THE GREAT PRETENDER
by Susannah Catalan
The history of psychiatry is a minefield—Edward Shorter.
Beware of the Shrapnel!—Susannah Catalan
It is a dangerous world. People suffering mental illness historically, if insightful enough to seek help beyond family, might go to a minister or a clergyman for counsel. Our modern day society sees less of this and the authority to help comes from the psychiatric professions. And like ministers and clergymen, they are not above suspicion.. And then there is the question, “what exactly is mental illness?”
It’s like pornography, right? You know it when you see it—regardless of your training..
Just as with pornography the soft power of our society has over the years changed our impressions of both the question and the professions regarding “mental illness.” The prejudice seems mostly negative. A huge number of people are forced into therapy by court order or the pressure of their lives falling apart—-all negatives. The culture’s appreciation of mental illness as seen in movies and literature: One Flew Over the Cooku’s Nest, The Snake Pit, or the King of Hearts come to mind. In Medical School, a grainy 1940’s documentary reflected on what was not going well for institutionalized people with mental health problems in Massachusetts. These made an impression on me, to be sure.
These impressions rode the wave of a societal change in attitude about what it was to be “insane” and what measures were to be taken in cases of insanity. There were medical issues tied to this and legal issues tied to this. They are different things. The Great Pretender examines our history regarding this question in the time frame of the 1970’s and beyond through the study of a reported group of cases presented in Science magazine in 1973: ”Being Sane in Insane Places.”
I was aware that such a study had occurred and when I saw this book, I thought it would be enjoyable to get the details of what happened to normal people tasked with proving their sanity once institutionalized. This book gives a good general history and tries to unravel the mystery of what actually happened in the study that helped catalyze a dramatic shift in how society interacts with citizens with dramatic mental health problems.
The author has an interesting chip on her shoulder; she has an unusual autoimmune disease that “attacked” her brain finding her presenting in distress and psychotic. She looked and acted like a “crazy person.” Her salvation from a likely outcome given this, a lifetime in an asylum with no hope of improving, much less getting out, was having a therapeutic connection with her internist, who went the extra mile to document her condition and in treating it, resolved her psychosis.
The book opens with a history of both the philosophical and psychological conceptualization of “insanity.” She makes the following points:
Is there a “ghost in the machine” or are all psychiatric diseases some form of, as-yet-not-understood neurological-chemical deficits, just waiting to be discovered and treated?
Even with a model of what insanity was understood to be in the past, were any of the treatments in any way understandable or humane? She goes to great lengths to point out the obvious answer, “NO.” She brings out names I had not heard for years like Dorothy Dix who was one of many reformers suggesting existing practices were immoral, wrong, and detrimental to the patients.
She points out that making diagnoses, even “simple” medical ones require an element of faith in the doctor and the same faith by the doctor in him/herself. Emanual Kant was a sceptic: “Yes, I understand they will give a diagnosis; but would they stand by it if they had to bet their home on being correct?”
Psychiatry, of all the medical disciplines is unusual; with the “correct” diagnosis, you can take away a person’s civil rights, force tortuous treatments on patients against their will, and can hold them captive. Habeus Corpus disappears when a person is deemed, “insane.”
“Once labeled, our medical and psychiatric records are segregated and a cloud of uncertainty lingers over your credibility at every level.” As in, forever…..
So, who is insane and who decides? She points out that the wealthy have always been able to take advantage of laws that in the past simply required two doctors to certify “insanity” and the person in question could be put away for life. Wives, daughters, and weird uncles all suffered this fate. With the popularity of Freudian psychology, the definitions were all over the place and a survey of such psychologists in Manhattan in 1962 after interviewing a random population of citizens could only certify 5% as completely sane…….
Enter Doctor Rosenthal, who landed for most of his career, in Stanford with a plethora of other famous psychologists. He wrote, “On Being Sane in Insane Places,” published in Science magazine in 1973. This much-cited study catalyzed the already growing anti-psychological movement in our society. The study? Eight pseudo patients presented to outpatient clinics complaining of auditory hallucinations: “I hear ‘thud,’ “empty,’ ‘hollow.’” Based on this symptom, the pseudo patients all were admitted to hospitals and after an interview assigned diagnoses associated with Schizophrenia. They averaged 19 day stays. The 8 pseudo patients consumed some 1200 antipsychotic pills. Their experiences were enumerated and were damning.
The author of the book gets access to notes by Dr. Rosenthal (long deceased) and tries to tease things out. Prominent are notes from when Dr. Rosenthal himself presented for admission. This one-off “experiment” flowed from the challenge his students presented him with as he taught abnormal psychology at a University in New Jersey. They wanted to see real patients when the topic was schizophrenia and he refused to bring such patients into the lecture circuit. He told them, “If you want to see schizophrenics, go get yourself admitted to a psych hospital.” No one took him up on it and he considered the ethical and liability issues of his advice, and came to the conclusion that maybe he should try it first.
His personal experience clearly ties to what was prominent in his paper, “On Being Sane in Insane Places.”
He was admitted for a mandatory 30 days (it was a voluntary admission but he had to commit to the time-frame, as did his wife). They hesitated with this condition AND the stipulation that when admitted, therapeutic interventions, including Electro Shock Therapy, might be used if deemed necessary.
He surrenders all his possessions and is put in a gown.
He comes to a ward that is chaotic with no one, staff or patients, engaging him.
The bathroom is in disrepair and filthy.
He looks in the mirror and sees a haggard old man.
He reflects on the writing of a famous and influential psychologist (Author of The Myth of Mental Illness) Thomas Szaz*, and concludes, “He’s wrong; these people are different than me.”
The routines on the ward were clearly not therapeutic: he was bored out of his skull. He wrote notes and disguised his comments given that anything he mailed would be censored—- and realized quickly, no one cared what he wrote. His copious writing was viewed as part of his condition! A peer patient told him the more normal you acted, the less attention you received from the staff. In fact, the advice continued, if you want to get out of here, you have to agree with whatever the doctor says…..
He witnesses a nurse unbuttoning her blouse in public to adjust her bra and realized she was not self-conscious because she did not consider the patients worthy of any consideration regarding her modesty. One of the attendants came and introduced himself, shook his hand (this was unusual on the ward and was the first time). They spoke briefly and then Rosenthall noted that upon returning to the nursing station, the nurses were laughing and teasing the attendant. Later, the attendant would not communicate with him as he attempted to restart their conversation. He looked in the mirror and saw the college professor that he was and realized with his writing (and he was now in his normal clothes) that the attendant mistook him for a doctor on the ward writing clinical notes.
He agrees that labelling theory is fully operational here; if people think you are crazy, whatever you do is interpreted in this light, ie negatively.
There is a power dynamic: the staff treated him as a child ie differently and they withheld benefits and even syrup for his pancakes, on a whim.
In addition, themes that he points out in the study from the other pseudo patients included:
Self doubt—the disorientation of the admission process and first days on the ward found one pseudo patient wondering if maybe she should actually swallow the antipsychotic medication (they were all taught to “cheek” their medication and dispose of it later).
One pseudo patient was so distraught by the environment and food, that he refused to eat much at all and lost considerable weight, this never being addressed by staff or his physician. He confounded his visitors showing them saved food from past meals to prove how bad it was…….
The conclusions that made a splash in 1973? Patients, sane or not, experience segregation, depersonalization, powerlessness , mortification, and dehumanization. How therapeutic can that be? The loss of credibility for those in authority in the mental health field were not the only ones facing the music; this was the time of Watergate, the end of the Viet Nam War, and the beginning of dramatic economic changes.
There was a reaction in the field of Psychiatry/Psychology. The systemization and refocus on the making of diagnoses. We doctors know of this as the DSM (Diagnostic and Statistical Manual of Mental Disorders) series of reference books with diagnoses and criteria for making psychiatric diagnoses. These references were to also be tied to insurance payments and billing.
The narrative brings us to another famous psychiatrist, a Dr. Robert Spitzer. He is famous for developing and shepherding the DSM —version 3 which was comprehensive and a change for the time. With this edition for the first time, homosexuality was off of the list of psychiatric diagnoses. He developed a tool for structuring psychological interviews so that the likelihood that the same patient, presenting to different therapists would be given the same or similar —and correct diagnoses.
Dr. Spitzer was methodical and a scientist. He savaged “On Being Sane in Insane Places” for being unscientific: Sptizer had reviewed the medical records from Dr. RosenthaI’s original admission and found inconsistencies in the medical records, his notes, and what was published. He claimed the article was, “pseudoscience presented as science” and editorialized: “Some foods taste delicious but leave a bad aftertaste…”. He concludes making a parody of the pseudo patient discharge diagnosis, “schizophrenia in remission,” with the article being discharged for having “logic in remission.”
Dr. Spitzer’s work on DSM 3 was intended to provide psychiatrists and therapists with a tool that would prevent a normal person from being admitted or mis-diagnosed. Humans being humans, it did not work so well over the years. To this day, for example, blacks presenting with the same scripted symptoms as whites are diagnosed with a schizophrenia diagnosis four times as often.
The book’s attempt to solve a mystery, ie can we learn more by interviewing the pseudo patients leads to a couple of interesting points, but the majority of pseudo patients could not be identified and with the author’s exhaustive search, the possibility that they may not have existed at all is raised. This is of course unknowable with certainty at this point but, she adds, Dr. Rosenthal is characterized by many as a bit of a “bullshitter” and his notes look suspicious with internal errors and incorrect accounting of data sets. Did he dry lab (fake results to get an expected result) his study?
The author learns of the original admitting doctor (for Dr. Rosenthal) and learns that he had identified much more than the existential voice saying, “thud,” “empty,” “hollow.” Dr. Rosenthal, in the clinical notes, identified himself with having suicidal ideation and attempts to keep the source of the hallucination out by putting copper cups over his ears……The author correctly points out in most settings, with most doctors, this combination of symptoms would lead to a concern about disability, self-harm, and a need for more evaluation in an in-patient setting. Once more, the admitting doctor (now deceased) as reported by his daughter, was ceaselessly striving to help the psychotic and on his own initiative gave his phone number and was on-call for social workers and the police when a homeless psychotic person was in need. He helped find services for them. It is ironic that his admission of Dr. Rosenthal would lead to a paper that vilified his profession and his personal efforts.
One pseudo patient from the San Francisco area was identified and his experience was in conflict with the conclusions of the Science article. He was housed in a pleasant environment with good interactions with staff and fellow patients. His ability to get a day pass was done by vote of his fellow patients! He was excluded from the Science article but later published his “rebuttal” but this raised little stir.
The concluding chapters bring up two interesting salient points: one is personal for the author and once again raises the question of “how sure can we be about any psychiatric diagnosis?”
The other is the net effect of this evolution of psychiatric care which was catalyzed by “On Being Sane in Insane Places.”
Nihilism evolved in the 1970’s that can be summarized as, “You are better off on the street with no plan than locked up in an asylum.” The statistics of our modern world are raised to question this without really offering up much of a solution.
In many large penal institutions, 20% of the population has disabling mental problems and in jail or a penitentiary (for what are they penitent?) where they are prey and without any therapeutic intervention. Cook County is raised as an exception where the lead manager identified in a 60 Minutes noted that if this is our population, ie patients, we will intervene with them as patients and reforms there are identified to that point.
She points out that the lack of beds is dramatic; there are 10% of the in-patient beds for psychiatric patients when compared to when John F Kennedy was president and the nation’s population was half of what it is today. People don’t get out of jail even when there is a clear psychosis; being insane, there is no chance to proceed to trial and there is nowhere for them to go.
I myself had an 80 year old demented man who was violent; he stayed in the local Emergency Department for months, without ever being formally admitted to the hospital out of fear—for the insurance company, of bills for an in-patient bed for an undetermined amount of time before transfer—and for the hospital who will get paid at a set rate but will have to pay for extra expenses like private duty nursing and extra security. No beds anywhere.
Our fellow citizens and elected representatives have been convinced that the therapy available in medication and counseling as well as the cost savings of not having enough beds for the severely mental ill add up to a win-win. It may be we have come back to a world of Charles Dickens where crazy people sleep on the street or get put in jail and regardless of where they land, are targeted in many many ways.
Oliver Sacks, of all people, wrote an editorial lamenting the loss of asylums and noted some of the positive qualities they offered. His remains a minority opinion. Popular as Oliver Sacks was, he took a hit on this one.
Big Pharma, the salary scale for people providing behavior health care, and the shortage of qualified providers round out the depressing story the book concludes with.
The author is willing to continue sharing her personal story with the original question in mind: despite all the advancements from the art of psychiatry with Freudian “fixings” to the more dogmatic and systematized DSM approach to diagnosis, she pays for a consultation with a well known psychiatrist who is a proponent of the DSM identifying to him ahead of time, her personal history and medical diagnosis. The DSM has concrete questions upon which to build the diagnosis. They are specific and she finds answering the specific questions daunting: recounting the events of her hospitalization from years before, he asks, if she was depressed during her illnes? “Yes,” is the answer. He wants to know for how long, down to the number of weeks. She finds it hard to respond meaningfully, but he wants a number…..”You had mania; now long did that last?” She wrestles with the fact that it was mixed with her depression and she cannot give a number of weeks or months. She does not remember. They wrestle with the notion of whether you can be psychotic and have a normal mood. He concludes, “At the time, the two diagnoses that would have been most reasonable were schizophreniform and schizoaffective disorder.” They both know these were wrong given her medical diagnosis of autoimmune encephalitis. The cost of the consultation, for what would have been an incorrect diagnosis? $550.
She is put off by the court-room interrogative style of the structured interview. Nonetheless, she finds herself wanting to please the interrogator and being at the same time, put off by the requested specificity of what she can’t specify.
She concludes something I concluded long ago: the likely success of anyone in therapy has more to do with the therapeutic connection between patient and therapist than the mechanism of counseling/therapy. That is nice, so far as it goes, one-on-one. The larger problem in modern America with the concerns raised in this book is how to organize society’s responsibility and resources for the severely mentally ill. Most of us —without a background in psychiatry cannot define it—but we recognize severe impairment when we see it; it deserves compassion and resources that are not clearly present now.
*Myth of Mental Illness by Szasz—selected quotes:
If you talk to god, you are praying—if he talks to you you are crazy.
If the dead talk to you, you are a spiritualist; if you talk to the dead, you are crazy.
Is it possible the mental institutions not only used arbitrary labels, a form of alchemy, but did patients harm with the care given?
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