The Great Pretender: The Undercover Mission That Changed Our Understanding of Madness

“‘Insanity haunts the human imagination. It fascinates and frightens all at once. Few are immune to its terrors,’ wrote sociologist Andrew Scull in his book Madness in Civilization. ‘It challenges our sense of the very limits of what it is to be human.’ It’s undeniable: There is something profoundly upsetting about a person who does not share our reality, even though science shows us that the mental maps we each create of our own worlds are wholly unique. Our brains interpret our surroundings in highly specific ways—your blue may not be my blue. Yet what we fear is the unpredictability of a mentally ill “other.” This fear emerges from the sneaking realization that, no matter how sane, healthy, or normal we may believe we are, our reality could be distorted, too.” In the 1970’s a Stanford psychologist, David Rosenhan, set out to show that anyone could get themselves admitted to an asylum by changing just a few of their answers on an evaluation, and to show how they were treated once admitted even if they acted completely “normal”. The results of his study had a broad impact on the world of psychiatry. But as the author looked deeper into his study, she found that not all may have been as it was presented. This book brings to light questions we should all be asking ourselves about psychiatry. About how patients are diagnosed and treated, and how we should all keep looking for solutions and answers rather than allowing the ones seeming to need treatment to disappear or remain on the outsides of society as other. I really would recommend this book to anyone. It was informative and interesting. It asks the tough questions. I give it 4.5 stars.

The author, Susannah Cahalan, spent five years trying to uncover the truth of psychologist David Rosenhan’s famous research paper. When she sticks to that story, which is only about half of the book, the book is riveting. The other half of the book discusses a wide range of topics that were a bit tangential and could have been handled differently. Cahalan had access to Rosenhan’s unpublished manuscript of a book, and his detailed notes of his own stay as a fake patient on a psychiatric ward in 1969. She tracked down two other fake patients. She uncovered numerous things that Rosenhan fabricated and lies he told. Much of Rosenhan’s famous paper could be neither supported nor discounted because many of the key players have passed away after more than 40 years, but Cahalan makes an interesting case that Rosenhan may have fabricated even more than what she was able to document. She uncovered the fascinating side story about psychiatrist Robert Spitzer, who was perhaps Rosenhan’s fiercest critic. Spitzer obtained a copy of Rosenhan’s hospital record and may have used it to his own advantage towards the development of the revolutionary Diagnostic and Statistical Manual, Third Edition (DSM-III). Weaknesses of the book include how Rosenhan described his experiences and the experiences of other fake patients as almost entirely negative because they felt bored, neglected, and dehumanized. He never seemed to be able to view it from the experiences of real patients who were helped by being hospitalized. The inability to view life from the perspectives of others, and Rosenhan’s know-it-all dismissiveness of other viewpoints, sounds like a narcissist. The author never seemed to question Rosenhan’s one-sided negative view of hospitals. This appears to view real patients as passively allowing themselves to be mistreated. The sections on her own medical illness that was mistaken briefly as a psychiatric illness, the history of insane asylums, and other history about psychiatry placed a focus on the history of psychiatry instead of on Rosenhan’s lies, which made the book feel like two different books. These topics might have been discussed more dispassionately in the context of how easy it is for nefarious things to happen when dealing with the human mind. Cahalan’s disparagement of the DSM is worthy of note. Her criticism of the DSM is naïve for repeating many of the criticisms about how it artificially creates categories, creates too many disorders, and how psychiatrists supposedly blindly embraced the DSM as a bible. Much could be said in response but I think the best response is that despite a lot of smart people criticizing the DSM for years, no one has proposed a better classification system. The DSM was never meant to provide a perfectly unassailable view of the human mind. Criticizing the DSM for not doing everything perfectly seems like criticizing a car because it can’t fly. If Cahalan had stuck to the facts of the Rosenhan story, I may have rated it five stars, but it felt like she could not remove her personal beliefs from the narrative. Cahalan writes well, and she did a good job of investigating and finding perhaps everything that was possible to find after more than 40 years. She found quite a lot. However, even though Rosenhan lied about the most central aspects of his study, the author still seems to find some validity in Rosenhan’s central premise that the doctors in his study were the ones who got it wrong. On her Today Show interview (Nov. 5, 2019), she said, “I still think there is a lot of validity in it (Rosenhan’s study) even though there are problems. He actually identified a lot of true things.” Like what?

Great book! Thought provoking and interesting!

The author does what appears to be an impressive amount of research on the Rosenhan study - trying to find the pseudopatients, fact-checking what is reported in Rosenhan's famous study, interview after interview, etc. It is a good example, I think, of an intensive investigation. However, that is the most interesting part of the book, the rest of it is filled with information about the history of psychiatry (and current problems with mental illness in prison, among homeless persons, etc. due to deinstitutionalization, etc), presented in a significantly disorganized manner. Others have written much better books about history and current problems in psychiatry and the challenges faced by individuals with mental illness. I agree with other reviewers who suggested that this book was much too long and a clearer focus on the Rosenhan "research" would have made for a very nice contribution either in a short book or another type of publication (e.g., article). Further, although the Rosenhan study certainly did have a noteworthy effect on the field, many other things going on in this country relevant to the field of psychiatry (and public opinion regarding psychiatry) also contributed significantly to changes that took place. I think the author gives this one study more credit for the changes in psychiatry than it deserves.

Ostensibly a book about the author's search for the story behind psychologist David Rosenhan's study of "pseudopatients" easily gaining admission into mental hospitals (which she discovers may have been a hoax), it's more about the history of psychiatry generally and its record of cruel treatments and repeated failures over the years in dealing with serious psychosis. The writing often reminds me of travel shows that follow the host more than the subject matter per se (realistically, I just want the information that the author or host or guide discovered, not the story of the adventure in obtaining that information) but the information developed here is pretty good. Cahalan does not come across as either rabidly anti-psychiatry or as an apologist for the field - she's got eyes wide open at all times and is evenhanded in her treatment of the subject - but she has good analyses of why the field is so fraught with failures and how efforts to fix psychiatry, even when well-intentioned (such as deinstitutionalization, or to come up with better and more nuanced diagnostic tools) have only resulted in their own failures. A good book about the field for the layman to read, even if the "quest" model for writing the story seems out of place to me.

I spent 30 years working in the mental health field and this is a superb telling of some of the key events in the history of psychiatry from the late 60s to now. It reads like a fast-moving mystery as the author uncovers some disturbing facts about a published study from the 1970s that changed psychiatry. Superb read and an important story.

I have not finished the book, but so far it is not what I was expecting. I was excited when I read the synopsis of the book. I thought it was going to be written from the point of view of the patients that went undercover into the psychiatric hospitals, but it is written more in a "journalistic" type of way (the author investigates the experiment and collects information from those involved in order to write the book). Otherwise, the points made so far are interesting.

I just read the author's first book (2012) about her rare auto-immune encephalitis which first manifested as mental illness. Here she probes in the story of the author of a study published in 1973 in Science. We follow along her journey of discovery, and ponder with her what was true in the Science article vs. what may have been concocted. She learns more about Western Medicine and Mental Health, and how much we still do not know. And she ponders what is genetic/biological/environmental when it comes to mental health. No easy answers.