And then, after years of being dismissed as a soft science, talk therapy, too, has seen a reconsideration as studies have shown that for some people, therapy creates profound changes in the brain—as pronounced, in some cases, as psychiatric medication. “Psychotherapy is a biological treatment, a brain therapy,” said Nobel Prize–winning psychiatrist and neuroscientist Eric Kandel in 2013. “It produces lasting, detectable physical changes in our brain.”
“One sees as far as one is limited by the technologies of that time,” said Lancet Psychiatry editor Niall Boyce. “If we were to draw an analogy, I’d say that we’re at the point of infectious disease research [when] the microscope has just been invented, and the story is really sort of getting cracking.” Child psychiatrist and geneticist Matthew State of the University of California at San Francisco uses a similar analogy, adding: “It’s true, [it’s like having] a microscope for the first time. And it’s not like a single microscope; we have like three different microscopes that we’ve never had before.”
There is, some say, a lot to be encouraged about.
Even Dr. Torrey, the same man who told me that the field hasn’t truly advanced since 1973, is optimistic. “You’re going to see the whole thing turn around,” he said.
“You think so?” I asked.
“Oh yeah. Keep your notes. Thirty to forty years from now, you’ll be writing something totally different.”
But we can’t sit back, fold our hands, and wait for the future to solve all our problems, because even if we gain all the insights we seek, there is still the unresolved issue of basic care and treatment on the ground level. So while this or that brain imaging technology makes its way through the ivory towers of academia, people are still languishing on the streets, hidden in the general population, or behind bars, neglected by all of us.
In response to this tragic situation, people like UCLA psychiatrist Joel Braslow, a practicing psychiatrist and historian, have come to this position: “In spite of the fact that state hospitals were incredibly overcrowded and often being seen as custodial… at least we were caring for people then. Now we’re not.”
The late neurologist Oliver Sacks agreed, writing in his essay “The Lost Virtues of the Asylum” that “we forgot the benign aspects of asylums, or perhaps we felt we could no longer afford to pay for them: the spaciousness and sense of community, the place for work and play, and for gradual learning of social and vocational skills—a safe haven that state hospitals were well-equipped to provide.”
When I first heard this reexamination, I thought of Nellie Bly. We’ve already tried that, and see how well it worked out? The snake pits of the past were a grotesque chapter in the history of medicine and the last thing we want to do is return to them. Yet you can’t call what’s happening now progress.
Three University of Pennsylvania ethicists, Dominic Sisti, Andrea Segal, and Ezekiel Emanuel, wrote an unfairly pilloried article subtitled “Bring Back the Asylum” in 2015. In it they argue persuasively for a new model of care that takes the best of the past and adapts it to a modern medical setting. No one can improve without the bare minimum—shelter, clothing, and food—but they also need care: intelligent medical intervention, personal contact, community, and meaning. In a perfect world (where money flowed freely into medical care), the authors envision a comprehensive approach that could provide all of the above—from full-time, inpatient care for the most acute and long-term beds for the most chronic, to community-based, family-supported outpatient therapy for those recovering: a tiered system (with ICUs, step-down units, and rehabilitation centers) like those that treat people with nonpsychiatric maladies.
Still, the paper’s authors faced rampant criticism when their article was published—and Dominic Sisti even lost a contract with the city of Philadelphia’s Division of Community Behavioral Health. One of the people who decided to pull his funding called his work “a disgrace.”
“The debate boils down to one question: What counts as a mental disorder?” Dominic said. “Fights about involuntary treatment, long-term care: If you dig down deep enough, it comes down to the disagreement over the fundamental concept of a ‘mental disorder.’ These are the stakes.”
These impossible questions have plagued us forever—the physical versus mental, brain versus mind—and they have profound, life-or-death consequences. As time marches on, the goalposts may move and the definitions may change, but it’s the same story again and again—we consider some illnesses to be worthier of our compassion than others. And this has to change.
The change doesn’t just require adding beds somewhere and letting people languish, it means taking a broader look at the infrastructure of each person’s life—past and present—and the myriad ways environment shapes both sickness and health.
“The brain is extremely plastic,” Dr. Maree Webster, the director of the Stanley Medical Research Institute’s Brain Research Laboratory, told me. “Every experience you have changes your brain in a certain way. And so all this stuff—I mean it’s very out of fashion thanks to psychoanalysis—but [early-life experiences], parenting, child abuse, these things increase your risk of developing a mental disorder.” Environmental factors—obstetric complications, living in an urban area, experiencing trauma as a child, migrating to a new country, using cannabis, even owning a cat1—may increase the risk of developing a serious mental illness. In the United Kingdom, for example, the higher incidence of schizophrenia found in the Caribbean population has been linked to social factors like migration, social isolation, and discrimination.
Living in cities is linked to higher rates of schizophrenia. Why? It’s unclear, but many have posited that urban environments are missing one element found in smaller, more tight-knit areas: support and community, a key part of the healing element found on Ward 11 and in Harry Lando’s hospitalization.
Other research bolsters this conclusion. A two-year government-funded study published in the American Journal of Psychiatry has shown that early intervention after “first breaks”—or the first time experiencing the profound symptoms of serious mental illness—involving antipsychotic medication management combined with a “comprehensive, multi-element approach,” which includes family support and psychotherapy, created the best outcomes.
New research and treatment models have emerged to train people who are troubled by hearing voices to better manage their lives alongside the auditory hallucinations—not by shutting the voices out completely but by interacting with them directly. Yale researchers found that a key difference in the hallucinatory experiences of psychics and of people with schizophrenia was that the psychics placed the voices in the context of a spiritual or religious experience, and were less disturbed by them. These new approaches to treating voice-hearing are supported by researchers at Stanford, who compared the experience of auditory hallucinations in people diagnosed with schizophrenia in the United States with those in developing countries. In America, where patients tend to subscribe to the biological model of mental illness, the patients reported antagonistic relationships with their hallucinations; the voices themselves were more likely to include violent, aggressive, and negative content. People in Chennai, India, and Accra, Ghana, by contrast, described more positive communions with their voices and reported better long-term outcomes. “Are those cultural judgments the cause of the illness?” Stanford anthropologist Tanya Marie Luhrmann asked. “Absolutely not. Do those cultural judgments make it worse? Probably.”
One popular therapy that takes these cultural judgments into account is open dialogue therapy, which is meant to create an immersive community support system that practitioners say eventually allows for the reduction of antipsychotics while mining the content of a person’s psychotic experience (which sounds like it would happily coexist with therapy at Soteria House or at R. D. Laing’s Kingsley Hall). Open dialogue has emigrated from its birthplace in Finland to McLean Hospital in Massachusetts, a private psychiatric hospital ranked number one in the US. I saw McLean’s version of op
en dialogue therapy in person and was struck by how simple it was: They treated the patient like a person.
The best in the field are expert at doing exactly that—relating to people and identifying symptoms that may be too subtle to pick up with other, more objective medical measures. This requires long meetings with patients where in-depth histories are taken and a sense of trust develops. Psychiatry at its best is what all medicine needs more of—humanity, art, listening, and empathy—but at its worst it is driven by fear, judgment, and hubris. In the end, the takeaway, repeated again and again in my interviews, is: Medicine in general, and psychiatry in particular, is as mysterious and soulful as it is scientific.
You’ve heard of the placebo effect—its press is almost as bad as psychiatry’s. The term originated in a religious context with the psalm Placebo Domine, “I shall please the Lord,” but by the fourteenth century had taken on a more negative association within the church to describe fake mourners paid to attend funerals to “sing placebos” about the dead. The word made its way into medicine five centuries later, when, in 1772, Scottish physician and chemist William Cullen gave his patients mustard powder treatments for all manner of ailments, even though he knew it was a sham: “What I call a placebo.” After World War II, researchers started to use sugar pills as controls to gauge the effects of “real” medicines. By the 1960s, the FDA had set double-blind placebo-controlled studies as the gold standard. And over time these seemingly inert sugar pills were found to have measurably physical effects on the body—though these effects were often viewed as illegitimate, mere noise that often got in the way of drug approval. Now we know that placebos set off complex parades of neurotransmitters—endorphins, dopamine, endocannabinoids, and others. If you receive a saline solution that you believe is morphine, your body reacts as if you have received six to eight milligrams of the drug—the equivalent of a pain-reducing dose. Parkinson’s patients will release dopamine, sometimes even enough to control their involuntary movements, when they believe they’re getting real L-Dopa drug treatments.
You can even augment the effects of a placebo with a caring, supportive environment, where the patient not only believes in the drug, but also believes in the doctor. Dr. Ted Kaptchuk, who heads the Program in Placebo Studies & Therapeutic Encounter at Harvard, pushes doctors to harness the power of the placebo in a more straightforward way. “Ultimately it’s about being immersed in a world where we know that we’re taken care of by healers, and that’s the bottom line,” Dr. Kaptchuk told me. “Every word counts, every glance counts, every touch counts. The five milligrams of a good medicine is very important, but it’s more effective if you take it in the context of being aware that the healer, the doctor, the nurse, the physical therapist, also have an effect on the patient.”
Just spending more time with the patient can improve outcomes. In a study of acid reflux sufferers, a group that had a forty-two-minute consultation with a doctor did twice as well as one that had only eighteen minutes. To reflect their very real role in healing, some doctors are pushing to rebrand the placebo effect to “contextual healing,” “expectation effects,” or even “empathy responses.”
This makes me think of my doctor Souhel Najjar, who had access to the fanciest, most cutting-edge tests, but whose breakthrough in my care came when he sat down on my bed, looked into my eyes, and said, “I’m going to do everything I can for you.” My family and I believed in him; and I know in my core that his warmth and optimism helped me heal.
This faith in medicine, our healers, our diagnoses, our institutions is what Rosenhan helped shatter, what Spitzer helped rectify, and what the controversies over the DSM-5 and the horror stories of our jail and prison systems have further shaken. Belief is what psychiatry has lost—and what it needs to survive.
This belief in a better way is what compelled the father at the beginning of this story to write to me about his son with schizophrenia. “Each time they tell me that schizophrenia is a lifelong condition, I ask them, ‘What allowed Susannah Cahalan to escape the same diagnosis?’” he wrote in a follow-up email. Even as his son’s condition has worsened, he has held on to a conviction that some change will come. I admire that so much.
This hope is essential. One mother told me about her experience navigating the mental health industry with her son, who was diagnosed with schizophrenia. After he started hearing voices in his teens, he was offered only a long list of medications that seemed to harm him more than help, because mainstream medicine insisted that there was no cure for schizophrenia. “If I’d adopted the conventional wisdom and accepted that my son would never get well, I’d have abandoned all hope,” she explained. Instead, she tried everything else: orthomolecular treatment, which involved giving her son high levels of vitamin B, and trying out energy medicine, magnets, and “gemstone caps” that pulsed energy into his body. She met with shamans and holistic psychiatrists; she channeled dead ancestors, dosed him with plant essences, tried to remove the copper from his body, and bought him a device that would shield him from “e-smog,” or electromagnetic radiation. Some people who hear this list might think she had lost her own grip on reality. But I don’t think so. I think she is searching for options beyond merely surviving, searching for answers that might make her son happier and healthier. She continues to do so today. Can any of us blame her?
I refuse to plug my ears and continue to believe that we all live in a world where everyone finds their Dr. Najjar. I’ve met enough people like her in the trenches living with mental illness and talked to enough families advocating for ill loved ones to discount the disconnection between the dreams of the future and the reality of the present.
I know all too well that I am one of the lucky ones. My story is a bright and shining example of what can happen when cutting-edge neuroscience meets thoughtful doctoring in the most opportune conditions. More than piles of data or years of careful research, stories make us believe. And belief is a pedestal on which great medicine stands.
Even though I know it’s a luxury many of us cannot afford, I still choose to believe. Though I’m painfully aware of terrible leads we’ve followed and the false promises of the past that were spurred on by bad science and blind hubris, I am still optimistic.
Yes, I’m skeptical when I hear of a new treatment or study “proving” this or that breakthrough, but I hold tight to the belief that what happened to me—finding a cure for what seemed to be “in the mind”—can happen to everyone. I’ve seen it happen over the years as I’ve traveled the country speaking on this topic, while also hearing the many heartbreaking ways medicine has failed others.
I believe in all the excitement emerging from neuroscience. And I believe that we will unravel the mysteries of the mind. I believe that we will puzzle out the seemingly unsolvable. I also believe that the puzzle is too complex for the human mind to grasp.
I am aware of all of the arrogance, incompetence, and failure, but I still believe that psychiatry—and the whole of medicine—will one day be deserving of my faith.
I believe. I believe. I believe.
EPILOGUE
Whenever the ratio of what is known to what needs to be known approaches zero,” Rosenhan wrote, “we tend to invent ‘knowledge’ and assume that we understand more than we actually do. We seem unable to acknowledge that we simply don’t know.”
Unlike Rosenhan, I don’t want to “invent knowledge” where it’s lacking. The truth is that I simply don’t know so much. I know that David Rosenhan exaggerated and fabricated parts of his own story, the results of which were introduced on one of the most exalted pedestals in academia. I know Rosenhan’s flawed work had an effect on Robert Spitzer and the creation of the DSM. I know that the study had a wide influence, contributing to the shuttering of psychiatric hospitals. I know that at least one pseudopatient’s experience supported Rosenhan’s thesis—and I know that one did not. I don’t know why he never finished his book, why he never published on the topic again, or how he would feel about this book. I
can guess, but I cannot know.
I don’t know what happened to the other six pseudopatients. Did they exist at all? I will admit that I still keep imagining all the different ways a pseudopatient could unmask herself (maybe I’ll walk down the street one day, and I’ll feel a light tap on my shoulder, turn around, and there you are). Because in the end I believe that he exposed something real. Rosenhan’s paper, as exaggerated, and even dishonest, as it was, touched on truth as it danced around it—the role of context in medicine; the dismissal of psychiatric conditions as less legitimate than physical ones; the depersonalization felt by the mentally ill “other”; the limitations of our diagnostic language. The messages were worthy; unfortunately, the messenger was not.
When I had unearthed everything I could possibly find, I met with Lee Ross, the Stanford psychologist who introduced me to Rosenhan, and with Florence, my Rosenhan whisperer—the two living people intellectually closest with Rosenhan and most responsible for my obsession with him—to share my findings. Lee wrestled with his reaction to the news that Rosenhan may have fabricated his work. We sat in his living room and picked apart the arguments. Florence shared her perspective: “I was surprised initially when Susannah suggested that, but I don’t find it reprehensible,” she said. “I know I should, and it’s science, but knowing David, David had a certain prankster quality to him.”
Florence has seen as much of Rosenhan’s files as I have and has no doubt that Rosenhan made up a good bulk of the paper, but she is more forgiving about the liberties he took. She likened him to a novelist creating a scene. She did not see him as a villain—she loved the man—but more as a rascal who had successfully punked the world; or, as she put it, as a latter-day Till Eulenspiegel, a prankster evoked in many German fairy tales, who “plays practical jokes on his contemporaries, exposing vices at every turn, greed and folly, hypocrisy and foolishness.
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