I just finished reading Susannah Cahalan’s (2019) The Great Pretender. It is an exploration of David Rosenhan’s famous article, “On Being Sane in Insane Places” (Rosenhan, 1973). The article was an account of eight healthy people who got themselves admitted to inpatient psychiatric facilities by stating that they were hearing voices. Seven of the eight were diagnosed with schizophrenia, and the last was diagnosed with bipolar disorder. After entering the hospital, each person started to act normally, but it took several days–sometimes weeks–for each to be released. When the “patients” were discharged, their illness was described as “in remission” (not cured) and a stigmatizing label to carry as they re-entered the world.

Rosenhan’s article caused a sensation in psychiatry and clinical psychology when it was published. A common interpretation of his work was that psychiatrists were unable to determine healthy from unhealthy people and that the institution setting caused staff to interpret normal behavior as being pathological. The article’s influence has lasted decades, (I remember learning about it in my undergraduate psychology classes about 30 years later.) and has been cited nearly 4,000 times.

By profession, Cahalan is a journalist, and this shows in every page of the book. Where her work is best is when she’s hunting down the details of Rosenhan’s life and his famous study. She has an insatiable appetite for pursuing leads (sometimes for weeks or months) and checking sources. She spends inordinate amounts of time in archives and carefully scrutinizes documents to understand the truth. Her efforts to ferret out the details of Rosenhan’s actions make the book essential reading for anyone who wants to understand “On Being Sane in Insane Places.”

And what details they are! Cahalan produces incontrovertible evidence that Rosenhan lied about the experiences and details of at least two “patients” in his study. Both had to report more than a single symptom, including suicide ideation, in order to get admitted. Cahalan also showed how Rosenhan threw out the data from a ninth “patient” because this person enjoyed his stay in the facility, which complicated Rosenhan’s message that inpatient facilities were unhealthy places. For these reasons alone, Rosenhan’s (1973) article should be retracted.

I also was surprised that the ninth “patient,” the one whose data Rosenhan dropped from the study, had told his story in a journal article decades ago–and was almost completely ignored by the professional community. His article (Lando, 1976) had only been cited 5 times before Cahalan published The Great Pretender.

Most shockingly, Cahalan raises the possibility that 6 of the 8 “patients” in Rosenhan’s study might not have existed. She can’t prove with total certainty that they were fabricated, but there is no evidence apart from Rosenhan’s claims that they existed and that their experiences match the reports in the article. Rosenhan’s surviving colleagues, friends, and confidants are split on the issue, and it will probably never be resolved.

But Cahalan’s strength is also her weakness. The Great Pretender (Cahalan, 2019) is journalistic, not scholarly. In her analysis, Cahalan relies far too much on secondhand sources from the media and activists. She lacks the skepticism and the independent analysis of the raw data that a scholarly assessment would require.

When Cahalan does cite the scholarly literature, it is uncritically. This tendency is most embarrassing when she discusses the placebo effect; I randomly selected two studies she cited (Dossett et al., 2015; Lidstone et al., 2010). The samples sizes? 35 and 24. You would think that Cahalan’s experience with the Rosenhan study would have taught her to be skeptical of studies with small sample sizes.

This is why the book is best when it focuses on her dogged pursuit of the facts behind Rosenhan’s life and work. Cahalan is in her element, asking probing questions in interviews and scrutinizing documents. But when she strays into discussing the context of the study or its impact, she leans far too much on other people, and her critical faculties desert her.

Cahalan also has her work colored by her personal experience as a misdiagnosed psychiatric patient. From a writing perspective, this is when the book is the least interesting. (Do we really need to read the transcript of her structured clinical interview? No.) And while her personal experience does give a human touch to the book, it sabotages her objectivity, especially when she discusses issues she feels passionate about, such as misdiagnosis and the difficulty in separating mental and physical illness.

Because of this, it is hard to take her seriously when she has prescriptions for society in how to fix America’s mental health system or the shortcomings of the DSM-5. Too often, it seems she is just parroting the things that she likes which activists have told her.

In conclusion, The Great Pretender (Cahalan, 2019), is a golden book if anyone wants the real story behind “On Being Sane in Insane Places” (Rosenhan, 1973). But the rest is dross. If you do read the book, skip the sections that do not discuss Rosenhan and his work. You won’t miss anything important.

References

Cahalan, S. (2019). The great pretender. Grand Central Publishing.

Dossett, M. L., Mu, L., Davis, R. B., Bell, I. R., Lembo, A. J., Kaptchuk, T. J., & Yeh, G. Y. (2015). Patient-provider interactions affect symptoms in gastroesophageal reflux disease: A pilot randomized, double-blind, placebo-controlled trial. PLoS One, 10(9), Article e0136855. https://doi.org/10.1371/journal.pone.0136855

Lando, H. A. (1976). On being sane in insane places: A supplemental report. Professional Psychology, 7(1), 47–52. https://doi.org/10.1037/0735-7028.7.1.47

Lidstone, S. C., Schulzer, M., Dinelle, K., Mak, E., Sossi, V., Ruth, T. J., de la Fuente-Fernández, R., Phillips, A. G., & Stoessl, A. J. (2010). Effects of expectation on placebo-induced dopamine release in Parkinson Disease. Archives of General Psychiatry, 67(8), 857-865. https://doi.org/10.1001/archgenpsychiatry.2010.88

Rosenhan, D. L. (1973) On being sane in insane places. Science, 179(4070), 250-258. http://dx.doi.org/10.1126/science.179.4070.250

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