Book Review: “The Great Pretender” by Susannah Cahalan

The Great Pretender by Susannah Cahalan

Pretty much everybody has at least heard about the famous paper by David Rosenhan, “Being Sane in Insane Places”.  Even in the era of bombshells, it was the big one.  “Only the patients knew I was sane.” Mental hospitals not only don’t help, they actually make you crazy even if you weren’t.

As Cahalan documents, the paper was a spectacular success.  It fit the currents of the times, and continues to resonate today. It contributed to the closing of large mental health facilities (which were not replaced with community care), remedicalization of psychiatry, the creation of DSM-2, -3, -4, etc., and the general distrust of authority and expertise.

For me, studying psychology at the time, it was one of many unsettling encounters in my academic studies.  I never studied clinical psychology spcifically, but the story was similar in social, cognitive, and other topics I was interested in:  study after study showed that our “science” was weak if not flat out wrong and/or wrong-headed.

Any sane student had to wonder, “Do we know what we are doing?”  Are we studying something real, or are we just projecting our own theories and biases?  Is there any there, there?  And if we have so little grasp, then how can we ethically apply our “science” to the real world?

Rosenhan’s report fit with the general pattern of the time, and from my adjacent specialty, it certain was plausible. It even generally conformed to many of our more social oriented theories:  mental health treatment clearly had (and has) a large element of belief and ritual, and many of the diagnoses were highly subjective despite the strong beliefs of the professionals involved.  Worse, there was (and probably still is) a lot of self-fulfilling prophecy, power games, and coercion; not to mention brutality, sexism, racism, and homophobia.

With the perspective of almost fifty years, the study still stands out.

But what really happened?  Cahalan sets out to dig into the actual events.

Cahalan herself has the interesting perspective of a person who luckily and barely escaped disaster in the mental health system.  So, she deeply identifies with the worst aspects of mental health care; self-fulfilling prophecies, blaming the victim, ignoring the patient, and general poor care.  Rosenhan’s j’accuse strikes a nerve for her because it’s so close to her own experience, and the experience of so many.

But she is a reporter, dedicated to documenting and digging out the facts.  And she quickly discovers that finding the documentation isn’t as easy as you would expect.  The true story becomes complicated and morally muddy.

Sounds like the essence 1970s to me.

I don’t want to spoil the mystery, but it is very clear to me that it is not possible to confirm the data reported in the famous article. Many of the reported “facts” are provably fiction, and there is grave question about much of the alleged experiment.

As Cahalan reports, this would hardly be the first or only famous study that was shown to be fraudulent or flat wrong.  Even back in Rosenhan’s day (when I was a young psychology study) we knew that there was a huge, huge problem with non-reproducible studies.  Things are scarcely better now, and the Internet makes sure that errors and lies spread fast and wide, and never die.  Sigh.

In short, it is very possible that “Sane in Insane Places” was partly or largely fabricated.  And this makes it a moral mess.

Cahalan documents the outsized influence of the study, including very damaging side-effects.  Undermining the institutions of mental hospitals destroyed not only the evil and incompetent ones, but also the only environment where patients might actually be cared for.  Sending mentally ill people to jail, where they are confined without hope of care, is hardly an improvement.

If the data was fabricated, and the study invalid (if there even was a study), Cahalan see that the argument and conclusions were true and valid. Whatever Rosenhan did or intended to do, the paper “exposed something real” (p. 295).  And it was something important.

I agree with her : if this was fiction, it was believable and had such impact because it represented a lot of truth. And st was important to make the case.

But fudging the story with faked or overstated claims of scientific methods not only undermines trust, it led to catastrophic side effects.

Cahalan shows how Rosenhan’s “truthiness” obscured the true complexity of the picture.  Worse, his claim to have “scientific” data gave the simplified story weight and trustworthiness beyond the actual facts in the world, which helped lead to simple and simple-minded “solutions”.

I doubt anyone could have foreseen these dramatic results, but Rosenhan is responsible for the use and misuse of this paper.

I also note that Rosenhan never followed up his study—he never even completed a contracted book on the story.  He doesn’t seem to have much interest in how to do things right, make things better, or fix the broken stuff.  There doesn’t seem to be much evidence that Rosenhan ever did much to actually help the afflicted.

I learned a long time ago that if you toss a bomb, you need to prepared follow up, to rebuild what you destroy.  Otherwise, you are little more than a nihilist.  (Today, we call you a “troll”.)

Personally, I think it’s far too late to undo or even moderate the damage done.  Mental health care needs to be rebuilt from the ground up. Cahalan’s book gives a clear view of this, and suggests ways forward.

Treat patients as if they are people.  What a concept!

This is a great book, and a great example of the difference between “truthiness” and real, honest reporting.

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1. Susannah Cahalan, The Great Pretender: The Undercover Mission That Changed Our Understanding of Madness, New York, Grand Central, 2019.

 

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