The Great Pretender

by Susannah Cahalan

  Again: “C’MON, YOU MOTHERFUCKERS, OUT OF BED.”

  Rosenhan’s roommates stirred, lifting their bodies as if in slow motion. Rosenhan averted his eyes to avoid intruding on these strangers’ morning rituals, but was too frightened not to track their movements out of the corners of his eyes. He didn’t know anything about these men besides the names yelled at them. Why were they here? Had they done something criminal? Were they dangerous? One of his roommates, a man named Drake, who had lost his mind sniffing glue, grabbed his toothbrush and walked by Rosenhan’s cot, waving a “hi” as he passed. “He knew I had been watching,” Rosenhan wrote.

  He shuffled into the bathroom line. Men joked and jostled. Rosenhan hung back, overwhelmed by the smell. The toilets had overflowed. Barefoot patients goose-stepped around the mess, complaining to an attendant who watched but did nothing. In the chaos, Rosenhan managed to muscle his way to the double-headed sink. “I looked in the mirror at a bearded, puffy-eyed man,” he wrote in his unpublished book. “I looked as I felt: haggard.”

  In the cafeteria, Rosenhan, uncertain about the rituals surrounding the meals, watched the others, copying their fluid motions: Remove a plastic tray, pick up a napkin, move steadily down the line, pick up a dish, place it on the tray, sidestep to your left, and repeat. Three lunch ladies stood behind the counter. Their job was to stop any patient from getting too greedy with the food.

  “Hey, one butter only,” one said.

  “You can have another cup after you’ve finished that one,” said another.

  “Hey you, get away from there!”

  “Desserts are no good for you. They’ll rot your teeth.”

  When Rosenhan sat down, he realized that he had forgotten to grab silverware and an orange. He was too intimidated to return to the line—“the freeze” again.

  When he was alone in the hallway or in a quiet part of the ward, he felt he had to constantly monitor his surroundings, eyeing every person, swinging around to catch someone sneaking up behind him. “Tom Szasz is wrong,” he wrote, referring to the author of The Myth of Mental Illness. “They really are different from me.” (Despite being associated with Szasz and the anti-psychiatry movement, Rosenhan complained about being lumped in with them, namely because of their belief that mental illness was not real.)

  There was nothing to do except wait. Wait for breakfast, wait for lunch, wait for the doctor, wait for the nurse. If he wanted to smoke—and he did almost constantly—he had to sit in the dayroom with its ever-present television. Rosenhan couldn’t even safely send letters without interference. At the beginning of his stay, he was sending his secret observations about the hospital back home through the mail. He had developed a code to get his messages out—to make it look like gibberish (as if Rosenhan needed help with that since his handwriting accomplished this goal on its own), he skipped every other line and then looped to the top of the page to fill in the lines that had been skipped with new writing. When Rosenhan licked the envelope, the nurse, Mrs. Morrison, asked him not to seal it because the staff would have to read his letters before they were sent out. “Not everyone reads them,” she reassured him. “Just the doctors and nurses.” But when there was no administrative reaction to the content of his mail, he soon realized that no one gave a damn about what he wrote on the ward, so he stopped mailing letters altogether and just wrote in his diary out in the open for everyone to see.

  Powerlessness. This is a word he repeats often in his notes. Patients lost many of their legal rights; movements were restricted; eating was confined to certain hours of the day, as were sleeping and watching television. The bathroom stink made its way to the dayroom as the urinals continued to overflow with human waste. The dormitory doors were locked. Rosenhan found one freedom that remained: his writing.

  2/7/69

  10:30am

  I’ve taken no pill but I’m exhausted, mainly from not sleeping last night. But also from boredom.

  The dayroom drama unfolded in waves:

  Over the monotonous yammering of the flickering television, two patients laughed so hard that they fell on the floor, appearing as if they lost control of their bodies.

  A patient hit another patient.

  Walter, one of the more disturbed patients, walked out of the bathroom nonchalantly carrying balls of excrement up and down the hallway until an attendant finally noticed and made him wash up.

  Sonny, one of the ward’s troublemakers, hit a nurse and was dragged kicking and screaming into a lockdown room. Rosenhan almost missed the whole commotion, “so drugged was I from heat and the general torpor of the place,” but everyone heard the sounds of Sonny pounding the hell out of his isolation room. “The walls here are plaster and no more—so there’s reasonable chance he’ll come through for a visit,” Rosenhan joked. Gallows humor had already set in, after less than twenty-four hours on the ward.

  But the joke was on him. It was time, a nurse alerted him, for his first meeting with his assigned psychiatrist, Dr. Robert Browning.

  The interview lasted less than half an hour and mainly retrod the same topics that Dr. Bartlett had addressed in Rosenhan’s intake interview. They discussed Rosenhan’s financial difficulties, his “paranoid delusion” about a former advertising executive boss, and of course his vague auditory hallucinations.

  Dr. Browning found Rosenhan’s speech “mildly constricted,” meaning that he seemed to express a limited range of emotions. Outside the hospital Rosenhan would never have been accused of being unemotional, but inside, it seemed, an apprehensive look or detached tone was viewed as “mildly constrictive.” On the outside people write; on the inside it’s a sign of underlying illness. This is a vivid example of labeling theory in action—a phenomenon Rosenhan himself taught in his abnormal psychology class.

  In 1946, Polish psychologist Solomon Asch studied the effect of certain “central” personality traits, such as “warm” or “cold” or “generous” and “ungenerous,” descriptions that are so powerful they completely shape how we view others. There are few more powerful descriptors than “crazy” or “insane.” In another later experiment, two psychologists played a recorded conversation between two men to clinicians. Half were told that the interviewee was a job applicant, the other half that he was a psychiatric patient. Those who thought they were listening to a job applicant deemed him fairly well adjusted and used terms like “realistic”; “unassertive”; “fairly sincere, enthusiastic, attractive”; “pleasant, easy manner of speaking”; and “responsible” to describe him. Those who believed he was a psychiatric patient used words like “tight, defensive”; “conflict over homosexuality”; “dependent, passive-aggressive”; “frightened”; “considerable hostility.” Once words like mental patient or schizophrenic are affixed to you, there is little you can do or say that can make them disappear, especially when anything that doesn’t support the doctor’s conclusion is discarded for evidence that does.

  How much of Rosenhan’s diagnosis, “constricted speech,” and “delusions of persecution” emerged from the expectation of how a mentally sick person should look and act? I recognized so much of this. During my own time in the hospital, I remember a psychologist noting that I wasn’t able to read or focus my eyes directly in front of me. It was only after I’d spent several weeks in the hospital that she realized my vision issues occurred because I had contacts lodged in my eyes. When I was deemed crazy, no one seemed concerned about my vision. My perceived craziness had colored everything else—even my eyesight.

  This was a typical outcome of “the medical gaze,” the dehumanization of patients first described by Michel Foucault in his 1963 book The Birth of the Clinic: An Archaeology of Medical Perception. Foucault wrote that this detached way of looking at illness emerged during the Enlightenment, as doctors learned more about the body, relying on empirical knowledge, rather than on magical thinking, to diagnose. Since then, clinicians had grown so reliant on these objective facts in the form of charts, percentages, and test results that they n
o longer saw their patients. Rosenhan’s experience was a perfect example of such clinical blindness—the doctors read Rosenhan’s chart but failed to see the patient standing right in front of them.

  Beyond the perceived issues with his speech, the doctor found Rosenhan to be an otherwise reasonably intelligent man who was sufficiently oriented to time and place. He could recall a series of eight digits forward and backward and could subtract from one hundred by sevens. When he asked Rosenhan to interpret a series of proverbs, the doctor was noticeably impressed. For the proverb “One man’s meat is another man’s poison,” Rosenhan responded, almost without thinking: “Good for one, bad for another.” For the proverb “A stitch in time saves nine,” Rosenhan responded: “An ounce of prevention is worth a pound of cure.” Touché. Then: “Do not cross your bridges before you come to them.” Rosenhan’s interpretation: “Don’t try to anticipate a situation.” How apropos.

  Yet the doctor concluded that Rosenhan was suffering from schizophrenia, this time reducing the diagnosis to “residual type,” defined as a person who has exhibited signs of schizophrenia but is no longer psychotic. This was a different diagnosis from the one that had landed him there just a day earlier: schizophrenia, schizoaffective type. Psychiatrists, steeped in the psychoanalytic tradition, shrugged off these differences as nonessential—you say potato, I say residual type.

  Rosenhan’s clothes, which he’d now worn for twenty-four hours, smelled of the ward. Nothing upset him more than this indignity. He wanted his belongings, but every time he asked for the bag that had been confiscated during his intake, they refused him. It became an obsession. He found himself muttering under his breath about his lost clothing.

  “Have my clothes come up yet?” he asked an attendant.

  “What clothes?”

  Rosenhan sighed. “I came into the hospital with some clothes and they were left downstairs to be marked. Could you call now?”

  “No, they’re probably closed. Will try if they don’t come up at four.”

  “But they’re more likely to be closed at four,” Rosenhan said.

  “We’ll see,” the attendant said. “Keep the faith.”

  During a shift change before going to bed, Rosenhan again asked for his bags.

  “They came yesterday,” a new attendant said, checking the label.

  When Rosenhan made a face, he responded: “Well, he probably didn’t see them under the desk.”

  DAY THREE

  Nurses’ Note: 2/8/69 Very quiet. Taking notes on other patients. No problems on the unit.

  While awaiting Mollie’s daily visits, Rosenhan passed the time “whiling it away,” which he defined as “the daydreaming, the snoozing, the coffee sipping, and the long inspections of space.” Saturday was the dullest day, when the ward was understaffed and the psychiatrists and psychologists were home with their families. He learned the unofficial rules. Queue up when medications are dispensed (so you can spit them out quickly in the bathroom with the other patients); get cigarettes lit by other patients instead of waiting to find a staff member; arrive at the cafeteria quickly, as getting there late meant missing out on the truly edible items like bread, sugar, creamer, and desserts. Another ward rule: The healthier you were, the more the psychiatrists stayed away. In other words, the saner you appeared, the more invisible you became.

  Without grounds privileges, Rosenhan was a literal prisoner. He managed to cheek the pills—two milligrams of Stelazine, an antipsychotic; and twenty-five milligrams of Elavil, an antidepressant—but still he was groggy, drugged by the place itself. The blinds were open regardless of the sun’s glare. The patients’ discomfort didn’t matter one iota to the nurses, who hardly left their cage (everyone was a prisoner there, it seemed). In Rosenhan’s notes, he made rough estimations of their comings and goings, finding that they spent only half their time on a ward and a mere fraction of that interacting with patients. The staff existed in a different world—they ate separately, gossiped separately, and even used their own bathrooms, “almost as if the disorder that afflicts their charges is somehow catching,” he would later write.

  At one point a nurse in full view of twenty male patients opened the first five buttons of her uniform and adjusted her breasts. “No, she was not being seductive,” Rosenhan wrote. “Just thoughtless.”

  Eventually Rosenhan spotted two newspapers on the ward for the first time—the local paper and a week-old New York Times dated January 31, 1969. Rosenhan snatched it up, desperate for something to distract him. He wrote in his notes:

  “Where is today’s paper?” I ask a nurse.

  “Doesn’t come until the afternoon mail.”

  Which is to say that the paper has been coming everyday but the patients never see it.

  He flipped through articles on the growing arms race against the Soviet Union and the launching of the Sentinel antiballistic-missile system. Nixon announced a plan to replace the draft with volunteers. Ads for Frank Sinatra Jr. playing at the Rainbow Grill at Rockefeller Center ran alongside news of renewed fighting in Laos.

  After reading the paper, Rosenhan returned to his own writing.

  “Would I have to be secretive? Hardly. One guy rocks, another leans, and I write.”

  The third day’s diary entries are filled with musings on the hierarchy of the hospital, which he described as a pyramid structure with psychiatrists at the top, nurses just below them, and patients at the very bottom, of course. Skin color, he noted, also determined rank. Attendants, a notch above the patients, were almost all black. They were also paid the least, treated the worst, and had the most hand-to-hand contact with the patients. Rosenhan identified them as fellow “nether people.”

  “I’m Bob Harris.” The sound jolted Rosenhan back into the world of the dayroom. The voice belonged to one of the attendants he had met his first day in. Harris offered his hand and Rosenhan shook it, delighted by the unexpected intimacy of the moment. No one here had yet greeted him this way; most didn’t even lift their eyes. “I’ve been on the ward for six months now. You’re new here?”

  Rosenhan said he was. Harris told Rosenhan a bit about himself: He was struggling financially and working two jobs (the other at a gas station) to make ends meet to support his wife and three children. He planned to train as a nurse because the pay was much better than the fifty-five dollars a week he was making as an attendant.

  The two chatted about the ward and its patients. “Now Jumbo, he’s one I don’t understand,” Harris said. “He got no family so far as I can see, except an occasional friend that comes to visit, and he hasn’t visited for months. He’s got a very hot temper. Couple of months ago he just tore off at Harrington for no reason at all. I’d watch out for him.”

  Then there was Carroll: “With a name like that no wonder he’s got troubles. I think he’s been babied too much, even here on the ward. Mrs. Purdy really looks out for him. Same for the kitchen staff. He always gets another dessert, you can be sure of that.” Sam was in “because of homosexuality,” and Peter “gets the largest Thorazine dose on the ward.” Then Rosenhan’s roommate shuffled by. “He’s new. Probably been hospitalized before. Doesn’t he just look like someone who’s been in and out of hospitals since the war? Surprised he’s not at a V.A. Hospital. They’ve got him in a room with those two kids, Drake and Foster. He won’t notice it, but they’re trouble. They’re here on court orders and their lawyer has been in several times to see them. Drug rap.”

  Rosenhan nodded away, hoping that the conversation would continue, as it was the first real one he’d had since Mollie’s visit the previous day. Harris moved on to the staff. The foreign residents weren’t very good, except “a really good Cuban” named Dr. Herrera, he said.

  After nearly an hour, Harris noticed the group of nurses in the cage waving him over. He excused himself, saying he’d be right back: “There’s a lot more about this place.”

  Rosenhan felt a warm rush of gratitude. Perhaps this place wasn’t so bad after all. This attendant ha
d treated him like a person, not a leper. But as Rosenhan watched, he saw that the nurses were doubled over in laughter. They handed Harris a chart.

  Could they be laughing at him? Was Rosenhan growing paranoid? What could be so funny about a middle-aged man with a family ending up in a psychiatric hospital?

  Harris did not return to Rosenhan’s table as promised. And when Rosenhan bumped into him later that same day, Harris’s demeanor had clouded.

  “Mr. Harris?”

  “I’m busy now.”

  Rosenhan allowed himself to be brushed off—perhaps Harris was in a bad mood or something troubled him on the ward. But when he tried again later near the patients’ bathroom, Harris still seemed irritated.

  “Mr. Harris.” Maybe he didn’t hear. “Mr. Harris?”

  “Didn’t I say I was busy?” he snapped.

  Normally Rosenhan wouldn’t have taken such insolence without comment, but he couldn’t muster up the reserves to defend himself. He was so distressed that he scribbled a quick note: “Even Harris’ differentiated friendliness runs rapidly into friendly disdain.”

  DAY FOUR

  Nurses’ Note: 2/9/69 Patient spends a lot of time by himself writing and watching TV

  Each day seemed to yawn into the next, especially on that wintry Sunday with its skeleton crew. Harris, the only attendant on duty, continued to avoid Rosenhan. People walked the halls hunched over with blankets wrapped around their shoulders like depressed ghosts. Rosenhan joined the pantomime, pacing up and down the hallway with his own blanket and a blank expression. “The pacing, the sitting, eyes glued to the TV, was something that I, a sane man, came to do, often and for long periods of time. Not because I became crazy—at this writing, 72 hours after I came in, I still think I’m sane, although I can’t guarantee my future—but because there is simply nothing else to do. How can I communicate the daily boredom, punctuated for me by my wife’s daily visit but nothing for the others? The apparently psychotic behavior is not determined by psychosis at all—but by ennui.”