Into the cuckoo's nest
Thirty years ago psychiatry was rocked by the revelation that nine sane volunteers had faked hearing voices and fooled thier way on to locked wards. Has diagnosis improved since? Psychologist Lauren Slater repeats the experiment
Saturday January 31, 2004 The Guardian
In 1972, David Rosenhan, a newly minted psychologist with a joint degree in law, called eight friends and said something like, "Are you busy next month? Would you have time to fake your way into a mental hospital and see what happens?"
Surprisingly, so the story goes, all eight were not busy the next month, and all eight - three psychologists, one graduate student, a paediatrician, a psychiatrist, a painter and a housewife - agreed to take the time to try this treacherous trick, along with Rosenhan himself, who could hardly wait to get started. Pseudopatient Martin Seligman says, "David just called me up and said, 'Are you busy next October?' "and I said, 'Of course I'm busy next October', but by the end of the conversation he had me laughing and saying yes."
First, there was training. Rosenhan instructed his confederates very, very carefully. Five days prior to the chosen date, they were to stop shaving, showering and brushing their teeth. And then they were, on the appointed date, to disperse to different parts of the country, east to west, and present themselves at various psychiatric emergency rooms. Some of the hospitals Rosenhan had chosen were posh and built of white brick; others were state-run gigs with urine-scented corridors and graffiti-scratched walls. The pseudopatients were to present themselves and say words along these lines: "I am hearing a voice. It is saying thud." Rosenhan specifically chose this complaint because nowhere in psychiatric literature are there any reports of any person hearing a voice that contains such obvious cartoon angst.
Upon further questioning, the eight pseudopatients were to answer honestly, save for name and occupation. They were to feign no other symptoms. Once on the ward, if admitted, they were immediately to say that the voice had disappeared and that they now felt fine. Rosenhan then gave his confederates a lesson in managing medication, how to avoid swallowing it by slipping it under the tongue, so it could later be blurted back to the toilet bowl.
The pseudopatients practised for a few days. Much of the practice was, admittedly, passive, letting entropy and odour wend their way in. Their hair grew out and clumped. Their breath got a greenish tinge.
The day that Rosenhan departed for one of Pennsylvania's state hospitals was brilliant. The sky was a frosty, pre-winter blue, the trees like brushes dipped in paint, turned upward and wet with colour. Rosenhan pulled into the parking lot. The psychiatric hospital had gothic buildings, every window caged. Orderlies in pale blue smocks floated on the grounds.
Once in the admissions unit, Rosenhan was led to a small white room. "What is the problem?" a psychiatrist asked.
"I'm hearing a voice," Rosenhan said, and then he said nothing else.
"And what is the voice saying?" the psychiatrist questioned, falling, unbeknown to him, straight into Rosenhan's rabbit hole.
"Thud," Rosenhan said, smugly, I imagine.
"Thud?" the psychiatrist asked. "Did you say thud?"
"Thud," Rosenhan said again.
The psychiatrist probably scratched his head. He could have been confused, bemused. The problem is, we don't know what exactly happened in any of the admitting rooms because Rosenhan has neglected to give any detailed reports. We do know that each pseudopatient, Rosenhan included, said that the voice was of the same sex as he or she, that it had been bothering the pseudopatient to some extent, that he or she had come to the unit on the advice of friends who had heard that "this was a good hospital".
Rosenhan was led down a long hallway. Across the country, the eight other pseudopatients were also being admitted. Rosenhan must have been scared, exhilarated. He was a journalist, a scientist at the apex, putting his body on the line for knowledge. He was taken to a room and told to undress.
Someone inserted a thermometer into his mouth, wrapped a black cuff around his arm, pressed on his pulse and read it: normal, normal, normal. Everything was normal, but no one seemed to see. He said, "You know, the voice isn't bothering me any more", and the doctors just smiled.
"When will I get out?" we can imagine Rosenhan asked, his voice perhaps rising now, some panic here - what had he done, my God.
"When you are well," a doctor answered, or something to this effect. But he was well: 110 over 80, a pulse of 72, a temperature that hovered in the mid-zone of moderate, homeostatic, a machine well greased. It didn't matter. He was diagnosed with paranoid schizophrenia and kept for many days.
There was a glassed-in office, which Rosenhan came to call the "bull pen". Inside, nurses flurried about, busy as a blizzard, pouring cherry-red medicines into plastic cups. Rosenhan cooperated absolutely. He "took" the pills three times a day and then rushed to the bathroom to spit them back out. He comments on how all the other patients were doing this, too, and how no one much cared so long as they were well behaved.
Psychiatric patients are "invisible ... unworthy of account", Rosenhan writes. He describes a nurse coming into the dayroom, unbuttoning her shirt and fixing her bra. "One did not have the sense that she was being seductive," Rosenhan reports. "Rather, she didn't notice us." He saw patients being beaten. He describes how one patient was severely punished simply because he said to a nurse, "I like you." Rosenhan does not describe the nights, which must have been long, lying in that narrow bed while orderlies with flashlights did 15-minute checks. Did he miss his wife, Molly? Did he wonder how his two toddlers were getting on? That world must have seemed so far away, even though it was no more than 100 miles; this is what science teaches us.
Rosenhan and his confederates were given some therapy, and when they told of the joys, satisfactions and disappointments of an ordinary life - remember, they were making nothing up save the original complaint - all found that their pasts were reconfigured to fit the diagnosis: "This white 39-year-old male ... manifests a long history of considerable ambivalence in close relationships ... affective stability is absent ... and while he says he has several good friends, one senses considerable ambivalence in those relationships."
In 1973, Rosenhan wrote in Science, one of the field's most prestigious journals, "Clearly, the meaning ascribed to his verbalisations ... was determined by the diagnosis, schizophrenia. An entirely different meaning would have been ascribed if it were known that the man was 'normal'."
The strange thing was, the other patients seemed to know that Rosenhan was normal, even while the doctors did not. One young man, coming up to Rosenhan in the dayroom, said "You're not crazy. You're a journalist or a professor." Another said, "You're checking up on the hospital."
Rosenhan followed all orders while in hospital, asked for privileges, helped other patients to deal with their problems, offered legal advice, probably played his fair share of ping pong, and took copious notes, which the staff labelled as "writing behaviour" and saw as part of his paranoid schizophrenic diagnosis. And then one day, for a reason as arbitrary as his admission, he was discharged.
Rosenhan's paper describing his findings, On Being Sane In Insane Places, was published in Science, where it burst like a bomb on the world of psychiatry. Early in the article, Rosenhan lays it on the line. He claims that diagnosis is not carried within the person, but within the context, and that any diagnostic process that lends itself so readily to massive errors of this sort cannot be a very reliable one. The paper generated a flood of fluorescent missives:
Most physicians do not assume that patients who seek help are liars; they can therefore, of course, be misled ... It would be quite possible to conduct a study in which patients trained to simulate histories of myocardial infarction would receive treatment on the basis of history alone (since a negative electrocardiogram is not diagnostic) but it would be preposterous to conclude from such a study that physical illness does not exist, that medical diagnoses are fallacious labels, and that "illness" and "health" reside only in doctors' heads.
The pseudopatients did not behave normally in the hospital. Had their behaviour been normal, they would have walked to the nurses' station and said, "Look, I am a normal person who tried to see if I could get into the hospital by behaving in a crazy way or saying crazy things. It worked and I was admitted to the hospital, but now I would like to be discharged from the hospital."
And my favourite:
If I were to drink a quart of blood and, concealing what I had done, come to the emergency room of any hospital vomiting blood, the behaviour of the staff would be quite predictable. If they labelled and treated me as having a peptic ulcer, I doubt I could argue convincingly that medical science does not know how to diagnose that condition.
Robert Spitzer, one of the 20th century's most prominent psychiatrists and a severe critic of Rosenhan, wrote a 1975 article in the Journal Of Abnormal Psychology, in response to Rosenhan's findings. "Some foods taste delicious but leave a bad aftertaste. So it is with Rosenhan's study," he said. In a footnote, he writes, "Rosenhan has not identified the hospitals used in this study because of his concern with confidentiality and the potential for ad hominem attack. However, this does make it impossible for anyone at these hospitals to corroborate or challenge his account of how the pseudopatients acted and how they were perceived." Spitzer later says, in a phone conversation with me, "And this whole business of thud. Rosenhan uses that as proof of how ridiculous psychiatrists are because there had never been any reports before of 'thud' as an auditory hallucination. So what? As I wrote, once I had a patient whose chief presenting complaint was a voice saying, 'It's OK, it's OK.' I know of no such report in the literature. This doesn't mean there isn't real distress."
I don't want to challenge Spitzer, but a voice saying, "It's OK" sounds pretty OK to me.
Spitzer pauses. "So how is David Rosenhan?" he finally asks.
"Actually, not so good," I say. "He's lost his wife to cancer, his daughter Nina in a car crash. He's had several strokes and is now suffering from a disease they can't quite diagnose. He's paralysed."
That Spitzer doesn't say, or much sound, sorry when he hears this reveals the depths to which Rosenhan's study is still hated in the field, even after 30 years. "That's what you get," he says, "for conducting such an inquiry."
Spitzer wrote two entire papers devoted to dismantling Rosenhan's findings, totalling 33 pages of dense, extremely cogent prose. "Did you read my responses to Rosenhan?" he asks. "They're pretty brilliant, aren't they?"
Spitzer argues many, many things. At root, he is arguing for the validity of psychiatry, and its diagnostic practices, as sound scientific, medical procedures. "According to Rosenhan," he writes, "all the patients were diagnosed at discharge as 'in remission'. A remission is clear. It means without signs of illness. Thus all of the psychiatrists apparently recognised that all of the pseudopatients were, to use Rosenhan's term, 'sane'."
Reading Spitzer's articles and the letters following Rosenhan's publication, I find myself swayed, as in a tennis match. On the one hand, the study was flawed. If I drank a quart of blood and if I vomited it in the ER ... which must mean psychiatry really is no different from its supposedly more medical kin. But wait a minute - in the blood scenario, I wouldn't be held for 52 days, and besides, blood is not thud .
For me, psychiatric illness is absolutely real. Just two years after Rosenhan presented his findings, I, a mawkish 14-year-old, entered an east coast psychiatric institution with all sorts of symptoms. I saw the glassed-in nurses' station, the candy stripers pushing chrome carts, the lunatic manic with sweat runnelling down his face, the woman named Rosa, found in the bathroom, neck bunched in a noose. I saw some things.
In Rosenhan's study, the staff beat patients and woke them with, "You motherfucking son of a bitch", and this in private as well as public facilities. I was in a semi-public facility and no staff ever swore at me. It is true that the psychiatrist in charge of my case spent very little time with me, but actually I remember him in crisp detail, because I liked him so much. His name was Dr Su, and he had a little broom of a moustache, and for some odd reason he often had a baseball mitt with him. We used to meet in a small office and he would lean forward, look at the cuts on my arms - like little lips these cuts were, because I kept them fresh and open with stolen shards. He would look at the cuts and say with true feelings, "It's such a shame, Lauren. It's such a shame you have to hurt yourself."
Rosenhan's experiment, like, perhaps, any piece of good art, is prismatic, powerful and flawed. You can argue with it, as in all of the above. Nevertheless, there are, it seems to me, some essential truths in his findings. Labels do determine how we view what we view. Psychiatry is a fledgling science, if it is a science at all, because to this day it lacks firm knowledge of practically any physiological basis for mental illness, and science is based on the body, on measurable matter. Psychiatrists do jump to judgment - not all of them, but a lot of them - and they can be pompous, probably because they're insecure. In any case, Rosenhan's study did not help this insecurity. The experiment was greeted with outrage, and then, at last, a challenge. "All right," said one hospital, its institutional chest all puffed up. "You think we don't know what we're doing? Here's a dare. In the next three months, send as many pseudopatients as you like to our emergency room and we'll detect them. Go ahead."
Now, Rosenhan liked a fight. So he said, "Sure." He said in the next three months he would send an undisclosed number of pseudopatients to this particular hospital, and the staff were to judge, in a sort of experimental reversal, not who was insane, but who was sane. One month passed. Two months passed. At the end of three months, the hospital staff reported to Rosenhan that they had detected, with a high degree of confidence, 41 of Rosenhan's pseudopatients. Rosenhan had, in fact, sent none. Case closed. Match over. Psychiatry hung its head.
Since Rosenhan, psychiatry has tried admirably to locate the physiological origins of mental disease - mostly in vain. Much of the current research is a knowing or unknowing response to Rosenhan's challenge and to the inherent anxieties it raises in "soft" scientists. Spitzer says, "I'm telling you, with the new diagnostic system in place, Rosenhan's experiment could never happen today. [In the 1970s, Spitzer and a group of colleagues completely revised the Diagnostic and Statistical Manual on Mental Disorders, or DSM for short, tightening the diagnostic criteria, taking away from it signs of subjectivity and psychobabble.] You would not be admitted and in the ER they would diagnose you as deferred." (Deferred, by the way, is a special category that allows clinicians to do just that, officially put off a diagnosis due to lack of information.) "No," repeats Spitzer, "that experiment could never be successfully repeated. Not in this day and age."
I decide to try.
Many things are the same. The sky is a poignant blue. The trees are turning, each scarlet leaf like a little hand falling down on our green autumn lawn.
"You're what?" my husband says to me.
"I'm going to try it," I say. "Repeat the experiment exactly as Rosenhan and his confederates did it, and see if I get admitted."
"Excuse me," he says, "don't you think you have your family to consider?"
"It'll never work," I say, thinking of Spitzer. "I'll be back in an hour."
"And suppose you're not?"
"Come get me," I say.
I do my preparations. I don't shower or shave for five days. I call a friend with a renegade streak and ask if I can use her name in lieu of my own, which might be recognised. The plan is to use her name and then have her, later, with her licence, get the records so that I can see just what has been said. This friend, Lucy, says yes. She should probably be locked up. "This is so funny," she says.
I spend a considerable portion of time practising in front of my mirror. "Thud," I say, and crack up, no pun intended. "I'm, I'm here ..." - and now I feign a worried expression, crinkled crow's-feet at my eyes - "I'm here because I'm hearing a voice and it's saying thud", and then, each time, standing in front of this full-length mirror, smelly and wearing a floppy black velvet hat, I start to laugh. If I laugh, I'll obviously blow my cover. Then again, if I don't laugh, and if I tell the whole truth about my history save for this one little symptom, as Rosenhan and company did in the original experiment, well, then I might really go the way of the ward. There is one significant difference in my re-test setup. None of Rosenhan's folks had any psychiatric history. I, however, have a formidable psychiatric history that includes lots of lock-ups, although, really, I'm fine now.
I kiss the baby goodbye. I kiss my husband goodbye. I haven't showered for five days. My teeth are smeary. I am wearing paint-splattered black leggings and a T-shirt that says, "I hate my generation."
"How do I look?" I say.
"The same," my husband says.
I drive there. I have chosen a hospital miles out of town with an emergency room set up specifically for psychiatric issues. I have also chosen a hospital with an excellent reputation, so factor that in. It is on a hill. It has a winding drive. In order to enter the psych ER, you must stand in front of a formidable bank of doors in a bustling white hallway and press a buzzer, at which point a voice over an intercom calls out, "Can I help you?"
I say, "Yes."
The doors open. They appear to part without any evidence of human effort, to reveal a trio of policemen sitting in the shadows, their silver badges tossing light. On a TV mounted high in one corner, someone shoots a horse - bang! - and the bullet explodes a star in the fine forehead, blood on black fur.
"Name?" a nurse says, bringing me to a registration desk.
"Lucy Schellman," I say.
"And how do you spell Schellman?" she asks.
I'm a terrible speller and I hadn't counted on this little hurdle; I do my best. "S-H-E-L-M-E-N," I say.
The nurse writes it down, studying the idiosyncratic spelling. "That's an odd name," she says. "It's plural."
"Well," I say, "it was an Ellis Island thing. It happened at Ellis Island."
She looks up at me and then scribbles something I cannot see on the paper. I'm worried she's going to think I have a delusion that involves Ellis Island so I say, "I've never been to Ellis Island - it's a family story."
"Race," she says.
"Jewish," I say. I wonder if I should have said protestant. The fact is, I am Jewish, but I'm also paranoid - not as a general rule, of course, but at this particular point - and I don't want the Jewish thing used against me. Of what am I so scared? No one can commit me. Since Rosenhan's study - in part because of Rosenhan's study - commitment laws are far more stringent, and so long as I deny homicidal or suicidal urges, I'm a free woman. I am in control.
I don't feel in control, though. At any moment someone might recognise my gig. As soon as I say, "Thud", any well-read psychiatrist could say, "You're a trickster. I know the experiment." I pray the psychiatrists are not well-read.
This emergency room is eerily familiar to me. I have been in many that were just like this, but that was a long time ago. Still, the smells bring me back: sweat and fresh cotton and blankness. I feel no sense of triumph, just sadness, for there is real suffering somewhere here.
I am brought to a small room that has a stretcher with black straps attached to it. "Sit," the ER nurse tells me, and then in walks a man, closing the door behind him - click click.
"I'm Mr Graver," he says, "a clinical nurse specialist, and I'm going to take your pulse."
A hundred per minute. "That's a little fast," says Mr Graver. "I'd say it's on the very high side of normal. But, of course, who wouldn't be nervous, given where you are and all. I mean, it's a psych ER. That would make anyone nervous." And he shoots me a kind, soft smile. "Say," he says, "can I offer you a glass of spring water?" And before I can answer, he's jumped up, disappeared, only to re-emerge with a tall, flared glass, almost elegant, and a single lemon slice of the palest white-yellow. The lemon slice seems suddenly so beautiful to me, the way it flirts with colour but cannot quite assume it.
He hands me the glass. This, also, I had not expected - such kindness, such service. Rosenhan writes about being dehumanised. So far, if anyone's dehumanised here, it's Mr Graver, who is fast becoming my own personal butler.
I take a sip. "Thank you so much," I say.
"Anything else I can get you? Are you hungry?"
"Oh no no," I say. "I'm fine really."
"Well, no offence but you're obviously not fine," says Mr Graver, "or you wouldn't be here. So what's going on, Lucy?" he asks.
"I'm hearing a voice," I say.
He writes that down on his intake sheet, nods knowingly. "And the voice is saying?"
The knowing nod stops. "Thud?" he says. This, after all, is not what psychotic voices usually report. They usually send ominous messages about stars and snakes and tiny hidden microphones.
"Thud," I repeat.
"Is that it ?" he says.
"That's it," I say.
"Did the voice start slowly, or did it just come on?"
"Out of the blue," I say, and I picture, for some reason, a plane falling out of the blue, its nose diving downward, someone screaming. I am starting, actually, to feel a little crazy. How hard it is to separate role from reality, a phenomenon social psychologists have long pointed out to us.
"So when did the voice come on?" Mr Graver asks.
"Three weeks ago," I say, just as Rosenhan and his confederates reported.
He asks me whether I am eating and sleeping OK, whether there have been any precipitating life stressors, whether I have a history of trauma. I answer a definitive no to all of these things: my appetite is good, sleep normal, my work proceeds as usual.
"Are you sure?" he says.
"Well," I say, "as far as the trauma goes, I guess when I was in the third grade, a neighbour named Mr Blauer fell into his pool and died. I didn't see it, but it was sort of traumatic to hear about."
Mr Graver chews on his pen. He's thinking hard.
"Thud," Mr Graver says. "Your neighbour went thud into his pool. You're hearing 'thud'. We might be looking at post-traumatic stress disorder. The hallucination could be your memory trying to process the trauma."
"But it really wasn't a big deal," I say. "It was just ..."
"I would say," he says, and his voice is gaining confidence now, "that having a neighbour drown constitutes a traumatic loss. I'm going to get the psychiatrist to evaluate you, but I really suspect that we're looking at post-traumatic stress disorder with a rule out of organic brain damage, but the brain damage is way far down the line. I wouldn't worry about that."
He disappears. He is going to get the psychiatrist. My pulse goes from 100 beats a minute to 150 at least - I can feel it - for surely the psychiatrist will see right through me or, worse, he will wind up being someone I know from high school, and how will I explain myself?
The psychiatrist enters the little locked room. He is wearing baby-blue scrubs and has no chin. He looks hard at me. I look away. He sits down, and then he sighs. "So you're hearing 'thud'," he says, scratching the chinless chin. "What can we do for you about that?"
"I came here because I'd like the voice to go away."
"Is the voice coming from inside or outside your head?" he asks.
"Does it ever say anything other than thud, like, maybe, kill someone, or yourself?"
"I don't want to kill anyone or myself," I say.
"What day of the week is it?" he asks.
Now, here I run into another problem. It's actually a holiday weekend, so my sense of time is a little thrown off. Sense of time is one way psychiatrists judge whether a person is normal or abnormal. "It's Saturday," I say, I pray.
He writes something down. "OK," he says. "So you're experiencing this voice in the absence of any other psychiatric symptoms."
"Do I have post-traumatic stress disorder," I ask, "like Mr Graver suggested?"
"There's a lot we don't know in psychiatry," the doctor says, and suddenly he looks so sad. He rubs the bridge of his nose, his eyes momentarily closed. With his head bowed, I can see a small bald spot on the dome of his scalp, and I want to say, "Hey. It's OK. There's a lot we don't know in the world." But instead I say nothing and the psychiatrist looks sad, and baffled, and then says, "But the voice is bothering you."
"Sort of, yeah."
"I'm going to give you an antipsychotic," he says, and as soon as he says this the sadness goes away. His voice assumes an authoritative tone; there is something he can do. "I'm going to give you Risperdal," he says. "That should quiet the auditory centres in your brain."
"So you think I'm psychotic?" I ask.
"I think you have a touch of psychosis," he says, but I get the feeling he has to say this, now that he's prescribing Risperdal. It becomes fairly clear to me that medication drives the decisions, and not the other way around. In Rosenhan's day, it was pre-existing psychoanalytic schema that determined what was wrong; in our days, it's the pre-existing pharmacological schema, the pill. Either way, Rosenhan's point that diagnosis does not reside in the person seems to stand.
"But do I appear psychotic?" I ask.
He looks at me. He looks for a long, long time. "A little," he finally says.
"You're kidding me," I say, reaching up to adjust my hat.
"You look," he says, "a little psychotic and quite depressed. And depression can have psychotic features, so I'm going to prescribe you an antidepressant as well."
"I look depressed?" I echo. This actually worries me, because depression hits closer to home. I've had it before and, who knows, maybe I'm getting it again and he sees it before I do. He writes out my prescriptions. The entire interview takes less than 10 minutes. I am out of there in time to eat Chinese with the real Lucy Schellman, who says, "You should've said 'thwack' instead of 'thud', or 'bam bam'. It's even funnier." Later on, I fill my prescriptions at the all-night pharmacy. And then, in the spirit of experimentation, I take the antipsychotic Risperdal, just one little pill, and I fall into such a deep, charcoal sleep that not a sound comes through, and I float, weightless, in another world, seeing vague shapes - trees, rabbits, angels, ships - but as hard as I peer, I can only wonder what is what.
It's a little fun, going into ERs and playing this game, so over the next eight days I do it eight more times, nearly the number of admissions Rosenhan arranged. Each time, I am denied admission, but, strangely enough, most times I am given a diagnosis of depression with psychotic features, even though, I am now sure, after a thorough self-inventory and the solicited opinions of my friends and my physician brother, I am really not depressed. (As an aside, but an important one, a psychotic depression is never mild; in the DSM, it is listed in the severe category, accompanied by gross and unmistakable motor and intellectual impairments.)
I am prescribed a total of 25 antipsychotics and 60 antidepressants. At no point does an interview last longer than 12 and a half minutes, although at most places I needed to wait an average of two and a half hours in the waiting room. No one ever asks me, beyond a cursory religious-orientation question, about my cultural background; no one asks me if the voice is of the same gender as I; no one gives me a full mental status exam, which includes more detailed and easily administered tests to indicate the gross disorganisation of thinking that almost always accompanies psychosis. Everyone, however, takes my pulse.
I call back Robert Spitzer at Columbia's Institute for Biometrics.
"So what do you predict would happen if a researcher were to repeat the Rosenhan experiment in this day and age?" I ask him.
"The researcher would not be admitted," Spitzer replies.
"But would they be diagnosed? What would the doctors do about that?"
"If they only said what Rosenhan and his confederates said?" he asks.
"Yeah," I say.
"They would be given a diagnosis of deferred."
"OK," I say. "Let me tell you, I tried this experiment. I actually did it."
"You?" he says, and pauses. "You're kidding me." I wonder if I hear defensiveness edging into his voice. "And what happened?" he says.
I tell him. I tell him I was not given a deferred diagnosis, but almost every time I was given a diagnosis of psychotic depression plus a pouch of pills.
"What kind of pills?" he asks.
"What kind of antipsychotics?" he asks.
"Risperdal," I say.
"Well," Spitzer says - and I picture him tapping his pen against the side of his skull - "that's a very light antipsychotic, you know?"
"Light?" I say. "The pharmacological rendition of low-fat?"
"You have an attitude," he tells me, "like Rosenhan did. You went in with a bias and you found what you were looking for."
"I went in," I say, "with a thud, and from that one word a whole schema was woven and pills were given, despite the fact that no one really knows how or why the pills work or really what their safety is."
Spitzer clears his throat. "I'm disappointed," he says, and I think I hear real defeat, the slumping of shoulders, the pen put down. "I think," he says slowly, and there is a raw honesty in his voice now, "I think doctors just don't like to say, 'I don't know'."
"That's true," I say, "and I also think the zeal to prescribe drives diagnosis in our day, much like the zeal to pathologise drove diagnosis in Rosenhan's day, but, either way, it does seem to be more a product of fashion, or fad."
I am thinking this: in the 1970s, American doctors diagnosed schizophrenia in their patients many times more than British doctors did. And now, in the 21st century, diagnoses of depression have risen dramatically, as have those of post-traumatic stress disorder and attention deficit hyperactivity disorder. It appears, therefore, that not only do the incidences of certain diagnoses rise and fall depending on public perception, but also the doctors who are giving these labels are still doing so with perhaps too little regard for the DSM criteria the field dictates.
Here's what's different: I was not admitted. I was mislabelled, but not locked up. Here's another thing that's different: every single medical professional was nice to me. Rosenhan and his confederates felt diminished by their diagnoses; I, for whatever reason, was treated with palpable kindness. One psychiatrist touched my arm. One psychiatrist said, "Look, I know it's scary for you, it must be, hearing a voice like that, but I really have a feeling that the Risperdal will take care of this immediately." In his words, I heard my words, the ones I, as a psychologist, often use with patients: You have this. The medication will do this. I speak such words not to promenade my power, but just to do something, to bring a balm. If we can only fix a mystery in space - Atlantic blue depression, the haziness of happiness and where on the continuum it lies - if we can only pin these things down for just the time it takes a neuron to pulse, well then maybe we could get our hands and heads around emotion. I believe this is what drove the psychiatrists I saw, not pigheadedness. One psychiatrist, upon handing me my prescription, said, "Don't fall through the cracks, Lucy. We want to see you back here in two days for a follow-up. And you know we're here 24 hours a day, for anything you need. I mean that. Anything."
I felt so guilty then, so touched. "Thank you so much," I said. "I can't tell you how much your kindness means."
"Be well," he said.
Three weeks have passed since my last ER debacle, and out of the blue my daughter has developed an obsession with Band-Aids. Her dolls have many hurts not visible to the human eye. I come home at the end of the day and find Band-Aids applied to the exposed floor joists, the kitchen cabinets, the walls, as though the walls themselves are wounded. Our house hurts, and it is old. In the night it creaks. My daughter cries. Sometimes she cries for no reason at all, except, I think, that there are thuds we cannot capture, and when this knowledge dawns on her she throws herself to the floor and screams, "I just want to go to the zoo!" I comfort her, then, with Band-Aids. The Band-Aids soothe, even though we don't know just what or where her wound is.
Rosenhan used the results of his study to discredit psychiatry as a medical specialty. But are there not many, many diseases or wounds in our country's pain clinics, oncology centres, paediatric wards, where etiology, pathogenesis, even label itself, are hazy? Does the woman have fibromyalgia or Epstein-Barr virus? Does the person have epilepsy or a brain tumour too small to be detected? For a time, Rosenhan himself was suffering from a mysterious disease that could be given many names, depending on the practitioner.
I'd like very much to help Rosenhan, who is still in a west coast hospital, paralysed, even his vocal cords. I'd like to tell him that I redid his study and had a grand old time, because I think it would please him to know this. I would like to visit. "I don't think now would be a good time," Jack, his son, says. "He still can't talk and he's very tired."
But it's not talking I'm after. I'd just like to see him. I picture, right now, a nurse bathing him. I don't even know the man, but I have an unreasonable fondness for him. I'm partial to jokesters, to adventures, to people in pain. As an ex-mental patient, I'm impressed with anyone who cares to understand the intricacies of that distant world. So I would bring Rosenhan gifts, this essay, an apple, a watch with a face large enough to see the swirl of time and, from my daughter, boxes and boxes of Band-Aids
David Rosenhan recently recovered from his illness and returned to his post as emeritus professor of law and psychology at Stanford University.
This is an edited extract from Opening Skinner's Box: Great Psychological Experiments Of The 20th Century, by Lauren Slater, published on Monday by Bloomsbury at £16.99. To order a copy for £14.99 (plus UK p&p), call 0870 066 7979.