The Great Pretender

by Susannah Cahalan

  Rosenhan included this interaction… David Rosenhan, “On Being Sane in Insane Places,” 255.

  “The following year David Rosenhan published”… Michael First, Spitzer Memorial Lecture, October 26, 2016.

  “reification of psychiatric diagnoses”… Ken Kendler, Spitzer Memorial Lecture, October 26, 2016.

  “Rather than heading off”… Shorter, A History of Psychiatry, 302.

  “clustered around Spitzer”.… Decker, The Making of the DSM-III, 109.

  seventy to eighty hours a week… Janet Williams, phone interview, May 27, 2017.

  “There would be these meetings”… Spiegel, “The Dictionary of Disorder.”

  “There was very little systematic research”… https://www.newyorker.com/magazine/2005/01/03/the-dictionary-of-disorder Spiegel, “The Dictionary of Disorder.”

  In 1988, 290 psychiatrists… M. Loring and B. Powell, “Gender, Race, and DSM-III: A Study of the Objectivity of Psychiatric Diagnostic Behavior,” Journal of Health and Social Behavior 29, no. 1 (1988): 1–22, http://dx.doi.org/10.2307/2137177.

  One 2004 study showed that black men and women… Robert C. Schwartz and David M. Blankenship, “Racial Disparities in Psychotic Disorder Diagnosis: A Review of the Literature,” World Journal of Psychiatry 4, no. 4 (2014): 133–40, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4274585/.

  “In days of yore, most physicians”… Taylor, Hippocrates Cried, 171.

  “followed dutifully in Spitzer’s footsteps”… Scull, Psychiatry and Its Discontents, 284.

  “godfather of medication treatment for A.D.H.D.”… Benedict Carey, “Keith Conners, Psychologist Who Set Standard for Diagnosing A.D.H.D., Dies at 84,” New York Times, July 13, 2017, https://nyti.ms/2viAJFe.

  “The numbers make it look”… Carey, “Keith Conners.”

  “part mea culpa”… Frances, Saving Normal, xviii.

  “produce a very dangerous product”… Frances, Saving Normal, xviii.

  “to predict or prevent three new”… Frances, Saving Normal, 75.

  childhood bipolar disorder had increased fortyfold… C. Moreno et al., “National Trends in the Outpatient Diagnosis and Treatment of Bipolar Disorder in Youth,” Archives of General Psychiatry 64 (2007): 1032–39.

  there had been a fifty-seven-fold increase in children’s autism spectrum diagnoses… This number comes from comparing the 1960s/1970s numbers found in Thomas F. Boat and Joel T. Wu, eds., Mental Disorders and Disabilities Among Low-Income Children (Washington, DC: National Academies Press, 2015), https://www.ncbi.nlm.nih.gov/books/NBK332896/ to 2018’s rates found in “Data & Statistics on Autism Spectrum Disorder,” Centers for Disease Control and Prevention, https://www.cdc.gov/ncbddd/autism/data.html.

  attention-deficit/hyperactivity disorder, once a rarity… Melissa L. Danielson et al., “Prevalence of Parent-Reported ADHD Diagnosis and Treatment Among U.S. Children and Adolescents, 2016,” Journal of Clinical Child & Adolescent Psychology 47, no. 2 (2018), https://www.tandfonline.com/doi/full/10.1080/15374416.2017.1417860.

  “mislabel normal people”… Frances, Saving Normal, xviii.

  “a society of pill poppers”… Frances, Saving Normal, xiv.

  one in six adults… Thomas J. Moore and Donald R. Mattison, “Adult Utilization of Psychiatric Drugs and Differences by Sex, Age, and Race,” JAMA Internal Medicine 177, no. 2 (2017), https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2592697.

  “an absolute scientific nightmare”… Scull, Madness in Civilization, 408.

  “at best a dictionary”… Thomas Insel, “Post by Former NIMH Director Thomas Insel: Transforming Diagnosis,” National Institute of Mental Health, April 29, 2013, https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2013/transforming-diagnosis.shtml.

  I had tested this out myself… The SCID interview part of this chapter is from my interview with Michael First in his office on April 20, 2016.

  recently that of the murder… James McKinley Jr., “Patz Trial Jury, in Blow to Defense, Is Told Suspect Was a Longtime Cocaine Addict,” New York Times, March 10, 2015, https://www.nytimes.com/2015/03/11/nyregion/patz-trial-jury-in-blow-to-defense-is-told-suspect-was-a-longtime-cocaine-addict.html.

  a BBC reality show called How Mad Are You?… “How Mad Are You? Episodes 1 and 2,” Horizon, BBC, November 29, 2008, https://www.bbc.co.uk/programmes/b00fm5ql.

  PART FIVE

  The greatest obstacle… Quotation (often misattributed to Stephen Hawking) comes from this interview with Daniel Boorstin: Carol Krucoff, “The 6 O’clock Scholar,” Washington Post, January 29, 1984, https://www.washingtonpost.com/archive/lifestyle/1984/01/29/the-6-oclock-scholar/eed58de4-2dcb-47d2-8947-b0817a18d8fe/?utm_term=.a9cc826ca6cd. Thank you to Quote Investigator (https://quoteinvestigator.com/2016/07/20/knowledge/) for providing the proper sourcing.

  22: THE FOOTNOTE

  The bulk of this chapter relies on several interviews with Harry Lando conducted between 2016 and 2019. I also included parts of David Rosenhan’s scrap notes titled “My Basic Assumptions: Notes upon Notes” and a draft of his pseudopatient list found in his private files.

  The summary read… Excerpt from Harry Lando, “On Being Sane in Insane Places: A Supplemental Report,” Professional Psychology, February 1976: 47–52.

  “I was the ninth pseudopatient”… Lando, “On Being Sane in Insane Places,” 47.

  “Data from a ninth pseudopatient”… Rosenhan, “On Being Sane in Insane Places,” 258.

  taught by Dr. Thelma Hunt… For more on Dr. Thelma Hunt, see Nicole Brigandi, “Thelma Hunt (1903–1992),” Feminist Psychologist 32, no. 3 (2005), https://www.apadivisions.org/division-35/about/heritage/thelma-hunt-biography.aspx.

  one of her most cited works… Valenstein, Great and Desperate Cures, 165.

  measuring a patient’s “self-regarding span”… Walter Freeman and James W. Watts, Psychosurgery: Intelligence, Emotion and Social Behavior Following Prefrontal Lobotomy for Mental Disorders (Springfield, IL: Charles C. Thomas, 1942).

  his “Bobo doll study”… Albert Bandura, Dorothea Ross, and Sheila A. Ross, “Transmission of Aggression Through Imitation of Aggressive Models,” Journal of Abnormal and Social Psychology 63 (1961): 575–82, https://psychclassics.yorku.ca/Bandura/bobo.htm#f2.

  “Just why Walter changed his script”… David Rosenhan, “My Basic Assumptions: Notes upon Notes,” David Rosenhan personal files.

  “He engages in finger-cracking”… Rosenhan, “My Basic Assumptions.”

  talked down from the Golden Gate Bridge… A few examples: “Novato Man Held After Jump Threat,” Daily Independent Journal, November 2, 1964, 8; “Daly City Wife Plucked from Golden Gate Span,” San Mateo Times, March 14, 1963, 24; “Model Foils S.F. Suicide,” San Mateo Times, June 25, 1962, 9; and “Man Bound, Dynamite at His Throat” Los Angeles Times, June 5, 1970, 146.

  “Warning! Mental Patients are Notorious DRUG EVADERS”… Robert Whitaker, Mad in America, 213.

  “HE LIKES IT”… Rosenhan, “My Basic Assumptions.”

  “Didn’t your dad ever teach you”… Rosenhan, “My Basic Assumptions.”

  “I will miss it”… Rosenhan, “My Basic Assumptions.”

  23: “IT’S All IN YOUR MIND”

  This chapter was based on an in-person interview with Harry Lando in November 2016.

  His hospital facilities, he revealed, were “excellent”… Lando, “On Being Sane in Insane Places,” 47.

  ‘He was admitted and diagnosed’… Rosenhan, “Pseudopatient Description,” typewritten notes, private files.

  found an early draft of “On Being Sane in Insane Places”… David Rosenhan, letter to Walter Mischel, November 1971; “On Being Sane in Insane Places,” Second Draft, David Rosenhan private files.

  3.9 to 25.1 minutes… Rosenhan, “On Being Sane in Insane Places,” 396.

  “Another pseudopatient attempted a romance”… Rosenhan, “On Being Sane in Insane Places,” 396.

  The forty-five-year-old rec
ording opens… George Bower, It’s All in Your Mind, WGUC-FM, December 14, 1972, NPR, Special Collections, and university archives at the University of Maryland.

  24: SHADOW MENTAL HEALTH CARE SYSTEM

  She said that during this hospitalization… Elizabeth Lando King, phone interview, January 19, 2017.

  The Zuckerberg San Francisco General Hospital… Thank you to the San Francisco Gate’s reporting for insight into what life is like at Zuckerberg San Francisco General Hospital, specifically this article: Mike Weiss, “Life and Death at San Francisco’s Hospital of Last Resort,” San Francisco Gate, December 11, 2006, https://www.sfgate.com/health/article/GENERAL-LIFE-AND-DEATH-AT-SAN-FRANCISCO-S-2483930.php#photo-2639598.

  a woman who bit off her own finger… Weiss, “Life and Death at San Francisco’s Hospital of Last Resort.”

  “This is the sad part of this work”… Weiss, “Life and Death at San Francisco’s Hospital of Last Resort.”

  “state of emergency”… “SF General Hospital Nurses Claim Psychiatric Unit State of Emergency,” KTVU, April 28, 2016, http://www.ktvu.com/news/sf-general-hospital-nurses-claim-psychiatric-unit-state-of-emergency.

  “You’ve got your chow”… Heather Knight, “Ex-ER Psychiatrist: More Inpatient Treatment Needed in SF,” San Francisco Chronicle, October 9, 2018, https://www.sfchronicle.com/bayarea/heatherknight/article/Ex-ER-psychiatrist-More-inpatient-treatment-13291361.php.

  “the beds that never say no”… Mark Gale, email to Susannah Cahalan, May 27, 2019.

  “These are the choices we are making”… Mark Gale, phone interview, August 5, 2017.

  The US is a minimum of ninety-five thousand beds… DJ Jaffe, Insane Consequences: How the Mental Health Industry Fails the Mentally Ill (Amherst, NY: Prometheus Books, 2017), 78.

  It’s now harder to get a bed… Jaffe, Insane Consequences, 22.

  Sixty-five percent of the non-urban counties… C. Holly A. Andrilla, Davis G. Patterson, Lisa A. Garberson, Cynthia Coulthard, and Eric H. Larson, “Geographic Variation in the Supply of Selected Behavioral Health Providers,” American Journal of Preventive Medicine 54, no. 6 (2018): 199–207, https://www.ajpmonline.org/article/S0749-3797(18)30005-9/fulltext.

  national shortage of over fifteen thousand… Stacy Weiner, “Addressing the Escalating Psychiatrist Shortage,” AAMC News (Association of American Medical Colleges), February 13, 2018, https://news.aamc.org/patient-care/article/addressing-escalating-psychiatrist-shortage.

  “One or more nurses would take”… Nathaniel Morris, “This Secret Experiment Tricked Psychiatrists into Diagnosing People as Having Schizophrenia,” Washington Post, January 1, 2018.

  “so disorganized that she would just stand”… This psychologist prefers to remain anonymous.

  “when being assessed”… This nurse prefers to remain anonymous.

  “It shows just how quaint the study is”… Joel Braslow, phone interview, March 11, 2015.

  “It’s on the other end of the spectrum”… Thomas Insel, in-person interview, April 1, 2015.

  A 2015 study published in Psychiatric Services… Monica Malowney, Sarah Keltz, Daniel Fischer, and Wesley Boyd, “Availability of Outpatient Care from Psychiatrists… A Simulated-Patient Study in Three Cities,” Psychiatric Services 66, no. 1 (January 2015).

  “People with schizophrenia in the United States”… E. Fuller Torrey, “Second Chance Lecture” at the Schizophrenia International Research Society Conference, April 1, 2016.

  5 percent of people in jails… Torrey, American Psychosis, 98.

  Nearly 40 percent of prisoners… “Indicators of Mental Health Problems Reported by Prisoners and Jail Inmates, 2011–2012,” Bureau of Justice Statistics (2017), https://www.bjs.gov/content/pub/pdf/imhprpji1112_sum.pdf.

  Women, the fastest growing segment… “Indicators of Mental Health Problems,” Bureau of Justice.

  “are more likely to suffer disparities”… Lorna Collier, “Incarceration Nation,” American Psychological Association 45, no. 9 (2014): 56, https://www.apa.org/monitor/2014/10/incarceration.

  ten times more seriously mentally ill people… “Serious Mental Illness (SMI) Prevalence in Jails and Prisons,” Treatment Advocacy Center Office of Research and Public Affairs, September 2016, https://www.treatmentadvocacycenter.org/storage/documents/backgrounders/smi-in-jails-and-prisons.pdf.

  The largest concentrations of the seriously mentally ill… “Serious Mental Illness,” Treatment Advocacy Center; and Gale Holland, “L.A. County Agrees to New Policies to End the Jail-to-Skid Row Cycle for Mentally Ill People,” LA Times, December 7, 2018, https://www.latimes.com/local/lanow/la-me-ln-skid-row-jail-20181207-story.html.

  “Many of the persons with serious mental illness”… Richard Lamb, in-person interview, October 29, 2015.

  This is the current state… Some have argued that the clear-cut connection between deinstitutionalization and transinstitutionalization is oversimplified. For a more nuanced perspective on the history of incarceration, see Michelle Alexander, The New Jim Crow: Mass Incarceration in the Age of Colorblindness (New York: New Press, 2012); Bryan Stevenson, Just Mercy: A Story of Justice and Redemption (New York: Spiegel & Grau, 2014); and John Pfaff, Locked In: The True Causes of Mass Incarceration—And How to Achieve Real Reform (New York: Basic Books, 2017).

  “A crisis unimaginable”… Powers, No One Cares About Crazy People, 203.

  “one of the greatest social debacles”… Shorter, A History of Psychiatry, 277.

  “a cruel embarrassment”… “Denying the Mentally Ill” (editorial), New York Times, June 5, 1981, https://www.nytimes.com/1981/06/05/opinion/denying-the-mentally-ill.html.

  “Behind the bars of prisons and jails”… Dominic Sisti, “Psychiatric Institutions Are a Necessity,” New York Times, May 9, 2016, https://www.nytimes.com/roomfordebate/2016/05/09/getting-the-mentally-ill-out-of-jail-and-off-the-streets/psychiatric-institutions-are-a-necessity.

  the average stay for a mentally ill prisoner… E. T. Torrey, M. T. Zdanowicz, A. D. Kennard, “The Treatment of Persons with Mental Illness in Prisons and Jails: A State Survey,” Treatment Advocacy Center, April 8, 2014, https://www.treatmentadvocacycenter.org/storage/documents/backgrounders/how%20many%20individuals%20with%20serious%20mental%20illness%20are%20in%20jails%20and%20prisons%20final.pdf.

  The ACLU filed a lawsuit… J.H. v. Miller.

  languished in jail for 1,017 days… “Lawsuit Alleges Many Defendants with Mental Illness Jailed for Well Over a Year Awaiting Mental Health Treatment,” ACLU Pennsylvania, October 22, 2015, https://www.aclupa.org/news/2015/10/22/lawsuit-alleges-many-defendants-mental-illness-jailed-well-o.

  The lawsuit’s lead plaintiff is “J.H.”… “J.H. v. Miller (Formerly J.H. v. Dallas),” ACLU Pennsylvania, October 22, 2015, https://www.aclupa.org/our-work/legal/legaldocket/jh-v-dallas.

  “failed to produce constitutionally”… “ACLU-PA Goes Back to Court on Behalf of People Who Are Too Ill to Stand Trial,” ACLU Pennsylvania, March 19, 2019, https://www.aclupa.org/news/2019/03/19/aclu-pa-goes-back-court-behalf-people-who-are-too-ill-stand.

  “often nude, are covered in filth”… Eric Balaban, “Time Has Come to Save Mentally Ill Inmates from Solitary Confinement” (editorial), Arizona Capital Times, February 27, 2018, https://azcapitoltimes.com/news/2018/02/27/time-has-come-to-save-mentally-ill-inmates-from-solitary-confinement.

  In California, “Inmate Patient X”… Hannah Fry, “Inmate Rips Out Her Own Eye and Eats It: Report Slams Mental Healthcare in California Prisons,” Los Angeles Times, November 5, 2018, https://www.latimes.com/local/lanow/la-me-ln-prison-report-20181105-story.html.

  In Florida, Darren Rainey… Roth, Insane, 135.

  In Mississippi, “a real 19th century hell hole”… Craig Haney, “Madness and Penal Confinement: Observations on Mental Illness and Prison Pain,” Draft, provided to me by Craig Haney.

  a man named Michael Tyree screamed out… Tracey Kaplan, “Guard Trial: Fellow Inmate Testifies Michael Tyree Was ‘Screaming for His Life,�
��” Mercury News, March 23, 2017, https://www.mercurynews.com/2017/03/23/jail-trial-testimony-over-inmate-death-probes-delay-summoning-help-for-michael-tyree.

  “I have seen them”… J. E. D. Esquirol, “Des établissemens des aliénés en France, et des moyens d’améliorer le sort de ces infortunés: Mémoire présenté à Son Excellence le ministre de l’intérieur, en septembre 1818,” reprinted in Mark S. Micale and Roy Porter, eds., Discovering the History of Psychiatry (Oxford: Oxford University Press, 1994), 235.

  “It’s true that the hospitals”… Roth, Insane, 2.

  “Prisoners are under a tremendous amount of stress”… Craig Haney, in-person interview, February 17, 2017.

  “How do you know when a patient is lying?”… Jimmy Jenkins, “Whistleblower: Patients with Mental Illness Suffering in Arizona” (radio program), KJZZ, June 1, 2018, https://kjzz.org/content/644690/whistleblower-patients-mental-illness-suffering-arizona-prisons.

  “I mean people who have documented histories”… David Fathi, phone interview, April 7, 2015.

  “What’s the secondary gain?”… Craig Haney, in-person interview, February 17, 2017.

  Dr. Torrey, the psychiatrist who warned… Thank you to Dr. Torrey and to DJ Jaffe for taking time to speak to me about these issues. For more on Dr. Torrey’s perspective, see his large body of work, including some of his books cited here: American Psychosis, Surviving Schizophrenia, The Insanity Offense, and Out of the Shadows. For more from DJ Jaffe, see https://mentalillnesspolicy.org/ and his book Insane Consequences. For a great summary of DJ Jaffe’s solutions to these many issues in New York City see DJ Jaffe and Stephen Eide, “How to Fix New York’s Mental Health Crisis Without Spending More Money,” New York Post, May 11, 2019, https://nypost.com/2019/05/11/how-to-fix-new-yorks-mental-health-crisis-without-spending-more-money/.

  adding more beds across the board… Doris A. Fuller, Elizabeth Sinclair, H. Richard Lamb, James D. Cayce, and John Snook, “Emptying the ‘New Asylums’: A Beds Capacity Model to Reduce Mental Illness Behind Bars,” Treatment Advocacy Center, January 2017, https://www.treatmentadvocacycenter.org/storage/documents/emptying-new-asylums.pdf.