The Great Pretender

by Susannah Cahalan

  R. D. Laing came to Esalen in 1967, speaking in his enchanting Scottish brogue about his work at Kingsley Hall, a house in the East End of London that provided therapeutic supportive housing as an alternative to hospitalization. Kingsley Hall was a utopian place, Laing said, with no de-individualization, no power struggles over keys, no forced meds, where people engaged in twenty-four-hour therapy sessions and meditated. (He didn’t mention the young woman who smeared feces on the walls, the LSD sessions, the drug raids, or the parade of celebrities who gawked at the scene, but that’s a different story.)

  That same year psychologist Julian Silverman, a National Institute of Mental Health schizophrenia researcher, arrived at Esalen to teach a seminar on “Shamanism, Psychedelics, and the Schizophrenias.” He wasn’t your typical buttoned-up doctor type. Silverman had befriended the Grateful Dead and followed the teachings of John Rosen, the inventor of “direct analysis,” which used psychotherapy to treat schizophrenia by basically babbling with the patient. (Rosen later lost his license after patients accused him of sexual and physical abuse, landing him on the long list of doctors who exploited people under their care then and now.) Silverman and Price hit it off, and out of their friendship grew Ward 11, a way to scientifically test Laing’s therapeutic housing theories.

  Dick Price offered to supply funding from Esalen’s coffers, and the National Institute of Mental Health supplied grants. Somehow they convinced Agnews to allow them access to a ward where they could conduct the experiment. Maurice Rappaport and Voyce Hendrix (yes, he’s a close relative of that Hendrix) joined in to work in “ding dong city,” as Silverman lovingly called it.

  They selected a few Agnews staff members, vetted to be young, far out, and open-minded, to travel to Esalen to learn Gestalt therapy. The staff discouraged separation created by “the cage” and set up a quiet vigil room, where anyone who felt overwhelmed could get away and sit and pray or just think. Staff members were to interact with the patients as much as possible. Patients were allowed to roam freely throughout the ward—a big no-no in most hospitals, which steer patients into dayrooms so that they can be watched from the cage. The criteria were simple: Men between the ages of sixteen and forty, recently diagnosed with schizophrenia without prolonged history of mental illness, would live on Ward 11. They wanted patients with no prior hospitalizations—most of them were “first breaks.” Half would receive nine tablets a day of the typical course of Thorazine, a minimum of three hundred milligrams a day, while the other half would receive a placebo. (Interestingly, Bill Dickson himself, who was in a nearby ward, did fit the above criteria. It’s possible that he was considered for inclusion in the study, but he is confident he was never included.)

  The beginning was rough, to put it mildly. “The first thing we did was take some patients from the hospital and take them off medication. They broke all the windows the third day,” Alma Menn, a social worker on Ward 11, told me.

  The new freedom created some friction, it seemed.

  “We only really had one fire,” Alma added.

  The fire occurred during a visit by a psychotherapist, who lugged in a bin of toys, dolls, and musical instruments to facilitate playacting with adults. The staff rifled through the props alongside the patients. That’s when the fire department walked in.

  “Of course I had been holding my skirt on my head and playing like a mermaid. We all had an instrument and were playing music,” Alma said. “[The firemen] walked around the corner and there was a patient who’d been in bed and was standing at the drinking fountain with a cup trying to put out the fire that he had started on his mattress.”

  The result of all this playing was published in the 1978 paper “Are There Schizophrenics for Whom Drugs May Be Unnecessary or Contraindicated?” The paper showed that of the eighty patients studied, the placebo group showed greater improvement than its drugged counterpart, though both groups showed improved long-term outcomes over patients undergoing “typical” hospitalizations.

  Rappaport’s study added to the growing backlash against the “take your drugs” approach endemic to the traditional hospital settings. Patient groups, who now called themselves psychiatric survivors, had already started pushing against this refrain by filing class-action lawsuits against Big Pharma as many patients experienced permanent, disfiguring side effects. Suddenly these miracle drugs didn’t seem so miraculous—in some cases they were downright dangerous.

  Rappaport et al. gave an alternative approach scientific basis—though mainstream psychiatry successfully dismissed the findings as fringe science, missing the larger picture that the creation of a supportive environment had actually improved clinical outcomes for everyone. Something as simple as sitting and eating together, as listening, as goofing around, as playing dress-up, as being part of a community seemed to help.

  Even though mainstream psychiatry ignored it, a series of “med-free sanctuaries” sprouted up around California. The most prominent person to take on the mantle of Ward 11 was Loren Mosher, the head of the NIMH’s Center for Studies of Schizophrenia, who saw an opportunity to take Ward 11 to the next level. He recruited Ward 11’s cast of characters—including Alma Menn and Voyce Hendrix—to start Soteria House, an experiment in communal living located in a twelve-room Victorian house in downtown San Jose. Here a group of six people who would have ended up in an asylum lived together outside of it. The average stay was forty-two days—much shorter than the six-month average in an institutional setting—while the total doses of antipsychotic medications were three to five times lower. Papers published extolled the value of the environment and the success rate of using minimal antipsychotic drugs. As at Laing’s Kingsley Hall, there was neither commitment nor forced medication. One of the board members who helped mold Soteria House—and here it all comes full circle—was David Rosenhan, in the midst of the success of his groundbreaking study whose theories questioned the powers of traditional psychiatry and its hospitals.

  Over twelve years the outcomes of people living at Soteria, named after the Greek goddess of safety and salvation, varied. There were a few suicides. Some got worse and had to be hospitalized, but many reported that Soteria House was a transformative and ultimately healing experience. One former Soteria resident I interviewed credits his current life—he is a successful technology salesman with a wife and two children—to Soteria. It’s easy to dismiss Soteria House, as many do (and as I did at first), but its mission captured something essential missing from the institutional model: focusing on the patient, not the illness.

  The Soteria model continues in places like Alaska, Sweden, Finland, and Germany. There are echoes of it in the clubhouse model, which predates Soteria but provides similar restorative support, along with housing and employment opportunities to people living with serious mental illness. We see it also in Geel, a small town in Belgium with a long history of providing a safe haven to those with mental illness, where foster families in the community adopt “guests,” not patients. In Trieste, Italy (where a young Sigmund Freud first studied the sexual organs of eels), people are respected as members of the community with access to care across a wide spectrum of needs, along with supportive social networks.

  The legacy of Agnews’s Ward 11 is a long one. Sadly, Esalen’s Dick Price probably did not get to bask in the immediate celebrations surrounding the launch of his successful research study. Just before the project commenced in 1969, Price suffered another break. He began ranting about “having more kingdoms to conquer,” believing that he had channeled a whole host of historical figures, including Napoleon and Alexander the Great, and spent ten days in, of all places, Agnews State Hospital. Price did eventually recover and returned to Esalen, where he lived peacefully until his death in 1985.

  16

  SOUL ON ICE

  Meanwhile, in the same facility, Bill’s time on the acute ward was coming to an end. He spent forty-eight hours there before the hospital deemed him well—or rather, still unwell enough to be moved to the residential floo
r. The residential floor was less like a hospital, with lounge chairs and windows that lined the dayroom, giving it a “homier” feeling than the dark, gloomy acute floor. An outdoor space was open to those with grounds privileges (until a patient successfully jumped the wooden fence around it). Psychiatrists rarely visited the wards, and when they did their interactions with patients were swift and dismissive. A blunt male psychiatrist whose pointed questions bordered on the absurd had already been primed to ask Bill about his drug use and sexual orientation—foregone conclusions made by the previous psychiatrist, who had spent a mere half hour with him. Bill still received three daily doses of antipsychotic medication, but after that first incident in the cafeteria, he had learned how to properly dispose of the pills.

  The other patients were like him, young hippies. Well, most of them. There was “the crawler,” a young man in his mid-twenties who spent the majority of the day on his hands and knees navigating the grounds like a baby. “He was a very weird dude, obviously,” Bill said. “But I was talking with some other guys at one point, and we were just standing around talking and he’s crawling around. He crawls over to our area, gets up, and we start talking about college. He knew I was a college student, and he had been at junior college, community college somewhere in the area, and so we started talking about college courses, you know, and how hard it was and all that kind of stuff, and then we finished our conversation and he got back on his hands and knees and crawled off.”

  “Wow. It’s kind of comical,” I said.

  “It is, but it’s also… I mean, I think for a lot of people who are labeled psychotic, if you keep them out of the area that their psychosis is focused on, they can seem normal.” This observation would become the linchpin of Rosenhan’s work—that crazy people didn’t act crazy all the time; that there was a continuum of behavior that ran from “normal” to “abnormal” within all of us. We all slide around it at various times in our lives, and context often shapes the way we interpret these behaviors.

  Under the harsh glare of the hospital’s lights, Bill couldn’t help but reexamine his own idiosyncrasies, like his tendency to make loose associations and veer into tangents. “When people talk about something it reminds me of something extraneous, and… I often bring that into the conversation,” he said. “But taken to the extreme, you end up with the clang associations that you get with [serious mental illness]. There’s a dividing line in there somewhere. You could probably argue that everyone has something odd. I mean what is normal, what is sane?”

  Bill’s friend Samson joined him in the step-down unit. He and a few other patients had Bill pegged for a journalist because of his constant writing. “I don’t believe you’re a real patient. I think you’re checking up on the doctors,” Samson would say, reflecting a suspicion that Rosenhan also encountered. But not one of the doctors caught on, Bill told me.

  One morning, a nurse woke Bill up with a start. “Wake up, Mr. Dickson, you have to go see a doctor. You have diabetes.”

  Bill was shocked. He’d never had medical issues before—he’d hardly ever had a fever, let alone diabetes. How could he be so sick and no one told him? As he walked with the nurse to the doctor’s office, he remembered that his uncle had diabetes and had suffered debilitating side effects. The realization that Bill now had it, too, was chilling—especially when the nurse seemed so nonchalant about it. He’d have to make arrangements to get out as soon as possible to see a doctor; he’d have to tell his wife; he’d have to take those shots every day. Lost in thought, he hardly noticed when the nurse returned and told him he could leave.

  “You’re the wrong guy,” she said. She didn’t seem embarrassed or even apologetic. He was simply the wrong guy. Apparently, there was another Dickson on the ward (who was a good deal older, looked nothing like Bill, and lived in another building). The breeziness of the hospital’s mistake unnerved Bill. “I mean, jeez, if I was this close to getting treated for diabetes, what if it had been, you know, a lobotomy?”

  Maryon visited as often as she could, juggling the kids and the chores while ignoring the chorus of neighborhood questions about her missing husband. She couldn’t relax. “I guess I’d seen enough movies or something to know that they could haul him off and, you know, do a brain…,” she began, and then stopped. Even from the safe distance of nearly half a century, it was still hard for her to finish. “That they could do a lobotomy.”

  She wasn’t exactly being dramatic. Bad things could and did happen. Bill did not know this, but a psychiatrist who worked at Agnews at the time was nicknamed “Dr. Sparky” by the staff because of his fondness for electroshock therapy. “He would do [it] on anybody—and that includes the staff—if he had the chance,” former Agnews social worker Jo Gampon told me. Electroshock started with Italian doctor Ugo Cerletti, who came up with the idea after his assistant visited a Roman slaughterhouse and witnessed how subdued the pigs became after they were shocked with electrical prods on the way to be slaughtered. Oddly, a lightbulb went off. Electroshock took off in America in the 1940s, and Agnews zealously embraced the procedure. A psych technician from that era shuddered when he recalled the weekly lineups. “Our job was to hold the bodies down,” he told me. “One, after the other, after the other.”

  I saw an electroshock box at Patton State Hospital’s History of Psychiatry Museum and was pretty surprised at how small and portable the machine looked. This cute machine could do all that? I thought of the movie The Snake Pit, when Olivia de Havilland seizes on the table, her head thrashing back and forth, her body stiffening—it turned out the filmmakers did a good job of portraying the procedure, I learned. Patients would sometimes break their backs or necks during the induced seizures. Some would bite straight through their tongues. The “clever little procedure,” Ken Kesey wrote in One Flew Over the Cuckoo’s Nest, “might be said to do the work of the sleeping pill, the electric chair and the torture rack.”

  Doctors tell me that the treatment today, now called electroconvulsive therapy (ECT), has little in common with the electroshock therapy that Kesey described. ECT is deployed today for patients who are “treatment resistant,” the third of people with depression who don’t respond to meds. Psychiatrists say that it has evolved “to the point that it is now a fully safe and painless procedure” and is paired with an immobilizing agent to temper any body movements and with general anesthesia so that the patient is unconscious for the duration of the procedure. The amount of current administered is far less than it was then—and memory impairments are reportedly minimal. In one study, 65 percent of patients reported that getting ECT was no worse than going to the dentist. Still, a vocal community, who often picket at APA meetings, say that the possible side effects, including memory loss and cognitive defects, make it “a crime against humanity.” In recent years, more hospitals have used it on the East Coast than the West—a product, some say, of Hollywood’s vilification of the procedure.

  Maryon smuggled in for Bill a copy of the book Soul on Ice, a collection of essays written by Eldridge Cleaver, who, while an inmate in a maximum-security prison, chronicled his awakening from a drug dealer and a rapist to a Black Panther and a Marxist.

  One of the attendants saw Bill reading the book and struck up a conversation, as if seeing Bill as a human being for the first time.

  “What did you talk about?” I asked.

  “Well, just about the book, and just about stuff, you know, life in general, women.”

  “That’s interesting, because I haven’t heard much about any interactions with the ward, with the attendants. But it seems like it was pretty positive, he treated you like…”

  “Yeah, yeah, he treated me like a person, in fact he said as he was leaving to go to something else, he said, well, ‘You probably won’t be around here long,’ which I took to mean you’re kind of normal so you’ll be getting out of here.”

  As Rosenhan had valued his original, respectful conversation with the attendant Harris (before Harris learned that Rosenhan was a pati
ent, not a doctor), Bill found this interaction gratifying, precisely because it was so rare. He missed being treated as a normal human. He decided it was time to leave.

  The how of his release is fuzzy. Rosenhan didn’t write anything in his book about it, just that after eight days Bill “suddenly” remembered that he had an event that he had to attend. Bill said he just told the hospital that he wanted to leave (he really wanted to attend a motocross off-road racing event north of San Francisco), and they let him go. There is no indication that he even left with a discharge plan or against medical advice, as Rosenhan said all of the patients did. Did his psychiatrists use the term in remission? Did they arrange for him to take meds on the outside or set him up with a support system in the community? Bill didn’t think so. I tried to track down the hospital records, but all that remained was one sheet of paper with the “reason for discharge” blank.

  One psychiatrist did pull Bill aside, though, and say, “Sometimes, you know, things just kind of seem to build up on people and it’s just hard to deal with, and it’s really tragic if people do something when they’re feeling under that kind of stress that can’t be undone.”