19
“ALL OTHER QUESTIONS FOLLOW FROM THAT”
In therapy, the aha moment is the stage of realization when sudden clarity hits and feelings that you have suppressed come to the fore and begin clicking into place. Robert Spitzer offered this to me from a distance of four decades.
I dug into the medical records. On cursory reading, the records support Rosenhan’s paper: There was his pseudonym David Lurie; there were the accurate numbers of days he spent hospitalized (though I had noticed that sometimes he exaggerated this figure depending on the audience); and there were his diagnoses, “schizophrenia, schizoaffective type,” and later, “paranoid schizophrenia, in remission.” It conformed to his published paper. It checked out.
Except it didn’t, as Spitzer had found.
One of the foundational principles of “On Being Sane in Insane Places” was that all of the pseudopatients presented with one symptom, voices that said “thud, empty, hollow.” The only other amendments were meant to add a layer of protection for the participants, changing names, jobs, addresses, but “no further alterations of person, history, or circumstances were made,” Rosenhan wrote.
But this is immediately contradicted by the text of the intake interview, written by Dr. Bartlett, the man who first diagnosed Rosenhan and insisted that Mollie commit him. If Dr. Bartlett’s notes are to be believed, Rosenhan’s alleged symptoms went far beyond “thud, empty, hollow.”
This is what Dr. Bartlett recorded:
The first part checks out—again we see the key words thud, hollow, empty. But then Rosenhan goes off script. Bartlett wrote that Lurie was so disturbed by the voices that he had to put copper over his ears—an almost clichéd example of the “tinfoil hat delusion” commonly reported by people suffering from serious mental illness.
“He has felt that he is ‘sensitive to radio signals and hear[s] what people are thinking.’”
Hallucinations and disturbances in thought patterns, especially the belief in the ability to hear or control other people’s thoughts, is considered a key symptom of schizophrenia, one of Kurt Schneider’s “first rank symptoms for schizophrenia.” In Massachusetts General Hospital’s Handbook of General Hospital Psychiatry, “thought broadcasting,” or the belief that others can hear your thoughts or the thoughts of others, is a classic symptom for a quick and easy identification of psychosis in an emergency room setting. It was the sort of symptom I had displayed myself during my encephalitis when I believed I could read the nurses’ thoughts about me, or that I could age people with my mind.
On deeper examination, the red flags continued to wave. There is a philosophy of the psychotic experience underlying Rosenhan’s paper that feels authentic. According to Clara Kean, who wrote about her experience with schizophrenia in two articles for Schizophrenia Bulletin, psychosis involves an “existential permeability,” a belief that there is a softening of the space between the self and others. She described the experience as the “dissolution of ego boundaries,” when “what is originated from the self and what is not are confused.” I recognize Clara’s words in my own experience. When I was psychotic, I became more attuned to my surroundings (even if this attention was distorted, confused, misdirected) while also experiencing a loss of self that felt dangerous, more frightening than any other symptom I experienced. Whether intentionally or not, Rosenhan touched on something real, something that a good psychiatrist would identify as a fairly typical, though traumatic as hell, part of being psychotically ill.
Rosenhan’s timeline as reported to the doctor is also much longer than recorded in his paper. Bartlett wrote that Rosenhan started hearing voices more than three months before his admission, and that the hallucinations, in the form of amorphous sounds, started at least six months prior to that. According to another psychiatrist, Rosenhan “dated his illness to ten years ago [emphasis mine] when he gave up his job in economics.”
All of these factors created a “much clearer picture of schizophrenia, even by today’s standards,” according to Dr. Michael Meade, the chairman of psychiatry at Santa Clara Valley Health and Hospital System. (Dr. Meade added that it was unlikely David Lurie would have received a schizophrenia diagnosis today, however—the age of onset was too unusual, for example; he would likely have received the no-man’s-land diagnosis of “psychotic disorder, not otherwise specified.”) Still, the symptoms did conspire to create a realistic portrait of a man suffering from some kind of illness—not merely an “existential psychosis,” as Rosenhan said he intended.
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.
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.