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The Great Pretender is Susannah Cahalan’s recent follow up to her New York Times bestselling memoir, Brain on Fire, which chronicled her journey with sudden onset paranoia and psychosis that initially got her diagnosed as bipolar and then schizophrenic, but was eventually discovered to be a product of a physical disorder, autoimmune encephalitis. Cahalan’s symptoms disappeared when she was finally treated with the correct drugs, which she deemed to be a miracle of insight on the part of the neuroscientists and psychiatrists treating her, but led her to wonder how many people out there weren’t as lucky to receive this miracle diagnosis.
The response to her memoir, and the questions it brought up in terms of the viability of psychiatric diagnoses, sparked Cahalan’s interest, and ultimately led her to the landmark 1972 paper, entitled “On Being Sane in Insane Places”, by Stanford professor David Rosenhan. The paper summarized the finding’s of Rosenhan’s three year long experiment, wherein Rosenhan and eight other volunteers without a history of mental illness got themselves admitted into psychiatric institutions, with the goal of studying the environment and finding out whether doctors could tell the difference between their mentally ill patients and these “pseudopatients”.
The participants each complained to doctors of a voice in their head that repeated the same phrase, “thud, empty, hollow”, and only changed minor biographical details such as their names in their interviews with psychiatrists. All patients were committed for several days to their respective institutions, and all but one of them were given schizophrenia diagnoses. The paper includes testimonials from the pseudopatients, which describe the dehumanizing conditions that patients are forced to live in, low standards of care from the attendant staff, and little patient-doctor interaction. Rosenhan and the other patients describe the frustration they faced when trying to convince the doctors that they were not in fact schizophrenic, as it seemed that the label of mentally ill, once applied, was near impossible to shake. Rosenhan recalls his urge to shout his real name and profession at the top of his lungs after just 72 hours in a facility.
The paper was published in Science, and met with a massive response from those both inside and outside of the psychiatric community, in whom the seeds of mistrust were already planted by the anti-institutional counterculture movements in the 1960’s. These suspicions were not unfounded, as Rosenhan’s paper merely confirmed phenomena that many had already accepted as fact: psychiatric asylums present a great deal of harm to the patients they claim to treat, and most psychiatrists actually have no idea how to diagnose their patients. The paper, among other factors, led to the mass shuttering of these asylums, and also notably, to DSM III, which removed homosexuality from the registry of diagnosable mental illnesses. However, amidst all of the celebration, Cahalan begins to notice some cracks in Rosenhan’s study. It becomes clear that Rosenhan had fabricated his data, that he had purposely excluded data relating to a volunteer who had a positive experience in an asylum, and had even possibly fabricated a few of the pseudopatients entirely who were described in this paper. What emerges is a much murkier picture of this universally accepted and revolutionary study, as Cahalan probes what it means to falsify data in this context. It becomes quite clear that Rosenhan tailored his findings to support his preexisting hypotheses about psychiatric facilities, but what is less clear is why. Was it for glory or the more honorable effort to dismantle the institutional framework that Rosenhan believed to be exploitative and dangerous.
Cahalan writes that with “On Being Sane in Insane Places”, Rosenhan “missed an opportunity to create something three-dimensional, something a bit messier, but more honest.” It seems however that the widespread effects of Rosenhan’s study occurred precisely because Rosenhan’s findings were so dramatic. Anyone living in today’s current political climate is no stranger to the fact that those who shout the loudest will always have an audience, even if what they’re saying isn’t entirely true. This is precisely the trouble, as Cahalan makes quite clear in this book that nothing in psychiatry is black or white, that the gray area is much more expansive than anyone previously anticipate. Cahalan does not offer simple solutions about the answers to the problems plaguing psychiatry, nor does she offer simple conclusions about its history, but by addressing and deconstructing Rosenhan’s paper and the surrounding phenomena, she makes a strong case for continued research and diligence in the field.