The Great Pretender

by Susannah Cahalan

  In Rosenhan’s private writings, there was no insight to be found regarding how these people felt about their contribution to the history of medicine. Had it changed them as it did him? His unpublished manuscript gives only the sparsest of clues with no specifics about locations or time frames:

  Chapter Three: Getting In

  With the students out of the project, the entire study might have terminated for lack of manpower, were it not for an accidental encounter that occurred three months later. I was attending the meeting of the Society for Research in Child Development. It had been a long hard day full of heavy research discussions and disputes. A number of us were unwinding over dinner and I began to describe some of my experiences in a psychiatric hospital. Afterwards, a couple who had been at dinner whom I had not previously met, came over and introduced themselves. We talked deep into the night about psychiatric hospitals and psychiatric care.

  This was the couple he called John and Sara Beasley, recent retirees who had each logged many years in the mental health field, John as a clinical psychiatrist and Sara as an educational psychologist. The prior six months, they had traveled and read, thoroughly enjoying their retirement, all while keeping up on developments in their fields, which is how they ended up on March 29, 1969, at Rosenhan’s lecture on altruism in children in Santa Monica, California. The three hit it off. Of John, Rosenhan wrote: “It was his thoughtfulness that was especially striking, quite as if he had used the past six months of retirement to ponder the nature of psychiatry as he and others had practiced it.” Of Sara, he wrote, “I should have been delighted to confide my children’s school problems to her. She seemed to combine deep knowledge of children’s (and parents’) problems with a firm optimism that they could be solved.”

  Rosenhan met John and Sara two days later for dinner. “John was particularly struck by the symptoms that I had used. They reminded him of a question he had asked himself quite frequently: how well was he able to predict a patient’s behavior and in particular how much of what he thought he saw in patients was really there. Moreover, he was quite interested in obtaining a firsthand picture of treatment,” Rosenhan wrote. By the end of dinner, John had decided he would like to try Rosenhan’s experiment for himself. Rosenhan coached John about the “thud, empty, hollow” symptoms and taught him how to cheek pills. “The procedure was simple, but it involved some gall,” Rosenhan wrote. “After placing the pill on your tongue, you needed to flip it underneath and then drink the water that was given, all the while looking the nurse straight in the eye.” They came up with an occupation: John would be a retired farmer (for he lived on a defunct farm and was familiar enough with the work to fake it). They talked about how to get in, how to take notes, and the importance of having daily visitors.

  Six months later, in October 1969, John called Rosenhan with news: He had just left Carter State after having spent twenty days there with a schizophrenia diagnosis. John’s wife, Sara, was currently undercover, too, and John’s sister, known as Martha Coates, planned to go in. Rosenhan’s school project was suddenly multiplying like bacteria left overnight in a petri dish.

  Rosenhan recounted bits of John’s, Sara’s, and Martha’s hospitalizations in his unpublished book, quoting, he wrote, from their diaries and notes. John described the absurdist drama of hopscotching beds his first night. In the morning, he woke to a strange man sitting on the edge of his bed. “Bearded and burly, the combination of size and gentleness scared the daylights out of me,” John wrote. “He told me quietly ‘It’s time to get up.’ All the other patients were still asleep. I could see that the ward wasn’t up yet. But he insisted that I get up, and moved the covers off me. It was Kafkaesque.”

  Sara had admitted herself to Westerly County Hospital, a smaller teaching hospital close to her home. Though Rosenhan acknowledged that he “doubted” that Sara would join the study, he didn’t comment on why she ultimately did decide to, especially after her husband’s experience was so distressing.

  “I don’t know what’s troubling me,” she wrote in abbreviated shorthand, according to Rosenhan’s book. “I’ve never felt so uncomfortable with psychotic people before. There’s no reason for it.” She tried to make sense of her fear: “Maybe it’s because I lied my way in… Maybe it’s that I can’t tell what the patients will do next? But they seem to be doing very little. Most of them are drugged… So what if they check my bed once or twice? I can’t seem to get under control. Maybe I should swallow that medication. Careful now.” The tension abated after the second day, leaving almost as suddenly as it appeared. “I feel much better now,” she wrote on the morning of her third day. “I don’t know why, I hope it lasts.” Sara spent a total of eighteen days hospitalized and was released with the same diagnosis: paranoid schizophrenia in remission.

  Despite this unsettling experience, John was more devoted than Rosenhan himself had been, and decided one time through the wards wasn’t enough. He readmitted himself, this time to another, larger hospital called Mountain View, spending two more weeks institutionalized and once again diagnosed with schizophrenia. Before, he was focused on maintaining his charade; this time, Rosenhan wrote, he wanted to focus more on the patients and “evaluate their distress before it became masked by medications.”

  John’s sister, Martha, now the fourth pseudopatient, volunteered for what had grown into a family game of chicken. (What sort of family, one can’t help but wonder, engages in this kind of brinksmanship for fun, or even for science? I was desperate to know more.) Martha, a recent widow and a housewife with no professional experience with mental illness, Rosenhan wrote, had a personal connection with the mission. Her son had struggled for years with drug addiction and had spent time in and out of psychiatric facilities. She expressed “some wonderment about what his experiences were like” and decided to re-create them for herself. Martha was also diagnosed with paranoid schizophrenia and was released two weeks later with the illness “in remission,” now the fourth patient in a row to receive the same outcome. The symptoms that Rosenhan had devised as a joke in his Swarthmore class, “thud, empty, hollow,” seemed to have become a shortcut for doctors to a diagnosis of schizophrenia.

  Rosenhan didn’t report many details in the interim about signing up the other pseudopatients for the study, but he does write that six months after John Beasley’s first hospitalization, a “famous abstract artist”—successful enough for major museums across the country to feature her work—named Laura Martin, the fifth pseudopatient, exhibited the same “thud, empty, hollow” auditory hallucinations and was admitted to the study’s only private psychiatric hospital. Rosenhan named it William Walker Clinic, and described it as one of “the top five [hospitals] in the country.” Like the other pseudopatients, Laura had no trouble getting in; her problem, even more than the others, was getting out. Laura was released against medical advice (the hospital wanted to keep her longer) after fifty-two days with the diagnosis of manic depression, the first pseudopatient to receive a different diagnosis than schizophrenia, which is telling because manic depression has more favorable outcomes. Could it be that her perceived social class in the context of a fancy private institution made her seem less sick?1

  Laura’s husband, Bob, was the next to go in. He changed his occupation from pediatrician to lab technician and entered Stevenson State, an “otherwise unimpressive” psychiatric hospital. Twenty-six minutes into his intake, his psychiatrist diagnosed him with “schizophrenia, paranoid type”—the fifth such diagnosis. Becoming a patient was torture for the doctor. “The hamburger was so coated with grease that it looked and felt like slimy shellac. The potatoes were watery… I don’t know how the patients eat this shit. I can’t,” Bob wrote. After seventy-two hours, Bob stopped eating cooked foods—only bread, butter, coffee and tea, and the occasional fruit. “I’ve never seen such lousy food in any hospital… I’m afraid everything is buggy,” Bob wrote, according to Rosenhan. It got so bad that Laura and other visitors would sneak in food, like sandwiches and Ore
os. Bob squirreled away the most disturbing parts of his meals—chunks of gray meat, unappetizing sauce—in napkins just to show off how gruesome the fare was to his visitors. Rosenhan wrote about Bob in his unpublished book: “We ourselves were seriously concerned about his ‘symptom.’ Bob had not previously manifested any finickiness regarding food and was indeed regarded by some friends as omnivorous. His concerns about cleanliness in preparation, about the possibility of disease, his occasional comment about ‘poison’ had us sufficiently worried that had he not been discharged when he was, we would have removed him from the hospital.” Bob was released on his nineteenth day and carried the label “schizophrenia, paranoid type in remission,” but not one medical note addressed his one very real symptom: his refusal to eat. He left the hospital “hungry, sort of depressed, but smarter for it all.”

  Thanks to John, Laura, and the others, the data was pouring in. By the fall of 1970, Stanford had recruited Rosenhan to the campus as a visiting professor, based in large part on the reputation he was developing as the creator of this ingenious but still-unpublished study. He had lectured twice about his own experience, which he had titled “Odyssey into Lunacy: Adventures of a Pseudopatient in a Psychiatric Hospital.” In a letter to one colleague, he wrote, “With all due apologies for immodesty, the data are increasingly interesting.” Others agreed. A Psychology Today editor wrote him a personal note to inquire about publishing the findings. Whispers of his work reached Harvard, which sent out feelers to him. Chairman George W. Goethals wrote: “There was further agreement that if this research ‘took off’ this would be a major contribution to American psychology.”

  During the wild summer of 1970, as the world was hypnotized by the murder trial of a group of drugged-out hippies and their mastermind, Charles Manson, Rosenhan headed west. He loaded up his VW and drove his young family to California, taking the scenic northern route. “The country is a hell of a lot more beautiful than most of what I’ve seen in Europe,” he wrote to a friend. “Not only deep blue, but emerald green glacier fed lakes, that were symphonies in silence and isolation.” Though their camera broke halfway and his daughter, Nina, caught chicken pox, Rosenhan described the road trip as magical. The urbanite couldn’t get over Iowa: “I simply couldn’t believe all that fertile land, and was totally taken by the rolling farms and decency of the Midwest. I could teach at Iowa, though it might cost me a spouse.”

  When he reached Palo Alto, any fantasies of rural life disappeared. “We’ve really lucked out here,” he wrote in a letter to a former colleague at Swarthmore. “Palo Alto is a great place to live: civilized, urbane, with one hell of a lot doing.” The view from his ranch house in the “Prof Hill” section near Stanford was magnificent, especially when the fog cleared to reveal the foothills of the Santa Cruz Mountains. Eight-year-old Nina touchingly told her father how “lucky we were to be here.” Mollie tended to her new vegetable garden, picking pomegranates and planting a Meyer lemon tree, while Jack helped his father trim the hedges. Rosenhan soon traded in his VW for a gunmetal-gray 1957 Mercedes 190SL with red leather interior, his boyhood dream car. He was fond of the phrase “The coldest winter I ever spent was August in San Francisco”—an adaptation of a quote misattributed to Mark Twain—and used it to temper the glow of his happiness when sending notes to his colleagues out east. Despite making a pact with Swarthmore to return, he never did. A year after his arrival at Stanford, he was made a professor with a joint appointment in psychology and law. To Rosenhan, Palo Alto—the sunshine, the lush gardens, the Meyer lemon trees—must have felt like the academic land of milk and honey. He would spend the rest of his life tucked in the cradle of Silicon Valley.

  Stanford University had already set its sights on establishing a world-renowned psychology faculty and devoted ample funds to make this a reality, recruiting some of the best and brightest minds. As a show of its newfound importance, the Department of Psychology moved to Jordan Hall, right at the center of the Quad, the same summer that Rosenhan arrived. Bold-faced names included child psychologist Eleanor Maccoby, a powerhouse who pioneered research in the study of sex differences and gender development; cognitive psychologist Amos Tversky, whose later work with Daniel Kahneman on cognitive bias and risk would fundamentally challenge the fields of economics, philosophy, business, and medicine; Walter Mischel, whose work Personality and Assessment shook up psychology by arguing that personality is not fixed; and of course the great Lee Ross, who set me off on this expedition.

  “It was probably one of the most exciting academic places to be during that era,” said Daryl Bem, who originated the “self-perception theory” of attitude formation, or when attitudes are formed by observing one’s own behavior (say you’re always in a bad mood when a friend visits you; maybe you’ll conclude that you really don’t like her). Bem worked at Stanford with his wife, Sandra Bem, famous for her work on gender and identity. “Everyone was intensely interested in their research. There’s an old Jewish saying that there are only two admissible answers you can give if asked, ‘What are you doing?’ And the two answers are: ‘I am studying the Torah,’ and the other answer is, ‘I am not studying the Torah,’” he said. “That’s exactly how Stanford professors felt about their research. Either they were doing their research or they weren’t.” It was the only thing that mattered.

  There was another perk to the move. As he would explain in his book, “one of the main motivations” for taking the new job was to “continue the hospital study.” Stanford University offered him something Swarthmore College didn’t: access to graduate students. By this time—seven pseudopatients in—he knew he was onto something huge: “The ease with which we were able to gain admission into psychiatric hospitals and remain there undetected was beginning to raise a question in my and my colleagues’ minds… Could it not have been the luck of the draw that got us admitted by the less talented members of these hospitals?”

  He needed more data, which meant more willing volunteers.

  Rosenhan spoke of one graduate student, Bill Dixon, a red-bearded Texan whom he described as prodigiously normal. Bill enthusiastically signed on to the study and, sure enough, spent seven days at Alma State Hospital with a diagnosis of schizophrenia.

  It’s unclear exactly when or how Rosenhan recruited Carl Wendt, pseudopatient #7, a businessman-turned-psychologist who had recently finished his PhD and planned to practice clinical psychology in a psychiatric setting. His interest in being a pseudopatient came from a desire to acquire firsthand knowledge. “Much as it is common practice to require of potential psychotherapists to undergo treatment themselves,” Rosenhan wrote, “it seemed to make sense to Carl that he see what hospitalization is all about himself, before recommending it to patients.” Carl’s involvement lasted much longer than any of the other participants’. He would spend a total of seventy-six days locked away.

  Carl’s first hospitalization, at Memorial County, was the hardest. A psych interview, which lasted a mere twenty minutes, embarrassed the newly minted clinical psychologist. A bored shrink peppered him with questions in the following order: “What did you eat for breakfast? Have you ever wanted to murder your father? Did you grow up on a farm? Did you ever have sex with animals? Do you often feel that people are after you?” Carl recognized these questions from the Minnesota Multiphasic Personality Inventory, a paper-and-pencil psychological test used to assess patterns in thoughts or behaviors outside the norm; its revision is used today in everything from screening job candidates to legal proceedings.

  Carl spent his first night in the middle of an open dormitory, crowded with patients and their bodily noises. In a scene that sounds similar to John’s first night, Carl hunkered down only to find that a massive man had joined him under the covers and fallen into a deep sleep. An attendant moved Carl to the sleeping man’s bed, which they found had been soiled. The only open bed (or what passed for one) was the plastic settee in the dayroom that separated two large dorms. Carl covered himself with a blanket and placed his hands
over his ears to drown out the grunts, screams, and laughter echoing in the dayroom. He didn’t sleep that night.

  Per Rosenhan’s notes, the next day Carl wrote in his diary: “I must be awfully tired. The place seems full of zombies.”

  By the third day, he wrote just two sentences: “I’m like a stone. I have never felt so inert.”

  Carl spent thirteen days at Memorial County before he left the hospital against medical advice with the diagnosis of paranoid schizophrenia in remission.

  Once he was released, the depression lifted, and Carl (like John) volunteered to admit himself to Rice State, where he was released after thirty-one days with the same diagnosis. He admitted himself yet again at Godwin State, where he stayed for nineteen days. He went undercover a fourth time at Montadero Hospital, but this time Carl’s enthusiasm for the study began to worry Rosenhan.

  “Bizarre as it may seem, I was concerned that this unpleasant experience might nevertheless become somewhat addictive for him. For the purpose he had begun with, he had surely learned enough about psychiatric hospitals, at least for the moment,” Rosenhan wrote. Thirteen days later, Carl was released, yet again with “paranoid schizophrenia, in remission.”

  It was also Carl Wendt who would, perhaps entirely by accident, deliver the study’s pièce de résistance. His fifth and final hospitalization was the most important of all—because it never happened.

  This startling piece of the study grew out of a challenge from one of Rosenhan’s colleagues. Unconvinced that Rosenhan hadn’t simply been lucky in cherry-picking less prestigious or understaffed institutions, an unnamed doctor offered his own hospital—“an excellent treatment and research facility”—to Rosenhan. (The rumor is that this was the Stanford University hospital, but I have not been able to confirm this.) The psychiatrists, nurses, and social workers were confident that it “would never happen here”—and if it did, “they would soon detect it.”