Shrinks (15 page)

The pretense of Rosenhan’s pseudopatients was never detected. All but one was diagnosed as schizophrenic (the outlier was diagnosed as manic-depressive), and when they were discharged all but the manic-depressive patient were labeled as having “schizophrenia in remission.” The length of their hospitalizations varied from seven to fifty-two days. Yet, as Rosenhan observed with scorn, no one on the staff ever raised the issue of their apparent sanity. (This assertion is open to debate, since many nurses did record that the pseudopatients were behaving normally.) Rosenhan concluded, “We cannot distinguish the sane from the insane in psychiatric hospitals,” and he condemned the entire profession for unreliable diagnoses and excessive labeling. The latter accusation was somewhat ironic, considering that the majority of psychiatrists at the time rejected diagnostic labels in favor of nuanced and individualistic psychoanalytic interpretations.

Rosenhan’s
Science
article provoked widespread outrage and derision among both the general public and the medical community, a reaction that took psychiatrists completely by surprise. Their response was defensive. They criticized Rosenhan’s study head on, arguing (quite reasonably, in my opinion) that if someone shows up at a mental hospital and complains of hearing voices, the sensible and ethical course of action is to admit her for observation and treatment. After all, schizophrenia can be a dangerous illness. If the psychiatrists did not accept at face value what their patients told them, then not just psychiatry but the entire medical profession would be at risk. If a patient showed up in the emergency room and claimed to have chest pain, but the staff refused to admit her for testing without further proof of her pain, she might die. Similarly, if a person fabricated illness by intentionally swallowing a vial of blood in order to deceive doctors, then induced himself to cough up blood in the emergency room, it would be extremely cynical to declare the doctors incompetent if they performed an endoscopy to find the source of the bleeding.

Rosenhan openly admitted his antipathy toward the psychiatric profession, and on the heels of the outrage provoked by his first study, he saw another opportunity to inflict damage on psychiatry’s crumbling credibility. He approached a large prestigious teaching hospital that had been especially vocal in contesting Rosenhan’s findings with a new challenge: “Over the coming year, I will send in another round of imposters to your hospital. You try to detect them, knowing full well that they will be coming, and at the end of the year we see how many you catch.” The unidentified hospital took the bait, and—perhaps unwisely—agreed to the contest.

Out of 193 new patients evaluated over the course of the ensuing year, the staff identified 41 as potential impersonators. A gleeful Rosenhan then revealed that no imposters had been sent to the hospital. He then declared that, given psychiatry’s inability to distinguish the sane from the insane, the profession was doing the medical equivalent of convicting innocent people of crimes and sentencing them to prison.

While most psychiatrists dismissed Rosenhan’s study as a self-aggrandizing gimmick, the profession could not escape the embarrassment or ignore the public outcry. Newspapers were filled with op-eds and letters to the editor denouncing psychiatry as a sham and a racket. Even more distressing to psychiatrists, medical colleagues and insurance companies had begun to vocally express their own disillusionment with psychiatry. Following the publication of the Rosenhan study, insurance companies like Aetna and Blue Cross dramatically slashed the mental health benefits in their policies as they became increasingly cognizant of the fact that psychiatric diagnosis and treatment were freewheeling affairs that took place without oversight or accountability. In 1975, the vice president of Blue Cross told
Psychiatric News
, “In psychiatry, compared to other types of medical services, there is less clarity and uniformity of terminology concerning mental diagnoses, treatment modalities, and types of facilities providing care. One dimension of this problem arises from the latent or private nature of many services; only the patient and therapist have direct knowledge of what services were provided and why.”

As bad as this was, there was much more to come. The Rosenhan study fueled a rapidly accelerating activist movement that sought to eliminate psychiatry entirely, a movement launched a decade earlier by a man named Thomas Szasz.

The Antipsychiatry Movement and the Great Crisis

In 1961, Thomas Szasz, a Hungarian-born psychiatrist on the faculty of the State University of New York at Syracuse, published a highly influential book that has remained in print to this very day,
The Myth of Mental Illness
. In this book he argues that mental illnesses are not medical realities like diabetes and hypertension, but are fictions invented by psychiatry to justify charging patients for unscientific therapies of unknown effectiveness. Szasz declared that psychiatry was a “pseudoscience” like alchemy and astrology—not an unreasonable critique at a time when psychoanalysis was the cult-like force that dominated psychiatry.

The book won him instant fame, especially among young people who were embracing countercultural values and challenging traditional forms of authority. By the mid-1960s, students flocked to study with him at SUNY. He began publishing articles and giving lectures advocating a new approach to psychotherapy. The true and worthy goal of an analyst, Szasz contended, was to “unravel the game of life that the patient plays.” Psychiatrists, therefore, should not assume that there is something “wrong” with odd behavior, a message that resonated with a generation adopting other anti-authoritarian slogans such as “Turn on, Tune in, Drop Out” and “Make Love, Not War.”

Szasz’s views amounted to a form of behavioral relativism that viewed any unusual behavior as meaningful and valid if viewed from the proper perspective. Szasz might say that Elena Conway’s decision to accompany the sleazy middle-aged stranger to his apartment was a valid expression of her plucky personality and her admirable willingness to not judge someone by his appearance, rather than impaired judgment caused by an arbitrary “illness” that doctors called “schizophrenia.” Szasz wanted to completely do away with mental hospitals: “Involuntary mental hospitalization is like slavery. Refining the standards for commitment is like prettifying the slave plantations. The problem is not how to improve commitment, but how to abolish it.”

Szasz’s ideas helped give birth to an organized activist movement that questioned the very existence of the profession of psychiatry and called for its eradication, and
The Myth of Mental Illness
became its manifesto. Szasz’s final betrayal of his profession came in 1969 when he joined L. Ron Hubbard and the Church of Scientology to found the Citizens Commission on Human Rights (CCHR). Explicitly drawing upon Szasz’s arguments, the CCHR holds that “so-called mental illness” is not a medical disease, that psychiatric medication is fraudulent and dangerous, and that the psychiatric profession should be condemned.

Szasz served as inspiration for others who doubted the value of psychiatry, including an unknown sociologist named Erving Goffman. In 1961, Goffman published the book
Asylums
, decrying the deplorable conditions in American mental institutions. Since the population of asylums was near its all-time high, there was little question that most of these institutions were oppressive, overcrowded, and bleak. What was Goffman’s response to this indisputable social problem? He declared that mental illness did not exist.

According to Goffman, what psychiatrists called mental illness was actually society’s failure to understand the motivations of unconventional people; Western society had imposed what he called a “medical mandate over these offenders. Inmates were called patients.” Goffman wrote that his goal in investigating mental institutions was “to learn about the social world of the hospital inmate.” He intentionally avoided social contact with the staff, declaring that “to describe the patient’s situation faithfully is necessarily to present a partisan view.” He defended this overt bias by claiming “the imbalance is at least on the right side of the scale, since almost all professional literature on mental patients is written from the point of view of the psychiatrists, and I, socially speaking, am on the other side.”

The urge to propound theories of human behavior is a basic human impulse we all frequently indulge in; this may be why so many psychiatric researchers feel compelled to throw aside the theories and research of previous scientists in order to articulate their own Grand Explanation of mental illness. Despite the fact that Goffman was trained in sociology (not psychiatry) and had no clinical experience whatsoever, the urge for propounding his own Grand Explanation of mental illness soon overtook him.

Individuals diagnosed with mental illness did not actually have a legitimate medical condition, insisted Goffman, but were instead the victims of society’s reaction to them—what Goffman termed “social influences,” such as poverty, society’s rejection of their behavior as inappropriate, and proximity to a mental institution. But what if a person was
convinced
that something was wrong with her, as in the case of Abigail Abercrombie and her panic attacks? Goffman replied that her perceptions of her racing heart, her sense of imminent doom, and her feeling of losing control were all shaped by cultural stereotypes of how a person
should
behave when she is anxious.

As Szasz and Goffman were rising in prominence, another antipsychiatry figure emerged on the other side of the Atlantic: the Scottish psychiatrist R. D. Laing. While Laing believed that mental illness existed, like Goffman he placed the source of illness in a person’s social environment, especially disruptions in the family network. In particular, Laing considered psychotic behavior an expression of distress prompted by a person’s intolerable social circumstances; schizophrenia, to his thinking, was a cry for help.

Laing believed that a therapist could interpret the personal symbolism of a patient’s psychosis (shades of Freud’s dream interpretations) and use this divination to address the environmental issues that were the true source of the patient’s schizophrenia. To successfully decode a patient’s psychotic symptomatology, Laing suggested that the therapist should draw upon his own “psychotic possibilities.” Only in that way could he comprehend the schizophrenic’s “existential position”—“his distinctiveness, and differentness, his separateness and loneliness and despair.”

The ideas of Szasz, Laing, and Goffman formed the intellectual underpinnings of a burgeoning antipsychiatry movement that soon joined forces with social activists such as the Black Panthers, Marxists, Vietnam War protesters, and other organizations that encouraged the defiance of the conventions and authority of an oppressive Western society. In 1968, the antipsychiatrists staged their first demonstrations at an annual meeting of the American Psychiatric Association. The following year, at the APA meeting in Miami, delegates looked out the window to discover an airplane circling overhead pulling a banner that read “Psychiatry Kills.” Every year since then, APA meetings have been accompanied by the bullhorns and pickets of antipsychiatry protests, including the 2014 meeting in New York, over which I presided.

Despite the kernels of truth in the antipsychiatry movement’s arguments in the 1960s and 1970s—such as their quite valid assertion that psychiatric diagnosis was highly unreliable—many of their claims were based on extreme distortions of data or oversimplifications of clinical realities. The most elaborate antipsychiatry critiques tended to emerge from ivory tower intellectuals and political radicals who lacked any direct experience with mental illness, or from clinical mavericks who operated on the fringes of clinical psychiatry… and who may not have even believed the ideas they were touting.

Dr. Fuller Torrey, a prominent schizophrenia researcher and leading public spokesperson for mental illness, told me, “Laing’s convictions were eventually put to the test when his own daughter developed schizophrenia. After that, he became disillusioned with his own ideas. People who knew Laing told me that he became a guy asking for money by giving lectures on ideas he no longer believed in. Same with Szasz, who I met several times. He made it pretty clear he understood that schizophrenia qualified as a true brain disease, but he was never going to say so publicly.”

The antipsychiatry movement continues to harm the very individuals it purports to be helping—namely, the mentally ill. Aside from Laing, the leading figures of antipsychiatry blithely ignored the issue of human suffering, suggesting that a depressed person’s misery or a paranoid schizophrenic’s feelings of persecution would dissipate if we merely respected and supported their atypical beliefs. They also ignored the danger that schizophrenics sometimes presented to others.

The eminent psychiatrist Aaron Beck shared with me one example of the true cost of such ignorance. “I had been treating a potentially homicidal inpatient who made contact with Thomas Szasz, who then put direct pressure on the Pennsylvania Hospital to discharge the patient. After he was released, the patient was responsible for several murders and was only stopped when his wife, whom he threatened to kill, shot him. I think that the ‘myth of mental illness’ promulgated by Szasz was not only absurd but also damaging to the patients themselves.”

State governments, which were always eyeing ways to cut funding for the mentally ill (especially state mental institutions, usually one of the most expensive line items in any state budget), were only too happy to give credence to antipsychiatry arguments. While purporting to adopt humane postures, they cited Szasz, Laing, and Goffman as scientific and moral justification for emptying out the state asylums and dumping patients back into the community. While legislators were able to save money in their budgets, many patients in these asylums were elderly and in poor health and had nowhere else to go. This ill-conceived policy of deinstitutionalization directly contributed to the epidemic of homelessness, many of whom were mentally ill, and the rapid growth of the mentally ill population in prisons, which persists to this day. Insurance companies also readily accepted the antipsychiatrists’ argument that mental illness was simply a “problem in living” and not a medical condition and therefore treatment for such “illnesses” should not be reimbursed, leading to even more cutbacks in coverage.