On Being Sane in Insane Places

This article first appeared in the March/April 2004 issue.

It was 1972. Spiro Agnew had just resigned. Thomas Szasz had written The Myth of Mental Illness. R. D. Laing had challenged psychiatrists to rethink schizophrenia as a form of possible poetry. Only recently, flags had waved on the snouts of guns, signaling cease-fire in Vietnam. David Rosenhan, a newly minted psychologist with a joint degree in law, did not go to Vietnam, but according to one colleague, he had observed how many men used mental illness as a way of avoiding the draft. It was fairly easy to fake some symptoms–how easy, exactly, was it? Rosenhan, who loved adventure, decided to try something out.

Almost on impulse he 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, see if they can tell you’re really sane?” Surprisingly, so the story goes, all eight were not busy next month, and all eight–three psychologists, one graduate student, a pediatrician, 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. Says pseudopatient psychologist Martin Seligman, “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. I gave him all of October, which is how long the experiment took.”

In fact, it took longer than that. First, there was training. Rosenhan instructed his confederates very, very carefully. For five days prior to the appointed date, they were to stop showering, shaving, 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 the 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 completely honestly, save for name and occupation. They were to feign no other symptoms. Once on the ward, if admitted, they were to immediately say that the voice had disappeared and 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. “It took me a while,” recalls Seligman, “to get the pill thing right, and I was so nervous. I was nervous I’d accidentally swallow a pill if they forced one on me, but I was more nervous about homosexual rape.”

The pseudopatients practiced for a few days. Much of the practice was, admittedly, passive, letting entropy and odor wend their way in. Their hair grew out and clumped. Their breath got a greenish tinge. They learned to tuck fat pills and pea-sized pills in the cavern beneath the tongue, and then to turn the head sideways and surreptitiously spit. It was autumn then, and a fat harvest moon hung in the sky. Goblins in bright capes drifted down the streets, witches carrying flickering pumpkins. Trick? Or treat?

What happened once Rosenhan and his confederates were admitted? They were given some therapy, and when they told of the joys and satisfactions and disappointments of an ordinary life–remember, they were making nothing up save the original presenting complaint–all of them found that their pasts were reconfigured to fit the diagnosis. Wrote Rosenhan in Science, one of the field’s most prestigious journals, in 1973, “Clearly, the meaning ascribed to [our] verbalizations . . . was determined by the diagnosis, schizophrenia. An entirely different meaning would have been ascribed if it were known that [we were] ‘normal.'”

In 1973, “On Being Sane in Insane Places,” Rosenhan’s account of his study, burst like a bomb in the world of psychiatry. At one point early in the article, Rosenhan just 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 strange thing was, the other patients seemed to know Rosenhan was normal, even while the doctors did not. A number of the other confederates undergoing similar incarcerations all across the country also had this eerie experience, that the insane could detect the sane better than the insane’s treaters could. Said one young man, coming up to Rosenhan in the dayroom, “You’re not crazy. You’re a journalist or a professor.” Said another, “You’re checking up on the hospital.”

While in the hospital, Rosenhan followed all orders, asked for privileges, helped other patients deal with their problems, offered legal advice, probably played his fair share of Ping-Pong, and took copious notes, which the staff labeled as “writing behavior” and saw as a part of his paranoid schizophrenic diagnosis. And then one day for a reason as arbitrary as his admission, he was discharged. He had learned something severe: he had learned about inhumanity in asylums; he had learned psychiatry was psychiatrically sick. He wondered, in how many hospitals all across this country were people being similarly misdiagnosed, medicated, and held against their wills. Did the label of madness beget madness, so that the diagnosis sculpts the brain, and not the other way around? Our brains do not, perhaps, make us. Maybe we make our brains. Maybe we are made by the tags affixed to our flesh.

Rosenhan’s study certainly had its critics. One of those was Robert Spitzer, one of the twentieth century’s most prominent psychiatrists, who wrote in a 1975 article in the Journal of Abnormal Psychology in retort to Rosenhan’s findings, “Some foods taste delicious but leave a bad aftertaste. So it is with Rosenhan’s study.” He goes on to state, “We know very little about how the pseudopatients presented themselves. What did the pseudopatient say?” In a footnote to the article, Spitzer 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.” In a recent phone conversation with me, Spitzer elaborated. “And this whole business of thud,” he recalled. “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 okay, it’s okay.’ I know of no such report in the literature. This doesn’t mean there isn’t real distress.”

If Rosenhan single-handedly set out to dismantle psychiatry, Spitzer single-handedly set out to restore it. Together with a group of esteemed colleagues, he took that flimsy little DSM II , the one that contained enough ambiguity to allow Rosenhan and confederates to get admitted, and transformed it into DSM III . He plucked every ephemeral, subjective thing that he could. He scoured it for signs of psychobabble. He tightened diagnostic criteria so that each and every one of them was measurable, and in order to qualify for any diagnosis, there were very strict guidelines about which symptoms, for how long, how often.

So has psychiatry changed over the past 30 years? Says Spitzer, “I’m telling you, with the new diagnostic system in place, Rosenhan’s experiment could never happen today. It would never work. 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.

“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.

He touches his beard, which is getting a little long. He is wearing a geek shirt, closer to plastic than cotton in its contents, with a Rorschach ink splotch from an uncapped pen on the chest pocket.

“Come get you? You think they’ll believe me? They’ll lock me up too,” he says, almost hopefully. My husband was born too late to enjoy the sixties, which is something he sorely regrets. He pauses, fingering his beard. A moth flies in through the open window and beats insanely against the lit orb in the center of our dusky room. On the wall the moth’s shadow is as big as a bird. We watch the moth. We smell the season. I’m coming too,” he finally says.

No, he is not. Someone has to watch the baby. 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 recognized. The plan is to use her name and then have her, later, with her license, get the records so 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 practicing 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 retest setup. None of Rosenhan’s folks had any psychiatric history. I, however, have a formidable psychiatric history that includes lots of lockups, although, really, I’m fine now. I decide I’ll fake my history, deny any psychiatric involvement in the past, and this lie, I know, is a radical departure from the original protocol. Thud.

I kiss the baby good-bye. I kiss my husband good-bye. 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 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?” And you say, “Yes.” 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–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 phonetic 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. “You’re a free woman, Lauren,” I tell myself, while in the back of my mind is that rushing hysterical river with its buried alluvium and stink–smash smash.

I am in control. I tell this to myself while the rivers rush. I don’t feel in control though. At any moment someone might recognize 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. I am banking on this.

This emergency room is eerily familiar to me. The nurse takes the name that is not my name and the address that does not exist; I make up a street with a lovely sound to it: Rum Row, 33 Rum Row, a place where pirates grow green things in their gardens. The emergency room is similar because in my past I have been in many that were just like this for undeniably real psychiatric symptoms, 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, and a horse crumples into hay with a scarlet star on his forehead, and the smell is the smell and the nurse is the nurse; nothing changes.

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 beats 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 reemerge 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 color but cannot quite assume it, the way its whiteness is tentative, how it comes to the cusp, always.

He hands me the glass. This, also, I had not expected–such kindness, such service. Rosenhan writes about being dehumanized. So far, if anyone’s dehumanized here, it’s Mr. Graver, who is fast becoming my own personal butler.

I take a sip. “Thank you so much,” I say.

“Is there anything else I can get you? Are you hungry?”

“Oh no no,” I say. “I’m fine really.”

“Well, no offense 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?”

“Thud.”

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 screams. 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. I rub my temples.

“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 okay, 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 neighbor 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. I remember Mr. Blauer, an Orthodox Jewish man. He died on Shabbat, his yarmulke floating to the top of the pool, a deep velvet blue, just bobbing there.

“Thud,” Mr. Graver says. “Your neighbor 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’d say,” he says, his voice gaining confidence now, “that having a neighbor drown constitutes a traumatic loss. I’m going to get the psychiatrist to evaluate you, but I really suspect 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 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.

“Outside.”

“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. “Okay,” 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, the size of Mr. Blauer’s yarmulke on the dome of his scalp, and I want to say, “Hey. It’s okay. 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. A pill is so much more than a pill. It’s a point of punctuation. It breaks up the blurry long lines between this and that. Stop here. Start here. Begin.

“I’m going to give you Risperdal,” he says. “That should quiet the auditory centers 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. You can’t prescribe an antipsychotic unless your diagnosis supports that. It becomes fairly clear to me that medication drives the decisions, and not the other way around. In Rosenhan’s day it was preexisting psychoanalytic schema that determined what was wrong; in our days, it’s the preexisting 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. Maybe this experiment is making me depressed, driving me crazy, or maybe I chose to do this experiment as a way of unconsciously reaching out for help. The world is all haze.

He writes out my prescriptions. The entire interview takes less than ten 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, of course, I am denied admission–I deny I am a threat and I assure people I am able to do my work and take care of my child–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. “No, you don’t seem depressed like that, or at all,” my friends and brother tell me. Nevertheless, in the ERs I am seen as such, this despite my denying all symptoms of the disorder–and I am prescribed a total of twenty-five antipsychotics and sixty antidepressants. At no point does an interview last longer than twelve and a half minutes, although at most places I needed to wait an average of two and a half hours in the waiting rooms. 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 disorganization of thinking that almost always accompanies psychosis. Everyone, however, takes my pulse.

So what was the difference between what Rosenhan and his confederates experienced and what happened to me? I was not admitted. This is a very significant difference. No one even thought about admitting me. I was mislabeled 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. And I speak such words not to promenade my power, but just to do something, to bring a balm, somehow.

Now, 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. One for you, one for me, until we are wrapped. She loves to see me slide the Band-Aids out of their contained cardboard boxes, lift the paper wrapper to my teeth, tear a slit, and then, moments later, peel back the plastic layers to reveal the sticky tabs, the plump cotton pad smack in the tape’s taupe center. I lay it on her skin. The Band-Aids soothe, even though we don’t know just what or where her wound is.

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