Susannah Cahalan Investigates the “Pretenders” of a Groundbreaking Psychiatric Study

Book review: The Great Pretender, by Susannah Cahalan (Amazon / Book Depository)

The Great Pretender, Susannah Cahalan’s first book since Brain on Fire, her 2012 memoir of a rare, difficult-to-diagnose autoimmune disorder, investigates an infamous and groundbreaking 1973 study carried out by psychiatrist David Rosenhan. Rosenhan sent a group of eight healthy “pseudopatients” into mental institutions with the goal of determining whether it was possible for sane people to be admitted merely by faking symptoms of mental illness; namely, could doctors and staff “distinguish sanity from insanity.”

That study, published as “On Being Sane in Insane Places,” drastically reshaped psychiatry, and in doing so sparked a debate about not only the proper treatment of the mentally ill but also how we define and deploy the loaded term mental illness.

The more Cahalan delved into what Rosenhan’s study entailed, and tried to determine basics like who the pseudopatients actually were, the more complex the story became. This study was revolutionary in its own way; she notes that its publication “would upend the field of psychiatry and fundamentally change the national conversation around mental health”. And yet details and information around it, which should be clear and readily available for a study that had such major repercussions, proved scant and elusive, and Rosenhan’s own records confusing and secretive.

Not to mention a creeping sensation of something not being quite right. Cahalan’s dogged research begins to unpack this, and what the implications may be, as the narrative progresses.

Cahalan was understandably interested in the experiences of the pseudopatients, since she’d been a type of one herself, having been initially labeled schizophrenic during her hospitalization, and she took it as “a challenge, a call to learn more and understand how this study, and the dramatic questions Rosenhan raised almost fifty years ago, could help the untold others whom our health care system still leaves behind.”

This reads like a medical detective story, and Cahalan writes from a first person perspective in some sections to better put some of her findings and interviews into context. As in her first book, she’s a smart and enjoyable narrator, so her presence in these parts of the bigger history work well. Plus she had that deeply seated personal interest in exploring this story:

Diseases like the one that set my brain “on fire” in 2009 are called the great pretenders because they bridge medical worlds: Their symptoms mimic the behaviors of psychiatric illnesses like schizophrenia or bipolar disorder, but have known physical causes, such as autoimmune reactions, infections, or some other detectable dysfunction in the body.

Elsewhere, Cahalan retreats and only reports the story, drawing often on the notes that Rosenhan collected from his pseudopatients during their time institutionalized. He went undercover in one location himself, under the name David Lurie, where he was diagnosed schizophrenic like most of the participants, perhaps because they followed a set list of symptoms and behaviors. As Lurie he wrote constantly to record his experiences, and fellow patients and even doctors asked if he was writing an expose of the hospital but then waved it off themselves. “It was just a joke. Of course David Lurie wasn’t writing an expose. That would be crazy.” The insights like this are illuminating, and sometimes chilling.

In the course of the investigation, Cahalan fills in back story from medical and psychiatric history, as well as tying it to the present, including the prevalence of fraud in medical and psychological research: “I notice fraud everywhere now. In the fall of 2018, Cornell University professor Brian Wansink resigned after thirteen of his papers — including one that showed how serving bowl size increases food consumption — were retracted and Cornell found he committed “academic misconduct in his research and scholarship…” (Tell that bit about bowl size to this author, please.)

But, much as I love all the side dives this takes, including points like the above, it brings me to the problem I had with this book. Cahalan’s research is so extensive, so comprehensively no-stone-unturned, that the general thread of the study and Rosenhan’s work often gets lost. There are so many additional forays and explorations that it’s easy to lose sight of this primary story, or get confused and forget who’s doing what where and why. This isn’t helped by all the obfuscation and mystery around the study, its participants, and the question of whether at least some of it was fabricated.

It’s highly entertaining to read, and well written considering the wealth of information, which is probably why you don’t notice immediately that the organization is a mess. I only realized how scattered, and how much of a problem it was, once I started trying to write about it. I can barely articulate what exactly it’s about, or coherently explain what trails it veers off on.

So that’s worth knowing. It’s like a page-turning mystery, you’ll learn a lot, including about unexpected areas, but you might get lost and if you’re a stickler for organization, good luck. If you’re willing to just read it for what it is, it’s a compelling, unpredictable mishmash of psychiatric/medical history, fraud investigation, and detective story.

The Great Pretender:
The Undercover Mission That Changed Our Understanding of Madness
by Susannah Cahalan
published November 5, 2019 by Grand Central

I received an advance copy courtesy of the publisher for unbiased review.

Amazon / Book Depository