The Great Pretender

by Susannah Cahalan

  It’s safe to say that Bill Underwood, Harry Lando, David Rosenhan, and presumably the rest of the pseudopatients would never be hospitalized today. If you did have access to decent psych care—not a given in wide swaths of this country—you’d face the following (welcome and necessary) obstacles: “One or more nurses would take vital signs, complete a brief exam and gather some of the patient’s history. At least one emergency physician would repeat the process… The emergency physicians might order a CT scan of the head or other imaging, depending on the patient’s history… A psychiatrist would review the patient’s chart and any available electronic records… From start to finish, these evaluations can take hours,” wrote Stanford psychiatrist Nathaniel Morris in the Washington Post.

  A less welcome reality is this: Most states require that for a person to be hospitalized, she would need to pose a threat or be so gravely disabled and, according to a psychologist, “so disorganized that she would just stand in front of the facility, wander aimlessly in the street, or perhaps stand in the middle of a busy street, with no notion of how to get food or lodging for herself.”

  One psychiatric nurse laid out what it takes to get care. Ironically, just as it had with Rosenhan and his pseudopatients, it requires acting to get admitted—but follows an entirely different script. In the emergency department, “when being assessed, say (regardless of the truth): ‘I am suicidal, I have a plan and I do not feel safe leaving here. My psychiatrist asked me to come here for admission for personal safety, feeling I am a grave danger to myself.’ That statement get[s] you back to the psychiatric [emergency department]. Once there, you get interviewed by the psychiatric triage nurse. Repeat the same statement.” Only once past these various gatekeepers, onto the psych floor, and in a bed can the patient start telling people what is truly wrong.

  In fact, the horror show that is our mental health care system today makes Rosenhan’s critiques seem obsolete. “It shows just how quaint the study is—and how misguided it is in a funny way… Psychiatry [was seen] as the arm of the state, when in fact [it is] just as much of a victim of the larger relationships of power,” said psychiatrist and historian Joel Braslow during an interview.

  “It’s on the other end of the spectrum today,” added Dr. Thomas Insel, former director of the NIMH. “You have people who really do need help who don’t get it because there’s no place for them to go.”

  A 2015 study published in Psychiatric Services unintentionally imitated Rosenhan’s study when a team of researchers posed as patients and called around to psychiatric clinics in Chicago, Houston, and Boston trying to obtain an appointment with a psychiatrist. Of the 360 psychiatrists contacted, they were able to obtain appointments with only 93—or 25 percent of the sample. (This says nothing of the wait time required for the appointment, nor of the care they would—or would not—receive.)

  Dr. Torrey, who founded the Virginia-based Treatment Advocacy Center dedicated to “eliminating barriers to the timely and effective treatment of severe mental illness,” said it directly: “People with schizophrenia in the United States were better off in the 1970s than they are now. And this is really something that all of us in the United States are responsible for.”

  When the promises of community care—first championed by JFK—never materialized, thousands of people were turned out from hospitals (where some had spent most of their lives) and had nowhere to go. When Rosenhan conducted his study, 5 percent of people in jails fit the criteria for serious mental illness—now this number is 20 percent, or even higher. Nearly 40 percent of prisoners have, at some point, been diagnosed with a mental health disorder and their most common diagnoses (some people have more than one disorder) are major depressive disorder (24 percent); bipolar disorder (18 percent); post-traumatic stress disorder (13 percent); and schizophrenia (9 percent). Women, the fastest growing segment of America’s inmate population, are more likely to report having a history of mental health issues.

  These figures also disproportionately affect people of color who “are more likely to suffer disparities in mental health treatment in general, which results in their being more likely to be ushered into the criminal justice system,” said Dr. Tiffany Townsend, senior director of the American Psychological Association’s Office of Ethnic Minority Affairs.

  There are, at last count in 2014, nearly ten times more seriously mentally ill people who live behind bars than in psychiatric hospitals. The largest concentrations of the seriously mentally ill reside in Los Angeles County, New York’s Rikers Island, and Chicago’s Cook County—jails that are in many ways now de facto asylums. As someone who knows what it’s like to lose her mind, the only worse place than a jail I can imagine is a coffin.

  “Many of the persons with serious mental illness that one sees today in our jails and prisons could have just as easily been hospitalized had psychiatric beds been available. This is especially true for those who have committed minor crimes,” said University of Southern California psychiatrist Richard Lamb, who has spent the bulk of his half-century career studying and writing about these issues.

  This is the current state of mental health care in America—the aftershock of deinstitutionalization, which some call transinstitutionalization, the movement of mentally ill people from psychiatric hospitals to jails or prisons, and others call the criminalization of mental illness. Whatever term you want to use, experts agree that what has resulted is a travesty.

  “A crisis unimaginable in the dark days of lobotomy and genetic experimentation” (Ron Powers in No One Cares About Crazy People); “one of the greatest social debacles of our times” (Edward Shorter, A History of Psychiatry); “a cruel embarrassment, a reform gone terribly wrong” (the New York Times).

  Though some credit the rise in the mentally ill population behind bars to the fact that America has the highest incarceration rate in the world and to policies like mandatory minimum sentencing and three-strike laws, it’s clear that whatever the cause, the fallout has been disastrous. “Behind the bars of prisons and jails in the United States exists a shadow mental health care system,” wrote University of Pennsylvania medical ethicist Dominic Sisti. People with serious mental illness are less likely to make bail, and they spend longer amounts of time in jail. At Rikers Island, which is in the process of shuttering, the average stay for a mentally ill prisoner was 215 days—five times the inmate average. Jails are now holding people the same way asylums did in Nellie Bly’s era. The ACLU filed a lawsuit against Pennsylvania’s Department of Human Services (DHS) on behalf of hundreds of people who had been declared incompetent by the court. Problem was, there were no beds available, so they were left in jails—in one case in Delaware County, Rosenhan’s old stomping grounds, a mentally ill person, too incompetent to stand trial, languished in jail for 1,017 days. The lawsuit’s lead plaintiff is “J.H.,” a homeless man who spent 340 days in the Philadelphia Detention Center awaiting an open bed at Norristown State Hospital for stealing three Peppermint Pattie candies.1 During that time, “J.H.” had a greater chance of becoming a victim of assault and sexual violence—all because he was too sick to go to trial. In March 2019, the ACLU took the DHS back to court after it “failed to produce constitutionally acceptable results, with some patients remaining in jails for months at a time.”

  Depersonalization, something about which Rosenhan wrote extensively, is a key feature of prison life. Prisoners are given uniforms, referred to by their numbers, lack even the most basic privacies, and live without many personal belongings. It’s a place where the most valuable currency is to be viewed as powerful, and where the mentally ill are seen as inherently “weak.” Prisons and jails are places with “degradation ceremonies” and “mortification rituals.” They are not meant to be healing environments; rather, they are punitive, depriving ones.

  In Arizona, men, “often nude, are covered in filth. Their cell floors are littered with rancid milk cartons and food containers. Their stopped-up toilets overflow with waste,” wrote Eric Balaban, an ACLU lawyer
who chronicled his visit to Maricopa County Jail’s Special Management Unit in Phoenix in 2018. In California, “Inmate Patient X” at the Institution for Women in Chino in 2017 was not given medication despite being listed as “psychotic,” and, after being ignored in her cell after screaming for hours, ripped her own eye out of her skull and swallowed it. In Florida, Darren Rainey was forced into a “special” shower by prison guards. The shower’s temperature climbed to 160 degrees, which peeled his skin off “like fruit rollups” and killed him. In Mississippi, “a real 19th century hell hole,” non–mentally ill prisoners sell rats to the mentally ill prisoners as pets. In the same place, a man was reported fine and well for three days after he suffered a fatal heart attack. And in the shadow of Silicon Valley, a man named Michael Tyree screamed out “Help! Help! Please stop” as he was beaten to death by prison guards while awaiting a bed in a residential treatment program.

  It all reminds me of Erving Goffman’s Asylums, one of the key texts that inspired Rosenhan’s study. Goffman was the sociologist who went undercover at St. Elizabeths Hospital and argued that what he saw there was a “total institution,” no different from prisons and jails. He cited examples: the lack of barriers between work, play, and sleep; the remove between staff and “inmate”; the loss of one’s name and possessions. Remember Philippe Pinel, the man credited with introducing the concept of moral treatment? In 1817, his mentee Jean-Étienne-Dominique Esquirol described the conditions that led to their enlightenment: “I have seen them, naked clad in rags, having but straw to shield them from the cold humidity of the pavement where they lie. I have seen them coarsely fed, lacking air to breathe, water to quench their thirst, wanting the basic necessities of life. I have seen them at the mercy of veritable jailers, victims of their brutal supervision. I have seen them in narrow, dirty, infested dungeons without air or light, chained in caverns, where one would fear to lock up the wild beasts.”

  Today, it’s worse. We don’t even pretend the places we’re putting sick people aren’t hellholes.

  “It’s true that the hospitals have mostly disappeared,” wrote Alisa Roth in her 2018 book Insane. “But none of the rest of it has gone away, not the cruelty, the filth, the bad food, or the brutality. Nor, most importantly, has the large population of people with mental illness who are kept largely out of sight, their poor treatment invisible to most ordinary Americans. The only real difference between Kesey’s time and our own is that the mistreatment of people with mental illness now happens in jails and prisons.”

  And then there’s therapy—or the farce that passes for it in many prisons. Treatment is often rare and typically revolves around medication management. When therapy does occur in certain jails in places like Arizona and Pennsylvania, it involves doctors or social workers speaking to patients through the metal slats in closed cell doors or, in one egregious case, merely handing out coloring books, wrote Roth.

  “Prisoners are under a tremendous amount of stress, and they feel a tremendous amount of pain, and they’re not encouraged to think about that. In fact, there’s an incentive not to think about it or talk about it, because nobody is interested in it,” said Craig Haney, a psychologist who studies the effects of incarceration, whom you may remember as the graduate student who turned down David Rosenhan’s invitation to go undercover as a pseudopatient when he was at Stanford.

  The culture of distrust goes both ways. During her first day of training in an Arizona state prison, Angela Fischer, a health care provider who later testified as a whistleblower, heard this joke relayed to her by a Department of Corrections employee.

  “How do you know when a patient is lying?” the person asked her. Without waiting for an answer, he continued: “Their lips are moving.”

  Many guards grapple with threats (real or imagined) that the inmates are malingering (or faking) because they want out of a bad situation in the general population or feel they’ll get a cushier housing assignment. Though malingering does occur, David Fathi, director of the ACLU’s National Prison Project, said that it is not as common as it’s portrayed. More often, people are underdiagnosed and mismanaged: “I mean people who have documented histories of mental illness going back to when they were nine, they get to prison and suddenly they’re not mentally ill, they’re just a bad person.”

  Craig Haney agreed, adding that there’s no real incentive to lie and game the system: “What’s the secondary gain? The secondary gain is that they get taken out of one miserable cell and put into another one that is usually more miserable. If they put you in a suicide watch cell—then you’re in an absolutely bare cell with no property whatsoever, sometimes you’re in a suicide smock and sometimes they take all of your clothes away and leave you there naked.” It reminds me of the second part of Rosenhan’s study, when he told a hospital that he sent pseudopatients but never did. Doctors were primed to see pseudopatients everywhere; similarly, prison guards today are trained to see fakers everywhere.

  Dr. Torrey, the psychiatrist who warned me that it’s worse today than it was during Rosenhan’s time, does have some solutions. The Treatment Advocacy Center, which he founded, advocates for adding more beds across the board—in state hospitals and forensic settings—which would reduce wait times and get people out of jails and into proper treatment quicker. Advocate and author DJ Jaffe, Torrey’s mentee, a self-described “human trigger warning” and executive director of the Mental Illness Policy Organization, pushes for the implementation of more mental health courts, where judges can divert people with mental illness into appropriate housing and treatment before they’ve been absorbed into the prison system. He also backs the use of crisis intervention teams made up of law enforcement officers, with the assistance of psychiatric professionals, trained to identify and deal with people with serious mental illness. On the more controversial end, Jaffe has written extensively about the necessity of using legal force to get people to take their meds (something called Assisted Outpatient Treatment), pointing out that many people with serious mental illness don’t know that they’re sick (a symptom called anosognosia), and for civil commitment reforms so that more people can be hospitalized against their will before tragedy strikes. He and Torrey have both made the case that though the vast majority of people with serious mental illness are no more violent than people without mental illness, studies have shown that a small subset of people, who are typically untreated, are more violent. To those who say these policies infringe on people’s civil liberties, Jaffe has responded: “Being psychotic is not an exercise of free will. It is an inability to exercise free will.” (I agree that I had zero free will when I was psychotically ill, but I have to admit that it’s hard for me to reconcile this perspective with the rest of my experience and misdiagnosis, especially when I think about how many psychiatrists may not be deserving of the power necessary to fully enact these policies.)

  Some prisons and jails, resigned to the brutal reality, have implemented changes to reflect their true roles as society’s mental health care providers. Sheriff Tom Dart of Chicago’s Cook County jail, where a third of the 7,500 prisoners struggle with mental illness, has become a standard-bearer in doing the best with an untenable situation. “Okay, if they’re going to make it so that I am going to be the largest mental health provider, we’re going to be the best ones,” he told 60 Minutes in 2017. “We’re going to treat ’em as a patient while they’re here.” Cook County provides medication management, group therapy, and one-on-one visits with psychiatrists. Sixty percent of the staff has advanced mental health training, and the jail warden is a psychologist.

  But we need money to enact real change. Without the proper allocation of funds, we punish people three times: disinvesting from resources to support them in the first place, arresting them when they exhibit problematic behavior, and then hanging them out to dry when they reenter the community. The system remains broken, and the people who are sickest continue to be ignored and forsaken.

  “If I told you that was the case for cancer or
heart disease, you’d say no way, we’re not going to send people who have freshly diagnosed pancreatic cancer to jail because there’s no place to put them while they get treatment,” said Dr. Thomas Insel, former head of the NIMH. “But that’s exactly the situation we’re facing.”

  25

  THE HAMMER

  I got a tip to phone Swarthmore psychology professor and social constructionist Kenneth Gergen, who had a close relationship with Rosenhan during his time at Swarthmore. I shared with him what I knew about the study, about Rosenhan’s involvement, and about my inability to pin anything to the ground.

  He interrupted my ramblings.

  “To meet [Rosenhan] and talk with him, he was almost charismatic. Nice, deep voice with a very personable way of relating to people. He was a good networker. He kind of knew people who knew people, and he played the network. He was an excellent lecturer. I mean he just had a certain drama about him. But… a number of us in the department, and it wasn’t me because I was kind of a friend of his… people would say, ‘He’s a bullshitter.’”

  Then he laid the hammer down: “If you’ve [only] got one or two examples of things that really happened as they are written in the paper, then let’s assume most of the rest was made up.”

  I hung up the phone and sat still for a moment to take in his words. Could there be any truth to Kenneth Gergen’s offhand remark? Exaggerating findings and altering data to fit his conclusions were troubling enough, but inventing people out of whole cloth? That was inconceivable.