It was agreed that Rosenhan would address the staff at their weekly meeting, and alert them that in the next three months one or more pseudopatients would try to infiltrate the hospital. The orders were for the staff to document each admitted patient and rate how likely it was that the patient was an impostor:
Rosenhan arranged for Carl to go undercover at the unnamed hospital, but when the day approached Carl was waylaid by the flu. Rosenhan didn’t replace him. Maybe Rosenhan forgot, maybe it was planned, he doesn’t say—intentional or not, in the end Rosenhan sent no one. The result is, in my opinion, the most damning part of the study. Over the next three months, the staff kept an eagle eye out for any pseudopatients attempting admittance to their hospital. Of 193 new patients who arrived in that time period, staff members labeled 41 with high certainty as probable pseudopatients; psychiatrists, for their part, identified 23 likely pseudopatients. This miscalculation proved once again that we react to the world by what we are primed to see. In this case, these medical professionals were primed to see pseudopatients, so that is what they saw.
The New York Times interviewed Rosenhan about this ploy, which many newspapers focused on in the aftermath of the publicity craze the study created.
“Were the patients sane or not?” the reporter asked.
“We will never know,” Rosenhan responded. “But of one thing we may be certain: any diagnostic process that yields so readily to massive errors of this sort cannot be a very reliable one.”
Rosenhan had struck gold. And now it was time to share that gold with the world.
12
… AND ONLY THE INSANE KNEW WHO WAS SANE
And share it he did—in the splashiest way possible. Rosenhan landed a spot in one of the world’s most respected generalist journals, one that mainlines directly into the veins of the insatiable mass media. So how did he accomplish this coup? I don’t know for sure, but I have a suspicion that Rosenhan caught the ear of William D. Garvey, Science’s psychology editor, at an American Psychological Association conference that they both attended in 1970. However it came to be, Rosenhan then submitted his paper to famed Science editor Philip Abelson, a superstar researcher (co-discoverer of the chemical element neptunium, whose work on uranium contributed to the creation of the atomic bomb), in August 1972, summarizing his findings as follows: “The article presents experimental data on our inability to distinguish sane from insane people in psychiatric institutions. It also briefly describes the experience of psychiatric hospitalization as observed by pseudopatients.”
When Rosenhan’s study hit Science in January 1973, fan letters flowed into his Stanford office from around the world. Psychiatrists from Camarillo State Hospital down Highway 101 wrote to add their own anecdotal evidence confirming Rosenhan’s thesis about the ineffectiveness of psychiatric diagnosis; Robin Winkler, a psychologist from Australia, shared some of the data he had gathered doing his own pseudopatient-centered research down under; Thomas Szasz offered congratulations, as did Abraham Luchins, one of the country’s most important Gestalt psychologists, who pioneered the use of group therapy. Students wrote in asking to join his study. Former and current patients begged Rosenhan to prove that they, too, were sane people in an insane place and please could you get us out? “I read your article published Wednesday, March 1973 in the Huntington, West Virginia newspaper entitled: ‘Eight Wonder Who Can Tell The Sane From the Insane.’ I am number 9.” The letters were sent from all around the country from the known and the unknown, the famous and the infamous, including one that read “My name is Carl L. Harp. I am charged with murder and assault here in Seattle, Washington. ‘Bellevue Sniper.’ I am innocent.” Another: “Dear Dr. David Rosenhan, I am a 29 year old black, militant, social democrat… Those state hospitals are no more than concentration camps… Why can not the wealthiest country in the world take proper care of its mentally ill?”
Rosenhan personally responded to almost every letter. He engaged—sometimes with wit, sometimes with professorial authority, but always with interest and compassion. In response to the “black, militant, social democrat,” for example, he wrote: “I couldn’t help but wonder whether someone who is black and militant and who had moved from a small town in Louisiana to Cambridge, Massachusetts might not be expected to experience some stress. And I wondered further whether the stress might not be misdiagnosed as schizophrenia. Obviously I can’t tell—one doesn’t diagnose long distance. Regardless of diagnosis, it seems to me that you’ve been through one hell of a lot.”
(Most of his letters, it should be noted, were typewritten. He seemed to be aware of the impenetrable nature of his distinct handwriting, as he explained in a letter to his former student Pauline Lord: “I hope you forgive me—I never handwrite… I still write in hieroglyphics, but without a Rosetta Stone.”)
Rosenhan capitalized on this fame, lecturing widely about “The Horrors of Your Local Mental Hospital.” People were riveted. I can imagine the sound of Rosenhan’s resonant voice echoing out over the crowd as he swaggered around onstage, high on the life of a man-in-demand as the world begged him to visit their institutions, their fund-raisers, their conferences, their causes, because everyone wanted a piece of him, because he had proven what everyone already suspected was true.
The media co-signed. As of my count, which is by no means definitive, seventy local and national newspapers, in addition to television and radio shows, covered the study. Some, like the Los Angeles Times, ran it straight: “Eight Feign Insanity, Report on 12 Hospitals.” Others used it to anchor editorials, like the Independent Record in Helena, Montana, which posed the question: “Can Doctors Distinguish the Sane from the Insane?” Others took a more creative approach: The Burlington Free Press headlined its piece: “‘Mania,’ ‘Schizo’ Labels Cause Wrangle.” The Palm Beach Post used: “… And Only the Insane Knew Who Was Sane.” Immediately after its publication, two publishers approached Rosenhan about turning his study into a book. He signed on with an editor at Doubleday in May 1973. By the following year he had finished eight chapters—a good chunk of the book for which the publisher would, almost a decade later, be forced to sue him when he never delivered the manuscript.
The study smashed through the one-way mirror separating the layperson from psychiatric jargon and its judgment. Young upstart lawyers who had read Rosenhan’s study would trot it out in court to undermine the validity of a psychiatrist’s expertise on the stand. A year before Rosenhan’s study, ACLU lawyer Bruce Ennis had indicted the whole field of psychiatry by calling it an “enterprise” that treated patients as criminals in Prisoners of Psychiatry. Ennis and others maintained that psychiatrists were no more reliable than flipping coins—and that they “should not be permitted to testify as expert witnesses.” In the wake of the study’s publication, judges increasingly overruled expert testimony by psychiatrists, especially when the doctors recommended psychiatric commitment.
During a time when the president was insisting, “I am not a crook!” Americans could understand a study like this—one so sensational, yet seamlessly commonsensical—that provided a scientific basis for what so many of us had already experienced: The world was topsy-turvy and no one could prove who was on top and who was on the bottom.
Today the various factions that write about psychiatry agree about very few things, but do concede this: Rosenhan’s study had an overwhelming effect not only on public opinion but also on the way that the field saw itself.
“When the Rosenhan study was initiated it was right around the time that the Emperor’s New Clothes were about to come off,” Columbia psychiatrist Dr. Jeffrey Lieberman, the author of Shrinks, told me in an interview. “Rosenhan, I think dramatically and very effectively, pointed out glaring weaknesses in our knowledge base and our methods for making psychiatric diagnoses, and exposed it as fallible.”
“Rosenhan’s study was akin to proving that American psychiatry had no clothes. It was evidence that American psychiatry was diagnosing schizophrenia in a willy-nilly, frivol
ous manner,” wrote medical journalist Robert Whitaker in Mad in America.
“It was a landmark study that shook us all—it created a crisis of confidence,” said Allen Frances, the architect of the DSM-IV.
“The most celebrated psychological experiment of the era… [showed] that psychiatry—like mental illness—was a myth… as evidence accumulated that there simply was no there there, as Gertrude Stein might have said,” wrote Madness Is Civilization author Michael Staub.
If psychiatry could get its bread-and-butter diagnoses wrong, what else was it wrong about? A lot, it turned out. It was no coincidence that at the same time that Rosenhan’s study made waves, the field was facing another reckoning in the form of “the homosexuality problem.”
Being gay then was considered a mental illness—more specifically a form of “sociopathic personality disorder,” according to the DSM-I. (When Rosenhan arrived at Stanford, there was a joke going around about the professor who asked if the department would hire a gay professor. The answer: “You could be an ax murderer as long as you did that on your own time.”) Not only did gay Americans risk getting arrested (sodomy between consenting adults, for example, was still illegal in forty-nine states as of 1969) or losing their jobs; they could also be committed to a mental hospital. Psychoanalysts had given this belief a foundation. They claimed that homosexuality was pathological and emerged from unhealthy family relationships. In a widely read layman’s book, psychoanalyst Edmund Bergler charmingly asserted: “Homosexuals are essentially disagreeable people, regardless of their pleasant or unpleasant outward manner… [their] shell is a mixture of superciliousness, fake aggression, and whimpering.” (He added: “I have no bias against homosexuals; for me they are sick people requiring medical help.”) Before he became president, Ronald Reagan said, “We can debate what is an illness or whether it is an illness or not, but I happen to subscribe to the belief that it”—meaning homosexuality—“is a tragic illness, a neurosis the same as other neuroses.”
Some psychiatrists started to direct a more “biological” approach to “treating” homosexuality. “Homosexuality is in fact a mental illness which has reached epidemiological proportions,” said psychoanalyst Charles Socarides, an infamous practitioner of conversion therapy, which tried to “cure” gay people with analysis. Robert Galbraith Heath, of Tulane’s electrical brain stimulation program, was one such practitioner of bodily “cures” for the “homosexuality problem.” In 1970, Heath implanted electrodes onto the brain of patient B-19, a gay man, and subjected him to rounds of electrical stimulations as he watched heterosexual pornographic movies. According to Heath’s records, the patient reported “continuous growing interest in women” to the point that he wanted to consummate a sexual relationship with one. Heath obliged and brought a twenty-one-year-old prostitute into the lab. Despite the inhospitable surroundings, B-19 “ejaculated” and left the sickening experiment “cured,” at least according to Heath.
When news of the story reached the public, the Medical Committee for Human Rights protested at one of Heath’s events and a local journalist published a long account of Heath’s work titled “The Mysterious Experiments of Dr. Heath: In Which We Wonder Who Is Crazy and Who Is Sane,” a clear reference to Rosenhan’s study.
Gay rights groups had already started fighting back. The same year that Rosenhan started his study, police officers staged a raid on a gay bar in the West Village, inscribing the name Stonewall in the history books and galvanizing the gay rights movement.
But to win the larger civil rights battle, gay men and women had to force doctors to stop labeling their sexual preference a medical condition.
In May 1970, gay activists infiltrated the American Psychiatric Association’s conference in—of all places—San Francisco and “shrinked the headshrinkers,” disrupting seminars and forming a human chain around the facility. “This lack of discipline is disgusting,” said psychiatrist Leo Alexander at the meeting. He diagnosed the problem of one of the protesters. “She’s a paranoid fool,” the doctor said, “and a stupid bitch.” The optics weren’t great for psychiatry. A year later at the APA conference in DC, Dr. Frank Kameny, a gay rights advocate who had lost his job as an astronomer when the US Army’s Map Service learned about his sexual orientation, grabbed the microphone and yelled: “Psychiatry is the enemy incarnate. Psychiatry has waged a relentless war of extermination against us. You may take this as a declaration of war against you.”
Psychiatrists addressed these issues head-on at the 1972 APA meeting in Dallas with a panel with the tone-deaf title “Psychiatry: Friend or Foe to Homosexuals?”
One panelist was John Fryer,1 a young psychiatrist who lost several jobs when employers became aware of his sexual orientation. Fryer agreed to join the panel on one condition: He would remain anonymous. Fryer went to Uniforms and Costumes by Pierre on Walnut Street in Philadelphia and bought a sagging, flesh-colored mask and a black curly wig. He paired these with a baggy tuxedo with velvet lapels and a velvet bow tie, making an unsettling figure sitting on the APA panel. When he spoke, a special microphone distorted his voice as he read from his notes:
With these words, he became the first gay psychiatrist to publicly discuss his sexual orientation. Fryer also revealed that there were many others like him, over a hundred, who belonged to the APA as psychiatrists. This shook up the self-protective, insular field. (Fryer, however, would not publicly reveal his identity as “Dr. Anonymous” for another twenty-two years.) Heterosexual psychiatrists could not imagine that one of their own could have such a debilitating “dysfunction.”
On February 1, 1973, mere weeks after “On Being Sane in Insane Places” was published, the APA’s board of trustees called an emergency meeting in Atlanta to address the many thorns in the side of the profession. Chief among them: the “deep concerns over rampant criticism that attend psychiatry today” (ahem, Rosenhan). The key outcome of this special policy meeting was to revise the DSM-II. Later in 1973, the APA sent questionnaires out to psychiatrists asking them whether or not homosexuality should be included in the DSM as a psychological disorder (you can’t make this stuff up). Even to those who supported removing it, the idea that an “illness” could be stricken out with a survey showed how flimsy the whole operation was, and further supported Rosenhan’s theory that psychiatry’s diagnostic system was arbitrary and unscientific.
Columbia psychiatrist Robert Spitzer, then a junior member of the APA’s Committee on Nomenclature, joined the effort to redo the DSM-II. His first task was to define. “If you’re going to have some people saying homosexuality is not a mental disorder, well, then what is a mental disorder?” Spitzer asked. He scoured the DSM-II to see if any tie bound all of the conditions. “I concluded that the solution was to argue that a mental disorder must be associated with either distress or general impairment,” Spitzer later said. Around that same time, a secret group called the Gay Psychiatric Association invited Spitzer to sit in on a meeting, and this interaction provided the tipping point. If such successful people—without any obvious distress or impairment—could be gay, then how could they call it a disorder? The outcome of this revelation was that the APA scrubbed homosexuality from the new edition of the DSM—though traces remained in the diagnosis “Sexual Orientation Disturbance,” which described people distressed by their sexuality (which, frankly, was probably anyone who was gay during a time when it was considered criminal and ill). A local newspaper satirized the removal with the headline: “Twenty Million Homosexuals Gain Instant Cures.” Other interest groups took note: Veterans lobbied for the inclusion of post-traumatic stress disorder and got it in the manual in 1980; at the same time, feminists expressed their own concerns about diagnoses like “self-defeating personality disorder,” a victim-blaming illness category, they argued, that provided scientific basis for patriarchal oppression. “Not only are women being punished (by being diagnosed) for acting out of line (not acting like women) and not only are traditional roles driving women crazy,” wrote psycholog
ist Marcie Kaplen, “but also male-centered assumptions—the sunglasses through which we view each other—are causing clinicians to see normal females as abnormal.”
Psychiatry didn’t even try to cover up its freak-out.
All around them, other scientists were colonizing space, transplanting hearts, giving deaf people the gift of hearing with cochlear implants. Physicians reported successfully transplanting bone marrow from one woman to another with Hodgkin’s lymphoma. Mammography gave doctors a noninvasive way to look inside the body to detect breast cancer. We were mastering the great mysteries of the world—conquering space, cancer, and infertility. But we still couldn’t properly answer this question: What is a mental illness? Or better yet, What isn’t?
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W. UNDERWOOD
This was an exciting time for those who demanded a revolution in psychiatry’s ranks, and Rosenhan and his study stood on the front lines. Yet, strangely, at the height of his success, Rosenhan began pulling back from the spotlight. Why, for example, had he never finished his book? He had landed a lucrative book deal (the first paid installment, eleven thousand dollars, was the equivalent of an assistant professor’s yearly salary) and had even written eight chapters, well over a hundred pages of it. By 1974, Rosenhan had already shared several chapters with Doubleday book editor Luther Nichols, who was enthusiastic and hungry for more details. In an editorial letter, Nichols promised that success was all but assured. “More work of this kind will get the book finished before you know it,” Nichols wrote, “and then, if present interest can be sustained and certain features enhanced as described above, some very pleasant rewards should come your way. They will be well deserved.” But Rosenhan would never reach out for these “pleasant rewards.” He achieved what few academics ever do—worldwide attention and adoration, earning him a spot among the greats of the field—but in his son Jack’s words, the study “became the bane of his existence.”
The Great Pretender Page 13