Neurology

Revue Neurologique, 2012

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Brain, Mind and Medicine: Essays in Eighteenth-Century Neuroscience, 2007

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Annals of Neurology, 2003

Journal of the History of the Behavioral Sciences

How should we describe the late David Rosenhan's 1973 Science article, "On being sane in insane places" (Rosenhan's 1973)? It famously recounted how otherwise normal pseudopatients got themselves admitted to various psychiatric hospitals based on a single symptom-a voice apparently saying "thud, hollow, empty." Was it a social psychology experiment based on deception? Or was it more an ethnographic immersion study of institutional and professional practices? Now thanks to Susannah Cahalan's The Great Pretender, it can best be described as a dubious hoax. As we wearily know, hoaxes make for upheavals and lend themselves to causes, in spite and perhaps because they have such contestable implications. About all we can agree on is that you can fool others by lying to them. At the time, however, Rosenhan's article was popularly taken as an antipsychiatric vindication, while provoking anger and embarrassment amongst mental health care professionals. It seemed psychiatrists had trouble distinguishing the "sane" from the "insane." Once admitted, the pseudopatients' normality was never detected by hospital staff. Innocuous behavior was interpreted through a pathologizing lens. Daily life in the hospital wards was experienced as dehumanizing and degrading. And the diagnostic labels the pseudopatients were given-typically some form of schizophrenia-tended to stick. When the pseudopatients were able to secure their release, all trailed an "in remission" tag. However, Cahalan has thrown into doubt not only the accuracy of Rosenhan's reporting, but the basis of the study itself. Advance publicity had focused on the suggestion that six of Rosenhan's nine pseudopatients might not have existed at all. Knowing how hard it is to prove a negative, I had the "absence of evidence" fallacy firmly in mind. But as I read the book, I found these worries receding. Cahalan was able to locate Rosenhan's private files, along with the medical records of three pseudopatients-interviewing the two still living. Piecing it together revealed damaging discrepancies, so damaging they appear to render the legitimacy of this celebrated article unsustainable. Rosenhan was the first of the pseudopatients. His 9 day stay at Haverford State Hospital in 1969 left him shaken but would inspire what was to come. Rosenhan's study may well have been an exercise in fabulist extrapolation; it certainly began with a fundamental misrepresentation. Using the alias "David Lurie," Rosenhan had significantly embellished his presentation symptoms. His medical records speak of the distress these "voices" were causing him, his attempts to insulate himself from them, and the suicidal thoughts they gave rise to. Confronted with this cluster of red flags, the psychiatrist assessing Rosenhan/Lurie committed him to in-patient care-as any good psychiatrist would have-with the not unreasonable diagnosis of "schizophrenia, schizoaffective type." In contrast, the Science article specified a far tamer presentation script: only one hallucinatory symptom was offered alongside a truthful personal history. In any case, Rosenhan was released from Haverford with the diagnosis "paranoid schizophrenia, in remission." And while Rosenhan's experience in the wards may have been harrowing, it was not quite the norm for others in the study. The two other pseudopatients Cahalan identified-Harry Lando and Bill Underwood-both stuck closer to the presentation script. But they were given shockingly little preparatory instruction and support from Rosenhan. For example, Rosenhan didn't, as he claimed, have writs of habeas corpus prepared to extract his pseudopatients if necessary. Rosenhan would later drop Lando from the final draft of the Science article. Rosenhan claimed this was because Lando had given false details about his personal history. But in hindsight, it seems clear this was because Lando's very positive experience did not fit Rosenhan's narrative. While many psychiatric institutions were indeed wretched places, Lando found his stay genuinely calming, supportive and uplifting. As Cahalan notes, the inclusion of Lando's inconvenient counterpoint would have made for a more complex but representative story-and different lessons. Then there are the issues about the data. Rosenhan's article is illustrated with some specific numbers on ward routines, medications and interactions with staff-although they had a frustratingly unsystematic, anecdotal aspect to them. Gathering such data would require constant vigilance and detailed note taking. Rosenhan might have taken the necessary care to justify such precise numbers. However, Underwood barely paid any attention to this facet of the study during his eight-day stay. Conversely, Lando's data was included in an initial draft but excluded from the final article. But according to Cahalan, the numbers did not change in the process, not one. And Rosenhan still included useful snippets of Lando's experience in the published version of the article. Not only were admissions not as described, neither were releases. Rosenhan, Underwood and Lando were all able to leave soon after they asked to, following relatively short stays. Only Rosenhan's records featured the uncommon "in remission" tag. And the questions only mount. Rosenhan never explained how he supposedly got access to his pseudopatients' medical records. Underwood and Lando thought this might have been achieved by posing as their "clinical psychologist." Furthermore, Cahalan found no evidence that the guess-the-pseudopatient experiment described in the Science article was ever conducted (Cahalan, 2019). Rosenhan's audience readily accepted his account of the pathologizing psychiatric lens and the "stickiness" of diagnostic labels, for it rode a critical wave whipped up by various anti-psychiatric writers. However, we now know these ideas were not actually borne out in significant portions of Rosenhan's very loosely controlled study. The three known pseudopatients were not flagrantly misdiagnosed, given the way they had presented, asking for help. The mildness of both Underwood's and Lando's "conditions" did not go unrecognized, and the labels they were given did not stick in the way Rosenhan claimed. Rosenhan always had a valid point: psychiatric diagnosis was problematic, with the line between the "sane" and "insane" just one of the issues. But Rosenhan's prosecution of his "case" was like a lawyer framing a guilty man. The plot thickens when chief critic Robert Spitzer arrives to defend psychiatry's honor. Spitzer had the goods on Rosenhan, and Rosenhan knew it. Spitzer had been able to obtain Rosenhan's Haverford records, just as Cahalan did 40 years later. The psychiatrist who assessed Rosenhan/Lurie had passed them on, understandably offended by Rosenhan's article. We can thus read this inside knowledge into Spitzer's (1975) critique, as he hints at symptom embellishment and a lack of access to records while challenging Rosenhan to release his data (p.445 and p.447). Rosenhan had tried to stop Spitzer publishing his attack, telling him that his Haverford stay was purely a teaching exercise-which it was, initially. But this was odd, given Rosenhan's Science article clearly acknowledged he was the first pseudopatient (p.251). Was Rosenhan implying he had gone undercover a second time? He only did so after the Science article was published (Cahalan, 2019). But at this crucial turning point in history, Spitzer refrained from exposing Rosenhan. The collateral damage this might cause his colleagues at Haverford was probably a restraining factor. Instead, he leveraged Rosenhan's study to his advantage. Spitzer was able to enlist American Psychiatric Association support and recruit like-minded dataoriented psychiatrists for his quest to make psychiatric diagnosis more reliable. It would soon result in DSM-III, its checklist approach constructed with Rosenhan's fakers in mind. DSM-III was welcomed as a long-needed clarification and standardization. It provided the illusion of reliability and discrete syndromes, firmly consolidating the practice of diagnosis as a necessary administrative ritual. Spitzer's kompromat must have hovered over Rosenhan like the sword of Damocles, adding to the welter of criticism he received in academic journals. It was enough to discourage him from finishing a book on the study that was destined to be a bestseller. Instead of cashing in, Rosenhan retreated to examine other topics. His spurned publisher would eventually sue him for the lucrative advance they'd given him. BOOK REVIEWS | 53 And we ended up with the worst of all worlds. Rosenhan's eye-catching study added to a long line of trenchant critiques and well-documented exposés. Governing bodies overseeing ageing psychiatric hospitals across the Englishspeaking world had already taken note and would opt for the economically expedient way out. "Deinstitutionalization" became a rationale for simply closing the hospitals down. In turn, American psychiatrists got particularly hooked on prescribing, dispensing with their custodial duties and much of their pastoral role. Now it is very difficult to get inpatient psychiatric care in the US; one must present as gravely disabled, the golden ticket being dangerous suicidal ideation. Meanwhile, the DSM was successively revised and expanded. It has now morphed into the sprawling, overly inclusive DSM-5. Some former DSM architects wonder whether "normal" can still be saved from its pathologizing grasp (Frances, 2013). Ironically, Rosenhan's nemesis helped make aspects of his critique even more relevant today. Cahalan's book follows in the footsteps of recent historical deconstructions of seminal psychological studies, notably the work of Perry (2012). Towards the end, Cahalan puzzles over the reality of the other pseudopatients, as every promising lead goes cold. But it seems certain that if these pseudopatients did exist, their experiences would not match up well with...

Psychiatry for Neurologists, 2006

Studies in History and Philosophy of Biology and Biomedical Sciences, 2012

Much scholarship in the history of cybernetics has focused on the far-reaching cultural dimensions of the movement. What has garnered less attention are efforts by cyberneticians such as Warren McCulloch and Norbert Wiener to transform scientific practice in an array of disciplines in the biomedical sciences, and the complex ways these efforts were received by members of traditional disciplines. In a quest for scientific unity that had a decidedly imperialistic flavour, cyberneticians sought to apply practices common in the exact sciences-mainly theoretical modeling-to problems in disciplines that were traditionally defined by highly empirical practices, such as neurophysiology and neuroanatomy. Their efforts were met with mixed, often critical responses. This paper attempts to make sense of such dynamics by exploring the notion of a scientific style and its usefulness in accounting for the contrasts in scientific practice in brain research and in cybernetics during the 1940s. Focusing on two key institutional contexts of brain research and the role of the Rockefeller and Macy Foundations in directing brain research and cybernetics, the paper argues that the conflicts between these fields were not simply about experiment vs. theory but turned more closely on the questions that defined each area and the language used to elaborate answers.

Bulletin of the History of Medicine, 2003

This article explores the short history of “neuroscience” as a discipline in its own right as opposed to the much longer past of the brain sciences. It focuses on one historical moment, the formation of the first British “neuroscience” society, the Brain Research Association (BRA), renamed in 1996 to the British Neuroscience Association (BNA). It outlines the new ways of thinking brought about by this new science of brain, mind, and behavior, it sketches the beginnings of the BRA and the institutionalization of neuroscience in the British context, and it further explores the ambiguous relation the association had towards some of the ethical, social, and political implications of this new area of research.