The Great Pretender
The Undercover Mission That Changed Our Understanding of Madness
Susannah Cahalan
Having read it
★★★★☆
A book with a really interesting and enthralling first half about the author’s own troubled experiences with a misdiagnosis in response to her presented symptoms.
From that association the book is well grounded and researched in its narrative, interviews and insights into psychiatry and how a certain paper by David Rosenhan has not helped this medicinal branch of mental health.
A few mysteries and discoveries about psuedopatients were also used to help explore the workings, treatments and institutions of psychiatry that help explain and show some remarkable perspectives on what has happened around mental health attitudes and approaches in psychiatry.
The book’s last few chapters pull apart the long-held perspectives, even assumptions, of psychiatric knowledge and reveal some real stories and truths that, overall, help make for a surprising and insightful read.
A good passage
‘It is not known why powerful impressions of personality traits, such as “crazy” or “insane”, arise,’ Rosenhan wrote. ‘A broken leg is something one recovers from, but mental illness allegedly endures forever. A broken leg does not threaten the observer, but a crazy schizophrenic? There is by now a host of evidence that attitudes toward the mentally ill are characterised by fear, hostility, aloofness, suspicion, and dread. The mentally ill are society’s lepers.’
A second good passage
Rosenhan arranged for Carl to go undercover at the unnamed hospital, but when the day approached Carl was waylaid by the flu. Rosenhan didn’t replace him. Maybe Rosenhan forgot, maybe it was planned, he doesn’t say – intentional or not, in the end Rosenhan sent no one. The result is, in my opinion, the most damning part of the study. Over the next three months, the staff kept an eagle eye out for any pseudopatients attempting admittance to their hospital. Of 193 new patients who arrived in that time period, staff members labeled 41 with high certainty as probable pseudopatients; psychiatrists, for their part, identified 23 likely pseudopatients. This miscalculation proved once again that we react to the world by what we are primed to see. In this case, these medical professionals were primed to see pseudopatients, so that is what they saw.
A third good passage
Being honest about our limitations, as Dr. Lennox suggests, involves taking a harsh look at our history and the ‘truths’ that we’ve accepted at face value. if solutions seem too good to be true, too categorical, too concrete, they usually are. When nuance is lost, medicine suffers.
That’s where David Rosenhan and his paper come in. Rosenhan’s study, though only a sliver of the pie, fed into our worst instincts: For psychiatry, it bred embarrassment, which forced the embattled field to double down on certainty where none existed, misdirecting years of research, treatment, and care. For the rest of us, it gave us a narrative that sounded good, but had appalling effects on the day-to-day lives of people living with serious mental illness.
Rosenhan did not create these outcomes, but his study enabled them. And now psychiatry is overdue for a reassessment of the terms we deploy, the new technologies on the horizon, the way we treat the sickest.