The Great Pretender

by Susannah Cahalan

  In the same intake interview with Dr. Bartlett, Rosenhan also said that Mollie “did not know how disturbed and helpless and useless” he was and that he had “thought of suicide” and believed that “everyone would be better off if he was not around.”

  The thoughts of suicide and threats of self-harm, called suicidal ideation, would provide grounds for immediate and necessary commitment. “Active psychosis is one of the most serious comorbid risk factors in suicidal patients,” Dr. Meade said. “To not hospitalize such a patient would be professionally unethical, and, in almost every circumstance, malpractice.” No wonder Bartlett was so insistent that Mollie sign the forms. Rosenhan gave them no choice but to commit him.

  This seemed pretty damning. Out of fairness, could there be any other explanation? Was it possible that Rosenhan was being honest here, that he was feeling suicidal at the time? Problematic as it would be for him to present himself as a “sane, healthy” control case in a study about mental health if he was also sincerely suicidal, was there any possibility that he was following the rules, if not the spirit, of his own experiment, and telling the truth about everything but the voices?

  When I emailed Florence and asked if she knew whether Rosenhan was ever suicidal, she wrote: “It seems to me that any sentient human being, and surely Rosenhan was sentient, has considered suicide.” She added that some of his angry outbursts (he didn’t lose his temper often, but when he did it was frequently dramatic) might easily have been by-products of undiagnosed depression. But Florence acknowledged that the way the doctors portrayed his suffering was more urgent and potentially unsafe, and she firmly doubted that Rosenhan was ever clinically suicidal. At no time in their close friendship had he ever discussed feelings of desperation that cut this deeply.

  Yet, in his intake interview, Rosenhan elaborated with more fabrications—about a long-running feud with an employer and issues with work, adding a layer of desperation that would only heighten his suicide risk. In the interview, Rosenhan mentioned that after he had lost his job in advertising, his wife had to take a part-time job typing and they had to borrow money from his in-laws. “This has been very embarrassing,” Dr. Bartlett quoted “David Lurie.” Yet as far as I have been able to determine, not a word of this is true.

  Furthermore, the two other doctors who examined Lurie not only corroborated Dr. Bartlett’s impressions of the patient’s mental state, but expanded on them. Dr. Browning wrote that Lurie had “placed the bottom of a copper pot up to his ear to differentiate the noises that he was hearing and he tried to interfere with this signal he thought he was receiving” and that he had contemplated suicide but thus far not taken any action because, as Browning quoted Lurie, “I don’t have the guts.”

  In the most charitable reading possible, one could imagine that perhaps Rosenhan worried that his “thud, empty, hollow” symptoms would not be enough to get himself inside the hospital, so he had exaggerated his story to ensure admittance for what, at the time, had been a mere teaching exercise. (None of this, of course, excuses the choice to use tainted data in the study later on, nor to lie about it to Spitzer in the aftermath.) Or perhaps he felt the curious dynamic so often present in doctor-patient relationships where patients want to impress clinicians or convince them of the legitimacy of their suffering by offering up heightened details. Either way, I could now picture Lurie more accurately from Dr. Bartlett’s perspective: a “tense, anxious” middle-aged man whose suffering had grown so acute that he decided to check himself into a psychiatric hospital. What else could Dr. Bartlett have done but help him?

  No matter how much benefit of the doubt one might try to give him, clearly the full story wouldn’t be found in Rosenhan’s papers alone. I had to find Dr. Bartlett.

  Unfortunately, it turned out I was almost three decades too late to hear Bartlett’s story firsthand. Dr. Frank “Lewis” Bartlett had died on May 24, 1989, at the age of seventy-four. He spent three decades working in mental health care, according to his obituary. I tracked down his surviving daughter, listed as “Mary Bartlett Giese of Chevy Chase, MD.”

  Dr. Bartlett’s interest in psychiatry came from his love for his troubled but beautiful wife, Barbara Blackburn, who became deeply ill shortly after the birth of her first child, Mary’s brother Gus. Before he became a psychiatrist, Dr. Bartlett was a rabbit farmer who joined the Merchant Marine, leaving his wife and young child at home. Neighbors intervened when they discovered that Gus, just three years old, had been left to fend for himself while his mother refused to leave her bed for several weeks. This led to Barbara’s first psychiatric hospitalization in California. When she returned home, she spiraled into a depressive state so severe that her own son found her in the kitchen with her head in the oven ready to end her life, at which point her husband gave up rabbit farming, enrolled in medical school, and moved the family to Vermont.

  Bartlett became obsessed with finding a cure for his wife, even after she eloped to California with a fellow psychiatric patient, leaving Dr. Bartlett to raise their two children alone. He published passionate op-eds decrying the treatment of the mentally ill in America and coined the term institutional peonage, comparing forced work during hospitalization to slavery. He even began a pen-pal relationship with Ken Kesey after reading One Flew Over the Cuckoo’s Nest, admitting in one mournful letter that Kesey’s use of lobotomy in the novel’s climax gave him a “creepy feeling” as he remembered “two young colored girls I worked up for a lobotomy ten years ago.”

  Until the very end, deep into retirement, even after the cigarettes got the better of his lungs, these issues still dominated his life. He formed a small group called the Philadelphia Advocates for the Mentally Disabled, basically a helpline that you could call at any hour and Bartlett or one of his associates would come and help a psychotic person on the street find a safe and warm place to stay the night. At his funeral a close friend said, “I just have this picture of Lew coming down the street in that old Plymouth, and it’s snowing, and he’s talking to some guy in a box. And eventually the man emerges and agrees to go to a shelter.”

  When I told Mary about Rosenhan’s study and about Dr. Bartlett’s miscalculation, she told me that he never discussed it with her (and since he was never named, his role in it never became public), but she was sure that it had “hurt him deeply.” This Dr. Bartlett, a man whom I—and likely many of Rosenhan’s readers—had first imagined as a bumbling stereotype, had lived a life dedicated to the cause, a man who intimately understood the toll serious mental illness takes on a person and on a family. Dr. Bartlett wasn’t a bad doctor who made a bad decision. He wasn’t even a good doctor who made a mistake. He was a good doctor who made the best call given the information he received.

  If I could get Bartlett so wrong, had I also been reading Rosenhan wrong?

  And then there was the interview with Rosenhan’s colleague Ervin Staub, emeritus professor of psychology at the University of Massachusetts, Amherst.

  Before I continue, remember: Rosenhan was bald. I’ve mentioned this fact repeatedly because it was one of his most defining characteristics. He lost his hair as a young man, and when people describe him, his domed head and his deep voice are the two features that come up over and over again.

  Professor Ervin Staub, like Rosenhan, studies altruistic behavior in children and adults. His key work is on “active bystanders,” or the study of the people who witness a situation and do (or do not) offer help. (I’m sure I’m oversimplifying, but Ervin’s work reminds me of the Seinfeld finale when Elaine, Jerry, George, and Kramer witness a carjacking, do nothing, and are arrested on a “duty to serve” violation.) Rosenhan befriended Ervin when he came to Stanford in 1973 as a visiting professor. At a party at Rosenhan’s house (such parties were legendary), Rosenhan regaled a group of people with the story of his hospitalization, mesmerizing the crowd with his dramatic tale. He spoke about how “difficult it was to get out.” At one point Rosenhan described a wig that he wore to hide his identity.


  “Do you want to see it?” Rosenhan asked.

  Rosenhan took Ervin and company upstairs to his bedroom where he kept the wig.

  “It was somewhat wild, a bit long,” Ervin said. “It was an interesting wig—kind of right for a professor.” We both laughed out loud at the thought of Rosenhan hamming it up with a long wig. After a few more questions, I thanked him for the enjoyable interview.

  It wasn’t until I returned to the medical records that I stopped at his medical care plan. Not only had Dr. Bartlett described a “balding” David Lurie, but there was also a picture attached to his record: In it, Rosenhan stares straight ahead. Though the photocopy is dark, you can still see the gleam reflecting off Rosenhan’s hairless head.

  Rosenhan wore no wig during his hospitalization.

  As bewildering as the wig story was on its own, the full extent of his distortions came to light once I placed the published study next to the medical record. Rosenhan had even amended the parts of the medical record that he excerpted in his paper, exaggerating and focusing on certain details while dropping other ones.

  The medical record

  This white 39-year-old male… manifests a long history of considerable ambivalence in close relationships, which begins in early childhood. A warm relationship with his mother cools during his adolescence. A distant relationship to his father is described as becoming very intense. Affective stability is absent. His attempts to control emotionality with his wife and children are punctuated by angry outbursts and, in the case of the children, spankings. And while he says that he has several good friends, one senses considerable ambivalence embedded in those relationships also.…

  The version published in “On Being Sane in Insane Places”

  The medical record included no reference to his fluctuating relationship with his parents—nothing about a “warm relationship with his mother” that cooled during his teenage years or a “distant relationship with his father” that intensified with age. Neither of these sentences appeared at any point in his record: “manifests a long history of considerable ambivalence in close relationships, which begins in childhood” or “while he says that he has several good friends, one senses considerable ambivalence embedded in those relationships also.” Even though Rosenhan wrote in his published paper and more extensively in his unpublished book that a psychiatrist fixated on a spanking episode involving his son, there is no mention of this in the medical record, either. Rosenhan invented all of this, while conveniently excising any reference to copper pots or suicidal thoughts.

  In “On Being Sane in Insane Places,” Rosenhan wrote: “The facts of the case were unintentionally distorted by the staff to achieve a consistency with a popular theory of the dynamics of schizophrenic reaction.”

  Instead, it was becoming alarmingly clear that the facts were distorted intentionally—by Rosenhan himself.

  What else, then, was misrepresented in Rosenhan’s study? I’d only begun getting to the truth after my conversation with Bill; now I understood that the other six pseudopatients were the only ones who could fill out the real story. But I didn’t know where to begin looking for them. I didn’t know what hospitals they’d been in. I didn’t even know their real names.

  20

  CRITERIONATING

  In the back-and-forth between Rosenhan and Spitzer, Rosenhan seemed fixated on how Spitzer managed to get his hands on the records, focusing on this transgression to deflect from his own. Eventually, through sheer force of rage, Rosenhan learned that Spitzer received the records, secondhand, from Haverford State Hospital itself. Dr. Bartlett, feeling slighted by Rosenhan’s paper and its misleading portrayal of the care he received, sent Rosenhan’s medical records to a psychiatrist named Robert Woodruff, who would later join the DSM-III task force. Woodruff was vocal in his critiques of Rosenhan’s study and had written a fiery op-ed in the Medical World News, which Bartlett had seen. When Dr. Woodruff heard that Spitzer was organizing a conference on Rosenhan’s paper, he sent Rosenhan’s records to Spitzer. Spitzer knew everything that we know now—how far Rosenhan exaggerated his symptoms, how he unambiguously exaggerated some of the portrayals of his care—yet Spitzer never published these findings. If Spitzer, the “truth seeker,” had all the same information I had, why hadn’t he sounded the alarm about this popular study that was embarrassing his profession?

  Once again, however, it was too late for me to find out. Woodruff took his own life in 1976, so I could not ask him why he remained silent. By the time I learned about the records, Spitzer was battling serious health problems that restrained him from sparring in the arena of academic controversy. The last time that the public heard from him was his 2012 denouncement of his prior research that supported the use of conversion therapy. And then the day after Christmas in 2015, the New York Times ran Spitzer’s obit: “Dr. Robert L. Spitzer, who gave psychiatry its first set of rigorous standards to describe mental disorders, providing a framework for diagnosis, research and legal judgments—as well as a lingua franca for the endless social debate over where to draw the line between normal and abnormal behavior—died on Friday in Seattle. He was 83.”

  I’m left with the actions and words he left behind. Why had he said, once, that his critique of Rosenhan’s study was the paper he was most proud of, “the best thing I have ever written”? Spitzer had even returned to the Rosenhan well in 1976 by writing a follow-up on Rosenhan’s study called “More on Pseudoscience in Science and the Case for Psychiatric Diagnosis.” In it, Spitzer concluded that despite the paper’s glaring issues, Rosenhan got one thing right: his “recognition of the serious problems of the reliability of psychiatric diagnosis”—and Spitzer had a plan in place to solve it.

  “For Spitzer, paradoxically, Rosenhan’s study and the extraordinary publicity it received was manna from Heaven. It provided the final impetus for a study he had been agitating to conduct for some time, to set up a task force of the American Psychiatric Association charged with revamping psychiatry’s approach to diagnosis,” wrote sociologist Andrew Scull.

  In other words, the study was instrumental in achieving Spitzer’s goals: It gave him the grounds to move forward with the overhaul he knew the field needed to survive. So why deliver the fatal blow to something that could be so useful?

  In the spring of 1974, APA medical director Melvin Sabshin tapped Spitzer to shepherd the creation of a new version of the DSM, setting in motion a “fateful point in the history of the American psychiatric profession.” The job was perfect for Spitzer, which worked for everyone because no one else wanted it. Most psychiatrists were far too enamored with sexier, Technicolor explorations of the motivations behind human behavior (with its mining of Greek myths like Oedipus and Electra for sources of interior conflict) to take on the drab black-and-white statistical backwater of diagnosis.

  This new manual would be nothing like the DSM-I, a puny spiral-bound booklet created in 1952 after physicians witnessed the psychic horror that war wreaked; it would render the DSM-II, an analytically oriented text that used Freud-friendly terms like psychoneurotic and phobic neuroses, obsolete.

  This third edition would highlight the teachings of psychiatrists reemerging at that time. “They were determined to create a psychiatry that looked more like the rest of medicine, in which patients were understood to have diseases and in which doctors identified the diseases and then targeted them by treating the body, just as medicine identified and treated cardiac illness, thyroiditis, and diabetes,” wrote Tanya Marie Luhrmann in Of Two Minds.

  Spitzer recruited from the staunchly anti-Freudian, biologically focused constituency at Washington University in St. Louis a group of like-minded psychiatrists who called themselves neo-Kraepelinians, a direct callback to the German psychiatrist who proposed a new diagnostic language with dementia praecox. The Wash U group also referred to themselves as DOPs, or data-oriented persons, whose “guns [were] pointed” at psychoanalysis. Rumor was that they kept a picture of Freud above the urinal in their bathroom. In 197
2 the Wash U contingent published the “Feighner Criteria,” one of the most cited papers in modern psychiatric history, which provided rigorous diagnostic criteria based off a descriptive approach—or the grouping symptoms that are common to diagnosis (again, much as Kraepelin did in the late 1800s)—and set the groundwork for Spitzer’s DSM-III.

  In 1980, the third edition of the Diagnostic and Statistical Manual of Mental Disorders roared to life. The big fat book (494 pages, compared with the DSM-II, which was 134 pages) offered up 265 disorders, more than double the number found in the first edition. The manual scrubbed most psychoanalytic references found in the previous DSMs and successfully ushered psychiatry back into the good graces of mainstream medicine. The DSM-III introduced “axes.” Axis I was devoted to disorders such as anxiety, anorexia, schizophrenia, and major depression. These were different from the personality disorders (like borderline, sociopathic, and narcissistic personality disorders) and developmental disorders in Axis II, described as “conditions and patterns of behavior that are defined as enduring, inflexible, and maladaptive.” The third axis was devoted to “physical” disorders, like cirrhosis of the liver, pneumonia, encephalitis, and brain tumors.

  Diagnosing patients would never be the same, nor would interviewing them. Patients who expected open-ended psychoanalysis were surprised to find doctors boxed in by literal boxes—doctors were provided diagnostic criteria to tick off one by one, a process that some have called “the Chinese menu” approach. It may not have been creatively fulfilling, but now there were strict boundaries in place that kept psychiatrists from drawing outside the lines if they wanted reimbursement from insurance companies, who had fully embraced the manual. The goal was to make diagnosis standardized in such a way that someone in Maine who was diagnosed with schizophrenia would be diagnosed using the same criteria as someone in Arizona, ensuring that psychiatrists on either side of the country had a far greater chance of making the same diagnosis if they were faced with the same patient. Doctors now had a shared language. Reliability.