The Great Pretender, by Susannah Cahalan, is one of the most extraordinary, best written works of nonfiction I think I’ve ever read. I have so much to say about it that I’m honestly not sure where to begin! This book takes on our existential fear of mental illness, our cultural dread of asylums, and the possibly unsolvable problem of where mental illnesses come from and how to cure them. Cahalan uses all her skills as a journalist to dig deep into a contentious scholarly and societal argument about the the legendary Rosenhan Experiment.
After her own hospitalization and initial misdiagnosis (documented in Brain on Fire), a doctor told her about David Rosenhan and “On Being Sane in Insane Places,” published in Science in 1973. Earlier this year, I read “On Being Sane.” I recall being horrified and struck by the truth of what Rosenhan was saying: that even professionals have a hard time diagnosing mental illness, especially in institutions like the old mental hospitals that existed up to the 1970s. Once the label of mental illness is applied, everything the “patient” does is a symptom of that illness. Thus, once you’re in, it’s hard to prove you’re sane and get out. Cahalan, who turned out to be suffering from autoimmune encephalitis, was labeled as schizophrenic until a doctor spent some more time on her case and figured it out. It’s no wonder that “On Being Sane” resonated with Cahalan.
Initially, Cahalan set out to find the pseudopatients in “On Being Sane,” who volunteered to get themselves committed to various asylums. The article refers to eight pseudopatients (with one thrown out for improvising too much) who presented with claims of auditory hallucinations that riffed on the words thud, empty, and hollow. They then spent various lengths of time before wrangling their way out again. One of the pseudo patients was diagnosed with manic depression (now called bipolar disorder); all the rest were diagnosed with varieties of schizophrenia. When “On Being Sane” was published, it exploded on the discipline like a bomb. Its legacy touched on the development of new editions of psychiatry’s bible, The Diagnostic and Statistical Manual of Mental Disorders, the political dismantling of America’s state mental hospitals, and fueled lingering doubts about the veracity of psychiatry in general.
But when Cahalan starts to dig, she turns up an unexpected and troubling can of worms about Rosenhan’s experiment. I don’t want to say too much because Cahalan’s writing about her investigation is beautiful, subtle, and credible. I started out like Cahalan. I trusted Rosenhan’s “On Being Sane.” It just seemed so true. But there are questions. Why didn’t Rosenhan finish his book about his experiment? He was eventually sued by his publisher to recover the advance. Why is it so hard to find the pseudopatients, even allowing for the passage of time? Like Cahalan, my opinion of Rosenhan started to shift right along with hers as she shared her findings. Cahalan takes us from certainty, to doubt, to a new plane of important, useful questions about mental illness and treatment.
This review barely scrapes the surface of Cahalan’s investigation. And I can’t say enough in praise of The Great Pretender. I loved this so much that I’m going to lobby our behavioral sciences librarian to buy a copy for the library and badger every reader I know who is interested in health and mental health to read this book.