let me go.”
He could have walked off the ward anytime and disappeared forever—it was not locked and he was using a fake name—but he felt that he needed to prove to these people that he could handle the real world. He pushed for an easier-to-obtain day pass, which was awarded with ease. Once out, he didn’t do anything particularly special, just visited the Stanford campus. He didn’t remember if he met with Rosenhan; all he could recall was the feeling of being an alien landing on a parallel version of his home planet. Everything familiar, yet slightly cockeyed.
When he returned to the ward, the staff felt he functioned well enough to be granted an overnight pass and so he took it, spending the night in his own bed (the simple pleasures) next to his wife. Again, he could have left then, never to return, but he felt that he had to see it through to the end. “I would have felt somehow kind of like I was deserting the place in a way,” he said.
Everyone seemed to think Harry had adjusted to his off-ward visits well. He was now approaching the hospital’s average length of stay—three weeks—and it was time for him to return to life on the outside. This time Harry wasn’t the one initiating his release; it was the staff, who approved his release two days after his overnight. During his discharge interview, his diagnosis of schizophrenia was never discussed (as far as Harry could remember); instead, the hospital staff inquired about his living arrangements, his return to school or work, and asked him to draw up a list of people who might be able to help him if an emergency arose again. He reassured them that his environment would be supportive. No drugs were discussed, though they did suggest follow-up therapy. The hospital seemed dedicated not only to discharging Harry, but also to ensuring that he remained well.
Harry was emotional when he said his good-byes. “These were vulnerable folks who in general were caring human beings that were showing their feelings much more than what I was used to academically. And it led me to a closeness that I didn’t feel as much on the outside, so I think that was part of it, just the emotion. And again, for somebody who was insecure, not sure I belonged to such an elite place as Stanford, to be in this psychiatric institution and to realize that simply keeping it together was significant. And that was pretty major for me at that time in my life.”
The last thing Harry wrote in his journal, according to Rosenhan’s notes, was: “I will miss it. I will miss it.”
23
“IT’S ALL IN YOUR MIND”
Harry and I met face-to-face in a chain hotel in Minneapolis, where I was invited to speak about autoimmune encephalitis to mental health advocates. In person, Harry is more frenetic than the measured cadence of his voice over the phone conveys. He moves his body as he speaks and fidgets in his seat, a ball of energy just waiting for the next marathon (he’s an avid runner) to exorcise it.
We spoke about the aftermath of the study and his shifting relationship with Rosenhan. At first Rosenhan was enthusiastic about Harry’s hospitalization—or that’s how Harry saw it. “He gave me the impression that this was something he really wanted me to be heavily involved with, and work with him, and that kind of stuff.” But over time Rosenhan withdrew, growing colder and more detached. They stopped discussing the study. Rosenhan distanced himself from his role as Harry’s thesis adviser. And then there was only silence.
“I’m waiting. I’m waiting. He’s not around. I’m waiting, and nothing ever happened,” Harry said.
Harry put the study behind him to focus on his thesis on smoking cessation, wrote his dissertation, had it reviewed, and finished it by August 1972. All the while Rosenhan maintained an uncomfortable distance. By the time “On Being Sane in Insane Places” came out in 1973, Harry had taken a professorship at Iowa State and hadn’t spoken to Rosenhan in over a year. He didn’t discover that he had been excluded from the study until he read about it in Science. “I felt like I kind of had the rug pulled out from under me,” he said.
So Harry decided to write his version—it took all of four hours, the draft coming together in a fever. Not a word was edited. In 1976, Harry revealed his identity as the ninth pseudopatient—the only person involved with the study other than Rosenhan to do so in print. Harry wrote that he had no de-individualization and experienced a deep connection with the staff. His hospital facilities, he revealed, were “excellent,” with the nearly 1:1 staff-to-patient ratio creating a “benign atmosphere” and a “genuine and caring” environment.
Though Harry felt vindicated because it helped to “set the record straight,” his article didn’t make the splash he had hoped, partially because the journal in which it was published wasn’t as prestigious as Science and partially because in the previous two years Rosenhan’s study had been embraced so wholeheartedly that it had become gospel. Rosenhan ignored Harry’s article (there are no records of his acknowledging it, even privately, and Harry said Rosenhan never contacted him about it).
I handed Harry the notes that Rosenhan had taken on “Walter Abrams” and braced myself for his response. As Harry read aloud, his brows furrowed: “So… let’s see… ‘He was admitted and diagnosed with paranoid schizophrenia.’ Wrong. It was chronic, undifferentiated schizophrenia. ‘He was discharged twenty-six days later.’ Wrong. It was nineteen days.”
The mild-mannered man had lost his cool.
“Interesting,” Harry said, forefinger on his chin as he read. “Okay. What’s fascinating to me is that these are some basic factual inaccuracies that, I mean, don’t advance anything. There’s no reason for it.” Harry was released with medical advice, not against. Harry didn’t leave “in remission.” Harry was not turned away for “three days” and his ward was not “full,” as Rosenhan had written. Yet again, Rosenhan was not only editorializing but filling in gaps with outright fabrications.
I also showed Harry some discrepancies with the numbers. In the files, I had found an early draft of “On Being Sane in Insane Places” sent to marshmallow test creator Walter Mischel for review. In this version, Rosenhan had included nine pseudopatients with no footnote, strongly suggesting that he had written this paper before he decided to remove Harry’s data. Not only did the tenor and
tone of the paper not change with Harry and without him, but, more strikingly, the numbers didn’t, either. That means when Rosenhan took Harry’s data out of a sample size of nine, not one number was affected—not the average length of stay, not the number of pills dispensed, not the amount of time nurses spent in and out of their cage. I’m no math whiz, but I know that if you remove one out of a relatively small sample size of nine, the aggregated data would have to change, at least a little.1 And the numbers Rosenhan used were so specific: In his paper, he wrote that average daily contact with psychiatrists ranged from 3.9 to 25.1 minutes, for example. This upset Harry—and me.
Just as egregiously, I found notes describing Harry’s hospitalization that were repeated almost verbatim in the published paper: “Another pseudopatient attempted a romance with a nurse… The same person began to engage in psychotherapy with other patients—all this as a way of becoming a person in an impersonal environment.” Both of these details came from Rosenhan’s notes on “Walter Abrams,” his pseudonym for Harry. How could he include this and also claim that he’d removed Harry as a pseudopatient from the study?
If the editors of Science had been aware of these transgressions, I doubt that they would have published Rosenhan’s paper. Data, even in a softer, journalistic piece, should at the minimum be sound. I have no doubt in my mind now. Rosenhan’s weren’t.
Still, Harry believed that the study changed his life for the better. He contemplated pursuing a degree in clinical work, but ultimately decided he could save the world by convincing it to quit smoking. He even changed his appearance.
“I grew a mustache,” he said and, as was his habit, moved on to another topic without explanation.
“What is the significance of the mustache?” I asked, guiding him back.
“I think being maybe just a little bit less conventional, because I thought of myself as being pretty conventional.” With a bit of facial hair, he had transformed himself into the rebel leader he never thought he could be.
“[The study] affected me, you know, deeply, just the whole experience affected me deeply,” he said. He told me about his work with the World Conference on Tobacco or Health’s planning committee and about his successful push to convince the group to move their conferences from places like Helsinki and Chicago to cities in developing countries, like Mumbai and Cape Town, where smoking rates are increasing, not decreasing, came from his work as a pseudopatient. “[I’m] quiet, introverted,” he told me. After his hospitalization, he realized that “if I really believe in something, I will fight for it.”
Harry felt it was pretty obvious what happened (and I agree): Harry’s data—the overall positive experience of his hospitalization—didn’t match Rosenhan’s thesis that institutions are uncaring, ineffective, and even harmful places, and so they were discarded.
“Rosenhan was interested in diagnosis, and that’s fine, but you’ve got to respect and accept the data, even if the data are not supportive of your preconceptions,” Harry said. “I do also feel pretty certain, and maybe I’m not being fair, that if I had the experience that the others had, I’m pretty confident that I would have been included… Clearly he had his idea, his hypothesis, and he was going to confirm that hypothesis.”
Rosenhan included a line at the end of the paper that seemed to subtly acknowledge Harry’s experience: “In a more benign environment… their behaviors and judgment might have been more benign and effective.” But it’s a line no one quotes or remembers. Instead, Rosenhan did what so many doctors do to their patients in the face of complexity—he discarded any evidence that didn’t support his conclusion. And we’re all worse off because of it.
The NPR program It’s All in Your Mind featured Rosenhan on its opening segment, which aired on December 14, 1972, shortly before the publication of his paper. In the wake of my conversations with Harry, knowing how much gray area Rosenhan had been confronted with, it’s infuriating to hear the blind confidence in Rosenhan’s voice on tape.
The forty-five-year-old recording opens with a distant trilling of bells. A tribal drumbeat builds into an angry roar. The bells grow louder, louder, louder until a man’s voice interrupts: “Psychology, exploring the human psyche. It’s all in your mind.”
It’s a total rip-off of the Twilight Zone theme song, which I guess is appropriate, since the radio show I’m about to listen to has a kind of upside-down quality. Hearing the voice of the man whose work you’ve spent years of your life struggling to understand, yet have barely ever heard speak—a man you once admired but now suspect may have engaged in serious foul play—does feel like being stuck in a room full of books without any reading glasses.
In the twenty-minute interview, Rosenhan walked the host through his experience as a pseudopatient, rehashing his hospitalization and adding a few details that I happened to know were exaggerated, like when he implied that his hospitalization lasted several weeks instead of nine days. “We were administered better than five thousand pills,” he said. (In the study, he claimed that two thousand pills were dispensed.)
Interviewer: Do you think that patients can get better going into institutions today as they are in this country?
Rosenhan: No. They were not in any way therapeutic institutions. When you’re treating people like lepers, when you can’t affiliate with them, when you can’t sit down and have a conversation with them, when your bathroom, if you will forgive me, is separate from theirs, and your eating facilities are separate from theirs, and your space is separate from theirs, in no way can you conceive that the half hour that you may spend with them once or twice a week is going to overcome all of that and make their lives better. By and large I think that psychiatric hospitals are non-therapeutic, and would look forward to their being closed.
In disregarding Harry’s data, Rosenhan missed an opportunity to create something three-dimensional, something a bit messier, but more honest—instead, he helped perpetuate a dangerous half-truth that lives on today. I would look forward to their being closed. Had he been more measured in his treatment of the hospitals, had he included Harry’s data, there’s a chance a different dialogue, less extreme in its certainty, would have emerged from his study, and maybe, just maybe, we’d be in a better place today.
24
SHADOW MENTAL HEALTH CARE SYSTEM
Decades after the study, Harry returned to a psychiatric hospital—this time as a parent, not as a patient. His daughter Elizabeth was sixteen when she had her first hospitalization for major depression, anorexia, and bulimia (which distracted from an underlying disease that would take another ten years to diagnose—a rare connective tissue disorder called Ehlers-Danlos syndrome). She said that during this hospitalization she felt more like a prisoner than a patient, as if she had done something criminally or morally wrong. “It still gives me that creepy, crawly feeling of being locked in,” she told me. There she was heavily medicated and “got so numb that I didn’t care anymore.” Unlike in the 1970s when her father was a patient, there were no sing-alongs, no ward votes on day passes, no meaningful emotional bonding moments between patients. Just take your meds, watch the TV, and stay quiet until you were “stabilized” enough to leave. Harry couldn’t believe what he saw when he visited his daughter. How had his experience decades before been so much more… sophisticated? Once she was released back into the care of her doctor, she tapered off the meds. She’s still not sure what happened. All she knew was that she needed help but she wasn’t sure that the hospital was the right place to provide it.
Meanwhile, Harry’s U.S. Public Health Service Hospital followed in the footsteps of Nellie Bly’s Blackwell Island—it too was abandoned for decades until it was recently developed into luxury apartments. The Zuckerberg San Francisco General Hospital (as it has since been renamed), where Harry almost ended up, still treats psychiatric patients, but you’d never find people sitting in circles singing “Puff the Magic Dragon” there. There are too few psych beds for too many bodies. Only extreme cases—like a woman who bit
off her own finger because the voices told her to—get quick care. “This is the sad part of this work. People so psychotic they can’t even get to the hospital without doing something terrible to themselves,” nurse manager Jean Horan told the San Francisco Gate in 2006. Conditions have gotten so dire that in 2016 dozens of nurses, doctors, and other health care workers protested, saying that the psychiatric unit was in a “state of emergency.” Former Bay Area ER psychiatrist Dr. Paul Linde described the revolving-door policy in 2018: “You’ve got your chow, you’ve got your shower, you’ve got your medication, you’ve got some sleep and now it’s time to get out the door.”
Patients are often taken by ambulance to emergency rooms, where they are boarded in general hospitals that lack psychiatric care. The hospitals then can’t discharge their patients to psychiatric facilities because more often than not, there are no beds available. It creates a logjammed system that fails everyone, as movement is stymied in almost every direction except to the streets or to jails and prisons, also known as “the beds that never say no,” said Mark Gale, criminal justice chair of the National Alliance on Mental Illness (NAMI). “These are the choices we are making as a society, because we refuse to fund the completion of our mental health system.”
The US is a minimum of ninety-five thousand beds short of need. It’s now harder to get a bed in New York City’s Bellevue Hospital than it is to land a spot at Harvard University, wrote advocate DJ Jaffe in his devastating 2018 book Insane Consequences. Sixty-five percent of the non-urban counties in the United States have no psychiatrists and nearly half lack psychologists, too. If the situation continues as it is, by 2025, we can expect a national shortage of over fifteen thousand desperately needed psychiatrists as medical students seek higher-paying specialties and 60 percent of our current psychiatrists gray out.
The Great Pretender Page 23
