The Great Pretender

by Susannah Cahalan

  these hospitals were “superfluous” institutions… Scull, Decarceration, 73.

  “therapeutic tyranny”… Thomas Szasz, The Manufacture of Madness: A Comparative Study of the Inquisition and the Mental Health Movement (Syracuse: Syracuse University Press, 1970).

  “merely a symptom of an outdated system”… George S. Stevenson, “Needed: A Plan for the Mentally Ill,” New York Times, July 27, 1947.

  “liquidated as rapidly”… Isaac and Armat, Madness in the Streets, 69.

  California governor Ronald Reagan closed… Torrey, American Psychosis.

  Modesto… “Inventory of the Department of Mental Hygiene—Modesto State Hospital Records,” Online Archive of California, https://oac.cdlib.org/findaid/ark:/13030/tf267n98b9/?query=Modesto.

  Dewitt… “Inventory of the Department of Mental Hygiene—Dewitt State Hospital Records,” Online Archive of California, https://oac.cdlib.org/findaid/ark:/13030/tf396n990k/?query=Dewitt+state+hospital.

  and Mendocino State Hospitals… “Inventory of the Department of Mental Hygiene—Mendocino State Hospital Records,” Online Archive of California, https://oac.cdlib.org/findaid/ark:/13030/tf2c6001q2/.

  converted Agnews into an institution.… “Agnews Developmental Center,” State of California Department of Developmental Services, https://www.dds.ca.gov/Agnews/.

  “better off outside of a hospital”… E. Fuller Torrey, Out of the Shadows: Confronting America’s Mental Illness Crisis (New York: Wiley, 1996), 143.

  Rosemary Kennedy’s first hours… Rosemary’s story was compiled from two recent biographies: Kate Clifford Larson, Rosemary: The Hidden Kennedy Daughter (New York: Houghton Mifflin Harcourt, 2015); and Elizabeth Koehler-Pentacoff, Missing Kennedy: Rosemary Kennedy and the Secret Bonds of Four Women (Baltimore: Bancroft Press, 2015).

  the official label was “mentally retarded”… Larson, Rosemary, 45.

  Moniz, who received a Nobel Prize… For more about António Egas Moniz and Walter Freeman, read Jack El-Hai, The Lobotomist: A Maverick Medical Genius and His Tragic Quest to Rid the World of Mental Illness (Hoboken, NJ: Wiley, 2005).

  Neurologist Freeman would adapt… For a devastating, must-read piece on Walter Freeman’s legacy, see Michael M. Phillips, “The Lobotomy Files: One Doctor’s Legacy,” Wall Street Journal, December 13, 2013, http://projects.wsj.com/lobotomyfiles/?ch=two.

  Sixty percent of lobotomies were conducted on women… Jack El-Hai, “Race and Gender in the Selection of Patients for Lobotomy,” Wonders & Marvels, http://www.wondersandmarvels.com/2016/12/race-gender-selection-patients-lobotomy.html.

  one study in Europe found that 84 percent… Louis-Marie Terrier, Marc Leveque, and Aymeric Amelot, “Most Lobotomies Were Done on Women” (letter to the editor), Nature 548 (2017): 523.

  “It’s nothing we want done”… Lyz Lenz, “The Secret Lobotomy of Rosemary Kennedy,” Marie Claire, March 31, 2017, https://www.marieclaire.com/celebrity/a26261/secret-lobotomy-rosemary-kennedy.

  Dr. Watts drilled burr holes… Dittrich, Patient H.M., 75–77, and Larson, Rosemary, 168–70.

  “a painting that had been brutally slashed”… Laurence Leamer, The Kennedy Women: The Saga of an American Family (New York: Random House, 1995), 338.

  she didn’t visit her daughter… Larson, Rosemary, 175.

  where she remained until her death… “Rosemary Kennedy, Senator’s Sister, 86, Dies,” New York Times, January 8, 2005, https://www.nytimes.com/2005/01/08/obituaries/rosemary-kennedy-senators-sister-86-dies.html.

  “yet more danger, death”… Larson, Rosemary, 180.

  “I have sent to the Congress today”… John F. Kennedy, “Remarks upon Signing a Bill for the Construction of Mental Retardation Facilities and Community Mental Health Centers, 31 October 1963,” John F. Kennedy Presidential Library and Museum archives, https://www.jfklibrary.org/asset-viewer/archives/JFKWHA/1963/JFKWHA-161-007/JFKWHA-161-007.

  “U.S. Army psychiatrists in World War II”… Appelbaum, Almost a Revolution, 8.

  “prolonged hospital stays might”… Appelbaum, Almost a Revolution, 8.

  “an ongoing exodus of biblical proportions”… Torrey, American Psychosis, 76.

  “payer, insurer, and regulator”… Richard G. Frank, “The Creation of Medicare and Medicaid: The Emergence of Insurance and Markets for Mental Health Services,” Psychiatric Services 51, no. 4 (2000): 467.

  Institutions for Mental Diseases (IMD) exclusion… “The Medicaid IMD Exclusion: An Overview and Opportunities for Reform,” Legal Action Center, https://lac.org/wp-content/uploads/2014/07/IMD_exclusion_fact_sheet.pdf.

  leaving the mentally ill to vie… Torrey, American Psychosis, 164.

  Medicaid continues to be the United States’… Alisa Roth, Insane: America’s Criminal Treatment of Mental Illness (New York: Basic Books, 2018), 91.

  “‘medicalized’ treatment settings”… Frank, “The Creation of Medicare and Medicaid,” 467.

  federal mental health parity law… For more on the Mental Health Parity and Addiction Equity Act (MHPAEA), see https://www.cms.gov/cciio/programs-and-initiatives/other-insurance-protections/mhpaea_factsheet.html.

  insurance companies now reimburse… Lizzie O’Leary and Peter Balonon-Rosen, “When It Comes to Insurance Money, Mental Health Is Not Treated Equal,” Marketplace, January 5, 2018, https://www.marketplace.org/2018/01/05/health-care/doctors-get-more-insurance-money-psychiatrists-when-treating-mental-health.

  just over half of psychiatrists take insurance… Tara F. Bishop, Matthew J. Press, Salomeh Keyhani, and Harold Alan Pincus, “Acceptance of Insurance by Psychiatrists and the Implications for Access to Mental Health Care,” JAMA Psychiatry 71, no. 2 (2014): 176–81, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3967759.

  A series of landmark acts… For a great treatment of the landmark rulings that changed health policy, see Appelbaum, Almost a Revolution.

  “mental illness treatment system had been essentially beheaded”… Torrey, American Psychosis, 89.

  dropped by almost 50 percent… Scull, Decarceration, 68.

  another 50 percent to 132,164… David Mechanic, Inescapable Decisions: The Imperative of Health Reform (Piscataway, NJ: Transaction Publishers, 1994), 172.

  Today 90 percent of the beds… This percentage change comes from comparing the number of beds in JFK’s era (504,600) to 52,539 in 2004, found in E. Fuller Torrey et al., “The Shortage of Public Hospital Beds for Mentally Ill Persons: A Report of the Treatment Advocacy Center,” Treatment Advocacy Center, Arlington, VA, https://www.treatmentadvocacycenter.org/storage/documents/the_shortage_of_publichospital_beds.pdf.

  “small long-term state hospital wards”… H. Richard Lamb and Victor Goertzel, “Discharged Mental Patients—Are They Really in the Community?” Archives of General Psychiatry 24, no. 1 (1971): 29–34.

  “We could see the light”… Dominique Kinney, in-person interview, October 29, 2016.

  PART FOUR

  When the going gets weird… Hunter S. Thompson, “Fear and Loathing at the Super Bowl,” Rolling Stone, February 28, 1974, https://www.rollingstone.com/culture/culture-sports/fear-and-loathing-at-the-super-bowl-37345/.

  18: THE TRUTH SEEKER

  “I’m simply not sure that more money”… David Rosenhan, letter to James Floyd, January 24, 1973, David L. Rosenhan Papers.

  “Bill Dixon’s” hospital held 8,000 patients… Rosenhan, pseudopatient list.

  Rosenhan wrote that all the pseudopatients… Rosenhan, “On Being Sane in Insane Places,” 252.

  71 percent of psychiatrists moved on… Rosenhan, “On Being Sane in Insane Places,” Early Undated Draft, private files.

  “He certainly wouldn’t have gotten”… Bill Underwood, email to Susannah Cahalan, March 26, 2017.

  “Seriously flawed by methodological inadequacies”… Fleischman, letter to the editor, 356.

  “It appears that the pseudopatient gathered”… Thaler, letter to the editor, 358.

  “If I were to drink a quart of blood�
�… Seymour S. Kety, “From Rationalization to Reason,” American Journal of Psychiatry 131 (1974): 959.

  “To point out that Rosenhan’s conclusion”… J. Vance Israel, letter to the editor, Science, April 27, 1973, 358.

  A representative said that she… Meagan Phelan, email to Susannah Cahalan, March 14, 2016. The message read: “Thank you for your query. Unfortunately the peer review process of research articles like the one you cite below is confidential, so I’m afraid I cannot provide answers to your questions.”

  “mainly because they have”… David Rosenhan, letter to Henry O. Patterson, July 31, 1975, David L. Rosenhan Papers.

  “Submitting to Science [may have been] a trick”… Ben Harris, phone interview, December 19, 2016.

  “Some foods taste delicious”… Robert Spitzer, “On Pseudoscience in Science, Logic in Remission, and Psychiatric Diagnosis: A Critique of Rosenhan’s ‘On Being Sane in Insane Places,’” Journal of Abnormal Psychology 84, no. 5 (1975): 442–52.

  “Sane comes closest to what”… David Rosenhan, letter to Alexander Nies, July 10, 1973, David L. Rosenhan Papers.

  “Until now, I have assumed”… Spitzer, “On Pseudoscience in Science,” 447.

  The first letter opened “Dear Dave”… Robert Spitzer, letter to David Rosenhan, December 5, 1974, David L. Rosenhan Papers.

  A close reading of Rosenhan’s response… David Rosenhan, letter to Robert Spitzer, January 15, 1975, David L. Rosenhan Papers.

  Spitzer himself had been long obsessed… Alix Spiegel, “The Dictionary of Disorder,” New Yorker, January 3, 2005, https://www.newyorker.com/magazine/2005/01/03/the-dictionary-of-disorder.

  Reichian psychology and its orgone box therapy… Decker, The Making of the DSM-III, 89.

  Another Reichian with a rumored orgone box… Tim Murphy, “‘You Might Very Well Be the Cause of Cancer’: Read Bernie Sanders’ 1970s-Era Essays,” Mother Jones, July 6, 2015, https://www.motherjones.com/politics/2015/07/bernie-sanders-vermont-freeman-sexual-freedom-fluoride.

  Spitzer’s grandfather had pitched his own wheelchair… Janet Williams, phone interview, May 27, 2017; email confirmation with his two children, Laura and Daniel Spitzer.

  His mother struggled with depression… Janet Williams, phone interview, March 16, 2016.

  He struggled with depression… Janet Williams, phone interview, March, 16, 2016.

  “a truth seeker”… Janet Williams, phone interview, April 27, 2017.

  “[This] implies that I have something to conceal”… Rosenhan, letter to Spitzer, January 15, 1975.

  “Let me make clear”… David Rosenhan, letter to the editor, Science, April 27, 1973, 369.

  “Perhaps all that we can hope for”… Spitzer, letter to Rosenhan, March 5, 1975.

  “You now have it from myself and the superintendent”… Rosenhan, letter to Spitzer, January 15, 1975.

  “You’re not crazy”… Rosenhan, “On Being Sane in Insane Places,” 385.

  19: “ALL OTHER QUESTIONS FOLLOW FROM THAT”

  “no further alterations”… Rosenhan, “On Being Sane in Insane Places,” 383.

  This is what Dr. Bartlett recorded… Excerpt from Haverford State Hospital medical records.

  Hallucinations and disturbances in thought patterns… “Schizophrenia: Symptoms and Causes,” Mayo Clinic, https://www.mayoclinic.org/diseases-conditions/schizophrenia/symptoms-causes/syc-20354443.

  “thought broadcasting,” or the belief… Theodore A. Stern, Massachusetts General Hospital Handbook of General Hospital Psychiatry (Philadelphia: Saunders, 2010), 531.

  an “existential permeability”… Clara Kean, “Battling with the Life Instinct: The Paradox of the Self and Suicidal Behavior in Psychosis,” Schizophrenia Bulletin 37, no. 1 (2011): 4–7, https://academic.oup.com/schizophreniabulletin/article/37/1/4/1932702; and Clara Kean, “Silencing the Self: Schizophrenia as Self-Disturbance,” Schizophrenia Bulletin 35, no. 6 (2009): 1034–36, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2762621/.

  Rosenhan “dated his illness to ten years ago”… Haverford State Hospital medical records.

  “much clearer picture of schizophrenia”… Dr. Michael Meade, email to Susannah Cahalan, March 17, 2019.

  Medical record excerpt from David Lurie’s Haverford State Hospital medical records.

  “Active psychosis is one”… Meade, email to Cahalan.

  “It seems to me that any sentient human being”… Florence Keller, email to Susannah Cahalan, November 9, 2017.

  “placed the bottom of a copper pot”… Haverford State Hospital medical records.

  Dr. Frank “Lewis” Bartlett had died… “Services Pending for Psychiatrist F. Lewis Bartlett,” TulsaWorld.com, May 26, 1989, https://www.tulsaworld.com/archives/services-pending-for-psychiatrist-f-lewis-bartlett/article_01472847-cb55-5e2e-b8b2-9daaf6c4f704.html.

  Dr. Bartlett’s interest in psychiatry… Information about Dr. Bartlett’s life came via interviews with Mary Bartlett, Claudia Bushee, and Carole Adrienne Murphy.

  coined the term institutional peonage… F. Lewis Bartlett, “Institutional Peonage: Our Exploitation of Mental Patients,” Atlantic Monthly, July 1964, 116–18.

  gave him a “creepy feeling”… F. Lewis Bartlett, letter to Ken Kesey, March 16, 1962, Mary Bartlett personal files.

  “I just have this picture of Lew”… Mary Bartlett, phone interview, January 30, 2017.

  And then there was the interview… Ervin Staub, phone interview, August 25, 2017.

  Medical record photo of David… Excerpt from David Lurie’s Haverford State Hospital medical records.

  Excerpt from David Lurie’s Haverford State Hospital medical records.

  Excerpt from David Rosenhan, “On Being Sane in Insane Places,” 387.

  “The facts of the case were unintentionally distorted”… Rosenhan, “On Being Sane in Insane Places,” 387.

  20: CRITERIONATING

  I am so grateful to the work of Hannah Decker and her engrossing and informative book The Making of the DSM-III for help in writing this chapter. Thanks also to Janet Williams, Michael First, Allen Frances, and Ken Kendler for providing some firsthand insight into the process.

  how Spitzer managed to get his hands… The information about how “David Lurie’s” medical records ended up in Spitzer’s hands came from the letters exchanged between Rosenhan and Spitzer.

  denouncement of his prior research… Robert Spitzer (guest), “Spitzer’s Apology Changes ‘Ex-Gay’ Debate,” Talk of the Nation, National Public Radio, May 21, 2012, https://www.npr.org/2012/05/21/153213796/spitzers-apology-changes-ex-gay-debate.

  “Dr. Robert L. Spitzer, who gave psychiatry”… Benedict Carey, “Robert Spitzer, 83, Dies; Psychiatrist Set Rigorous Standards for Diagnosis,” New York Times, December 26, 2015, https://www.nytimes.com/2015/12/27/us/robert-spitzer-psychiatrist-who-set-rigorous-standards-for-diagnosis-dies-at-83.html.

  “the best thing I have ever written”… Decker, The Making of the DSM-III, 103.

  writing a follow-up on Rosenhan’s study… Robert Spitzer, “More on Pseudoscience in Science and the Case for Psychiatric Diagnosis,” Archives of General Psychiatry 33, no. 4 (1976): 466, https://jamanetwork.com/journals/jamapsychiatry/article-abstract/491528?resultClick=1.

  “For Spitzer, paradoxically, Rosenhan’s study”… Scull, Psychiatry and Its Discontents, 282.

  “fateful point in the history”… Gerald L. Klerman, “The Advantages of DSM-III,” American Journal of Psychiatry 141, no. 4 (1984): 539.

  “They were determined to create”… Luhrmann, Of Two Minds, 225.

  The Wash U group also referred to themselves… Decker, The Making of the DSM-III, 115.

  whose “guns [were] pointed” at psychoanalysis… Decker, The Making of the DSM-III, 225.

  they kept a picture of Freud… Decker, The Making of the DSM-III, 71.

  the “Feighner Criteria”… John P. Feighner, Eli Robins, Samuel B. Guze, Robert A. Woodruff, George Winokur, and Rodrigo Munoz, “Di
agnostic Criteria for Use in Psychiatric Research,” Archives of General Psychiatry 26 (January 1972): 57–63.

  494 pages, compared with the DSM-II… Rick Mayes and Allan V. Horwitz, “DSM-III and the Revolution in the Classification of Mental Illness,” Journal of the History of the Behavioral Sciences 41, no. 3 (2005): 25.

  The DSM-III introduced “axes”… American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. (Washington, DC: American Psychiatric Association, 1980).

  “conditions and patterns of behavior”… Kutchins and Kirk, Making Us Crazy, 176.

  “It is as important to psychiatrists”… Gary Greenberg, “Inside the Battle to Define Mental Illness,” Wired, December 27, 2010, https://www.wired.com/2010/12/ff_dsmv.

  creating “rich pickings”… Healy, The Antidepressant Era, 213.

  “is conceptualized as a clinically significant”… American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 3rd ed., 6.

  “based on the tradition of separating these disorders”… American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 3rd ed., 8.

  “Hence, this manual uses”… American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 3rd ed., 8.

  also known as the field’s remedicalization… Wilson, “DSM-III and the Transformation of American Psychiatry,” 399.

  Gerald Klerman called it “a victory”… Shorter, A History of Psychiatry, 302.

  “no longer must carry the burden”… Andreasen, The Broken Brain, 249.

  “When we would write a criterion”… Janet Williams, phone interview, May 27, 2017.

  “Rosenhan’s pseudopatients would never”… Luhrmann, Of Two Minds, 231.

  “What Bob [Spitzer] did”… Allen Frances, phone interview, January 4, 2016.

  21: THE SCID

  his memorial lecture… The Robert L. Spitzer Memorial Lecture took place on October 26, 2016, at Columbia’s Herbert Pardes Building.