“Am I really this? Am I not this? What am I?”
In 1979, Raphael “Ray” Osheroff walked eight hours a day. Breathing heavily through pursed lips, he paced the corridors of Chestnut Lodge, one of the most elite hospitals in the country. “How many miles are you going to pace today, Ray?” a nurse asked him. Ray calculated that he walked about eighteen miles a day, in slippers. Another nurse wrote that he frequently bumped into people but “doesn’t even seem to realize he had physical contact.”
As he paced, Ray, who had a mustache and bushy black hair, recalled the lavish vacations that he and his wife had enjoyed. They were both doctors in northern Virginia, and they dined out so frequently that when they entered their favorite restaurants they were immediately recognized. They were the most popular medical couple in the Washington area, Ray decided. The motion of his legs became a “mechanism of self-hypnosis in which I would concentrate on the life I once had,” he wrote in an unpublished memoir. Ray’s feet became so blistered that orderlies at the Lodge took him to a podiatrist. His toes were black with dead skin.
In his medical notes, Ray’s psychiatrist, Manuel Ross, wrote that Ray suffered from “a form of melancholia, not mourning”—a reference to Freud’s 1917 paper “Mourning and Melancholia.” In the essay, Freud had proposed that melancholia arises when a patient is mourning something or someone but “cannot see clearly what it is that has been lost.” Ray, a forty-one-year-old nephrologist, had founded a once thriving dialysis company, but the business had faltered, and he was consumed by his missteps. Ross concluded that Ray’s obsessive regret was a way of staying close to a loss he was unable to name: the idea of a parallel life in which “he could have been a great man.” Ray ruminated over the details of his downfall, because he was still in denial, clinging to an idealized version of himself.
From a phone in the hallway of the Lodge, Ray often called his colleague Robert Greenspan, who was running Ray’s business in his absence, to share his regrets. In the background, Greenspan sometimes heard other patients shouting in “sort of unusual tones.” A young man wandered the halls saying, “Hyperspace, hyperspace, hyperspace.” Greenspan called a social worker at the Lodge to ask why Ray seemed to be deteriorating. The social worker explained that Ray “would get worse and that was part of the therapy. His personality had to be restructured. There had to be some tearing down and rebuilding.”
After Ray had been at the Lodge for half a year, his mother, Julia, visited him for the first time. She was alarmed by his appearance. His hair had grown to his shoulders. He was using the belt of his bathrobe to hold up his trousers, because he’d lost forty pounds. Ray had once been a prodigious reader, but he had completely stopped. He was also a musician—he was in a jazz band and played banjo, trumpet, clarinet, piano, drums, and trombone—and, although he had packed sheets of music in the suitcase he brought to the Lodge, he almost never looked at the pages. When a nurse called him Dr. Osheroff, he corrected her: “Mr. Osheroff.”
Julia asked the Lodge psychiatrists to give her son antidepressants. But at the time, the use of antidepressants was still so new that the premise of this form of treatment—to be cured without insight into what had gone wrong—seemed counterintuitive, even cheap. Drugs “might bring about some symptomatic relief,” Ross, Ray’s psychiatrist, acknowledged, “but it isn’t going to be anything solid in which he can say, ‘Hey, I’m a better man. I can tolerate feelings.’” Ross concluded that Ray was simply searching for a drug that would buy him the “return of his former status,” an achievement that, Ross believed, had always been illusory.
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THE LODGE ONCE had the atmosphere of a Southern plantation. Its main building, a brick mansion, had previously been the Woodlawn Hotel, the fanciest resort in Rockville, Maryland, catering to wealthy guests from Washington, D.C., twenty miles away. The building was designed in a French revival style, with a slate mansard roof, six chimneys, and roughly eighty white-framed windows. Surrounding the building were colonial bungalows scattered on a hundred acres of land shaded by sixty-foot trees.
The Lodge was founded in 1910 by a doctor named Ernest Bullard, and two decades later, his son, Dexter, took over the family business and transformed it into an institution where doctors believed they were finally uncovering the mysteries of the mind. Dexter had grown up on the first floor of the hospital, playing croquet and baseball with patients. “I knew the psychotic as a person long before I knew what the implications of the word ‘patient’ were,” he said. The idea that patients were beyond empathy “just never became part of the experience.” He found it frustrating to see them “labeled and put on the shelf.”
After reading Freud in his father’s library, Dexter decided that Chestnut Lodge could do what no other American hospital had done: psychoanalyze every patient, no matter how far removed from reality they were (as long as they could pay the admission fee). The Lodge would leave “no therapeutic stone unturned,” he wrote. His goal was to create an institution that expressed the ethos of the analyst’s office. “We don’t know enough yet to be able to say why patients stay sick,” he told a colleague in 1954. “Until we know that, we have no right to call them chronic.”
At the Lodge, the goal of all conversations and activities was understanding. “No single word used at the hospital is more charged with emotional meaning, or more slippery in its cognitive implications,” Alfred Stanton, a psychiatrist, and Morris Schwartz, a sociologist, wrote in The Mental Hospital, a 1954 study of the Lodge. The hope of “getting better”—by gaining insight into interpersonal dynamics—became its own kind of spirituality. “What occurred at the hospital,” the authors wrote, “was a type of collective evaluation in which neurosis or illness was Evil and the ultimate Good was mental health.”
Other hospitals were giving patients barbiturates, a sedating drug, as well as electroconvulsive therapy and lobotomies. But Dexter believed that “pharmacology has no place in psychiatry.” At a medical society conference, when Dexter’s colleague reported that he had lobotomized a patient and cured her in ten days, Dexter objected to the idea of a treatment that didn’t even require self-knowledge. “You can’t say that!” Dexter shouted.
The “queen of Chestnut Lodge,” as people called her, was Frieda Fromm-Reichmann, a founder of the Frankfurt Psychoanalytic Institute who lived on the grounds of the Lodge in a cottage that had been built for her. She sometimes took her patients to lunch at a country inn, or to an art gallery or a concert. She would imitate their posture, to more readily understand their perspective. The phrases “we know” and “I am here”—uttered at the right time, in a sensitive tone—“may replace the patient’s desolate experience of ‘nobody knows except me,’” she wrote.
Fromm-Reichmann described loneliness as “one of the least satisfactorily conceptualized psychological phenomena, not even mentioned in most psychiatric textbooks”—a state in which the “fact that there were people in one’s past life is more or less forgotten, and the possibility that there may be interpersonal relationships in one’s future life is out of the realm of expectation.” Loneliness was such a deep threat, she wrote, that psychiatrists avoided talking about it, because they feared they’d be contaminated by it, too. The experience was nearly impossible to communicate; it was a kind of “naked existence.”
Fromm-Reichmann and other analysts at the Lodge were described as “substitute mothers”; younger therapists vied for their attention, working through what they called sibling rivalries. The doctors, all of whom had undergone analysis themselves, felt that they had been incorporated into the Bullard household—as one psychiatrist put it, they were “part of a dysfunctional family.” As patients walked down the hallway to their appointments, others shouted, “Have a good hour!” Alan Stone, a former president of the American Psychiatric Association, described the Lodge as “the most enlightened hospital in North America.” He told me, “It seemed like Valhalla, the residence of the gods.”
At the time, faith in the potential of psychology and psychiatry seemed boundless. The psychological sciences provided a new framework for understanding society. “The world was sick, and the ills from which it was suffering were mainly due to the perversion of man, his inability to live at peace with himself,” declared the first director of the World Health Organization, a psychiatrist. Following the war, at the 1948 meeting of the American Psychiatric Association, President Truman sent a message of greeting: “The greatest prerequisite for peace, which is uppermost in the minds and hearts of all of us, must be sanity.” War was not just about power or resources—it arose from insecurity, neuroses, and other mental wounds. The psychologist Abraham Maslow said, “The world will be saved by psychologists—in the very broadest sense—or else it will not be saved at all.”
Chestnut Lodge embodied the utopian promise of psychiatry, but the story that the institution told about itself was unable to survive the demands of a patient like Ray. In 1982, Ray sued Chestnut Lodge for failing to make him better. In the lawsuit, the twentieth century’s two dominant explanations for mental distress collided. The psychiatrist Peter Kramer, the author of the landmark book Listening to Prozac, compared the case’s significance to Roe v. Wade. As Psychiatric Times put it, the case created a “showdown between two forms of knowledge.”
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BEFORE ENTERING THE LODGE, Ray had been the kind of charismatic, overworked physician whom we have come to associate with the American dream. He had opened three dialysis centers in northern Virginia and felt within reach of something “very new for me, something that I never had before, and that was the clear and distinct prospects of success,” he wrote in his memoir. He loved the telephone, which signified new referrals, more business—a sense that he was vital and desired. In the waiting room of his office, he installed plush theater seats. He befriended his patients, buying them air conditioners, paying their rent, or funding their funerals. He bought one patient, who had just immigrated, his own taxi.
But his “energies seemed to be so devoted to and focused on my training and career,” he wrote in his memoir, that he neglected his wife and their two young sons. Eventually, she filed for divorce. Ray moved on quickly, falling in love with a glamorous and ambitious medical student named Joy. Sometimes he took Joy to business meetings, and they held hands under the table. He and Joy married in 1974. “Life was a skyrocket,” he wrote.
But after the wedding, he lost his momentum. He agreed to let his ex-wife move to Luxembourg with their sons for a year but immediately regretted the decision. His own father, who had run a deli in the Bronx, had been neglectful and absent—then died young—and Ray worried that he was reproducing the same sense of abandonment for his own boys. He could no longer be “consoled by the mystical thought that closure was possible,” he wrote in his memoir, by being the “good father that I had lost.”
Ray’s thinking became circular. In order to have a conversation, his secretary, Dotty, said, “we would walk all the way around the block, over and over.” He was so repetitive that he started to bore people. He couldn’t sit still long enough to eat. “He would take a few bites and then get up, and then go to the men’s room, go outside,” Dotty said.
Joy gave birth to a baby less than two years after their wedding, but Ray had become so detached—he seemed to care only about the past—that he behaved as if the child wasn’t his. He felt increasingly incapable of handling the stress caused by rivals in the dialysis field, and he sold a portion of his interest to a larger dialysis corporation. Although he retained a managerial role, supervising thirty-five people, he once again became convinced he had made the wrong choice. After finalizing the sale, he wrote, “I went outside and sat in my car and I realized that I had become a piece of wood.” The air felt heavy, like some sort of noxious gas.
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IN A DRUGSTORE that year, Ray came across From Sad to Glad, a 1974 book by Nathan Kline, one of the most prominent psychiatrists in America. In the book, which Ray immediately read, Kline attributes depression to “some disarray in the biochemical tides that sweep back and forth within the body.” Kline was not curious about why his patients had become ill. “Do not try to dredge up reasons,” he told his patients. On the cover of the book was the motto, “Depression: you can conquer it without analysis!”
Kline had become famous by studying the tuberculosis drug iproniazid, which had the unanticipated side effect of making patients feel too good. They became incautious, overexerting themselves. At a sanitarium on Long Island, patients who took the medication felt so lighthearted that they danced in the corridors. An Associated Press photograph from 1953 shows a semicircle of patients wearing long patterned skirts, looking dazed but pleased, smiling and clapping. One woman later told her psychiatrist that she had experienced happiness only once, when she had a religious conversion while recovering from tuberculosis. “I couldn’t quite bring myself to tell her,” her psychiatrist told The New York Times, “that her ecstatic experience might not have come from the Lord, but may have been instead a biochemical reaction to the medication.”
Kline tried iproniazid on his patients and discovered that they became more competent and lively. When he gave iproniazid to a young married woman, he reported, she started “caring for her household efficiently and doing full time graduate work.” When he prescribed the pills to a nurse, “even her physical appearance changed. The scowling brow and the drawn mouth were replaced by a relaxed and smiling appearance, which incidentally made her look twenty years younger.” For another patient, an artist who had been unable to paint for more than a year, iproniazid lifted him out of the impasse: “He produced a profusion of oil paintings, water colors, and sketches totaling more than a hundred,” Kline wrote.
The antipsychotic Thorazine had been developed a few years earlier, in a lab in France, and for the first time many psychiatrists were confronting the possibility that people didn’t have to understand their childhood conflicts to get well. But the view was still unpopular. Kline said colleagues took him aside to warn him that, by claiming a drug could relieve depression, he was risking humiliation. “There was a large and adamant body of theoretical opinion that held that such a drug simply could not exist,” Kline wrote. The neuroscientist Solomon Snyder has written that, at the time, a psychiatrist engaged in biological research was “regarded as somewhat peculiar, perhaps suffering from emotional conflicts that made him or her avoid confronting ‘real feelings.’”
But Kline presented a new story about what sorts of feelings were “real.” One of the epigraphs to his book was a quote by Epictetus: “For you were not born to be depressed and unhappy.” When Kline tried iproniazid himself, he found that the drug produced a uniquely American kind of transcendence: he could work harder, faster, and longer.
Inspired by From Sad to Glad, Ray traveled to New York to see Kline at his office, a town house on East Sixty-Ninth Street in Manhattan. Ray promised Joy that after he took Kline’s medications he would “be a new man.” In Kline’s waiting room, patients told stories of miraculous recoveries. They were so devoted to Kline that they “felt he was God,” a colleague recalled. Kline was said to have more depressives in his private practice than any other doctor in New York, but he spent little time with them and much of the work was done by assistants. In a paper in the Proceedings of the American Philosophical Society, Kline boasted that it was now possible for psychiatrists to see four patients in an hour. “The chemicals produce their effects, as elsewhere in medicine, without the psychiatrist necessarily being present,” he wrote.
Ray’s appointment with Kline lasted ten minutes. Kline prescribed Ray a low dose of Sinequan, an antidepressant developed shortly after iproniazid. Ray tried the medication for a few weeks, but when it didn’t seem to improve his outlook, he stopped. He dismissed Kline’s clinic as a “cookbook-type operation.”
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RAY FELT THAT he’d carefully built a good life—the kind he’d never imagined he could achieve but, on another level, felt secretly entitled to—and with a series of impulsive decisions had thrown it away. “All I seemed to be able to do was to talk, talk, talk about my losses,” he wrote.
He found that food tasted rotten, as if it had been soaked in seawater. Sex was no longer pleasurable either. He could only “participate mechanically,” without “a sense of enjoyment or transportation,” he wrote in his memoir.
Ray and Greenspan, his colleague, used to browse music stores together after work, trying out different instruments. Greenspan’s wife, Bonnie, told me, “He wouldn’t just play the notes of the song—he really played beautifully, and nothing else he did in life had that nuance.” But even music gradually lost its appeal.
Ray began to threaten suicide. Worn down by his helplessness, Greenspan and Joy gave him an ultimatum: if he didn’t check into a hospital, Joy would file for divorce and Greenspan would leave the practice. Ray reluctantly agreed. He decided on Chestnut Lodge, which was then run by Dexter Jr., the founder’s grandson. Ray had read about the hospital in Joanne Greenberg’s bestselling 1964 autobiographical novel, I Never Promised You a Rose Garden, which tells the story of her treatment with Fromm-Reichmann. The book is a kind of ode to the power of psychoanalytic insight. “The symptoms and the sickness and the secrets have many reasons for being,” Greenberg, who had been diagnosed with schizophrenia, wrote. “If it were not so, we could give you a nice shot of this or that drug.” But, she wrote, “these symptoms are built of many needs and serve many purposes, and that is why getting them away makes so much suffering.”
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RAY TOOK A leave of absence from his business and checked into the Lodge on January 2, 1979—a time of year, following the loneliness and forced joy of the holidays, when many psychiatric admissions occur. It was a damp, overcast day. Ray’s stepfather drove him up a road lined with white rocks, past fields dotted with garden gnomes. In the parking lot, carved wooden signs for each psychiatrist’s car gave “the overall effect of a row of crosses,” Ray observed. “Almost like a cemetery.” The building’s exterior was stately, but inside the floors were linoleum, and the windows were lined with iron bars. Ceiling lamps were covered in wire cages. In a loud and frantic voice, Ray told his stepfather, “I don’t care to stay here.” But his stepfather said he could not allow him to go home.
Ray’s roommate, who was being treated for sexual perversions, told Ray that he was lucky: Manuel Ross, the psychoanalyst to whom Ray had been assigned, was considered one of the best analysts at the Lodge. Wiry, with a graying mustache and a widow’s peak, Ross had worked at the Lodge for sixteen years.
During Ray’s first few weeks of therapy, Ross tried to reassure him that his life was not over, but Ray would only “pull back and become more distant, become more repetitive,” Ross later told his colleagues. Hoping to improve Ray’s insight, Ross interrupted Ray when he became self-pitying. “Cut the shit!” he told him. When Ray described his life as a tragedy, Ross said, “None of this is tragic. You are not heroic enough to be tragic.”
During one analytic session, when Ray began to grasp that the problems in his life were of his own making, he was “just in utter pain at the idea that it wasn’t external forces but was inside himself,” Ross said. “And he called out in a very dour voice, ‘I’m lying midway between Eros and Thanatos on my bed and trying to decide whether I want to live or die.’”
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ALTHOUGH THE LODGE’S philosophy was that every patient deserved understanding, Ray’s medical records suggest that his doctors did not like him. At a staff conference a few months after he arrived, a psychologist, Rebecca Rieger, said that after spending time with Ray (who described his upbringing as “a caricature of a Jewish immigrant family”), she had a pounding headache. “The time that I spent with the patient left me more exhausted than I have been, I think, with any other patient,” she said. Ray was so agitated that, in order to administer a Rorschach test, she had to walk beside him as he paced.
“He is like ten patients in one,” a social worker complained.
Rieger wondered if Ray had a “possible delusion,” because “he kept talking about the brain, as though he might have some thoughts that there was something wrong with his brain in a physical sense.”
Robert Gruber, the director of admissions, said that Ray had come to the Lodge only because he’d been pressured by his wife, whom Gruber had met once and liked. “If she has any sense, she probably will not maintain” the relationship, Gruber said at the meeting. “I guess what I am trying to bring out is the destructive element and that maybe this is how he will do with us—destroy our availability to him as he has destroyed her availability to him.”
Ross agreed. “He treats women as if they are the containers for his anxiety and are there to indulge him and pat his hand whenever he’s in pain,” he said. “And he does that with me, too, you know—‘You don’t know what pain I’m in. How can you do this to me?’” Ross said that he had already warned Ray, “With your history of destructiveness, sooner or later you are going to try to destroy the treatment with me.” Nevertheless, Ross was confident that if Ray “does stay in treatment for five or ten years, he may get a good result out of it.”
“Five to ten years is about right,” another psychiatrist said.
The hospital’s clinical director said he hoped staff members weren’t treating Ray with disdain. “I had some sense hearing people talk today that people think he is in some way kind of a bad person who talks like he’s a big shot and sort of feel that he really isn’t very important and big and to hell with him.” He said that Ray seemed to him “very much a genuine little boy.”
“I like him very much and I like working with him,” Ross clarified. “He is quite a creative person. Perhaps he is so creative he won’t even—he can’t even be nailed down to one diagnosis. But it is mixed because, for example, he will say, ‘You’ve got to tell me what to do.’ And I say, ‘Your main job is to sit on your ass and not do anything at all. Just sit here and don’t do anything. Let us take care of you. Don’t move at all.’”
Copyright © 2022 by Rachel Aviv