'The Great Pretender' by Susanah Cahalan

Anyone who has an interest in mental illness, how it is diagnosed and treated, and especially an interest in society’s attitude to psychiatric practice will enjoy this book. It concerns the study published in Science in 1973 called “On being sane in insane places” by David Rosenhan, then professor of Psychology and Law at Stanford University. In summary this study purported to report on the fates of eight pseudo-patients who presented to psychiatric hospital. They reported hearing auditory hallucinations of a word such as “Thud” or a phrase such as “its hollow inside“. After this report, they behaved entirely normally without feigning any symptoms or exhibiting any unusual behaviour. The study reported that they were all admitted and diagnosed as mentally unwell (usually as having schizophrenia) and during weeks of admission given treatment for these conditions. The study suggested that psychiatrists could not distinguish between the sane and the insane, between health and mental illness.

This study shook psychiatry and mental health services to their core. At the time, following the work of the likes of Thomas Szasz (‘The Myth of Mental Illness’) and Erving Goffman (‘Asylums’), this seemed to give support and credence to the anti-psychiatry movement and provoked widespread, comprehensive and much needed change into the provision of in-patient psychiatric services. It was probably one of the prime drivers for the development of the DSM-III system of diagnosis which, at the time, helped address some of the major failings of psychiatric diagnosis.

I recall when I was a lecturer in psychological medicine referring to this study when lecturing to medical undergraduates, or psychiatric postgraduates, to try and inculcate a sense of shame that the profession was able to perform so poorly and fail our patients so badly.As a simple study with a blindingly obvious outcome it was very valuable.

However, it seems I may have been wrong. Without giving too much away this book looks into the study and checks the veracity of the reports. The author had a personal experience of psychiatric mis-diagnosis when she fell ill with autoimmune encephalitis and presented with psychotic symptoms. This kindled, in her, an interest in diagnostic accuracy and the interface between mental and physical illness and prompted her to look at this landmark study. Early in her research she noted significant defects in the study which she then started to explore. As the author follows clues, leading to the uncovering major flaws in the study, this book reads as easily as detective fiction. Although I suppose I should really class it as a true crime drama.

There is clear evidence that the ‘facts’ as reported are not the fact as they occurred. It is clear that some pseudo-patients actively feigned mental illness and threatened self-harm to capture the psychiatrists’ attention. The reports were also selectively reported so that positive or helpful experiences of psychiatric care were deliberately omitted from the published report. There is some, equivocal, evidence that Rosenhan was actively fraudulent in creating stories out of thin air to support his theories.

It is sad when our heroes turn out to have feet of clay. We feel duped when we discover the facts that were presented to us, and which we acted on, were misleading. However, many of the changes that followed this study were needed and one could argue that a “good lie” was more effective than many dry studies in forcing a change in the psychiatric services. I still hope that when people read the study they will think “how can we avoid problems like that ?“. However, a ‘good lie’ may prompt change but it is not a useful compass for what direction that change should take. We will all be glad to see that some of the bad practices are gone but this study did not help us see the positive aspects of “asylum” nor how we can preserve these. It lead us to throw the baby out with the bath water.

It is true that there are many less in-patient beds for patients with mental illness and that hospitals no longer degrade patients as they did. However, we now have many more psychiatric patients in prisons, nursing homes and general medical wards. Often the care here is poorer than that of the old institutions and I fear that the many mentally ill patients trapped in prisons are experiencing degrading and unpleasant treatment the equal of that in a seventies mental health hospital. In some senses we have just changed the nurse into a prison warder and the locked ward into a prison cell – the place and person may have changed but the crime hasn’t.

To improve the treatment of the mentally ill we need not only to understand mental illness better but also to understand better our own attitudes towards it. Although I will miss using this study in a ‘fire and brimstone’ talk about diagnostic accuracy I would (were I still teaching) have to be very cautious referring to it now. When we think we understand, but don’t, we are at the greatest risk of making mistakes. As this book reveals, even with good intentions, a prejudiced and dishonest look at the facts helps no-one in the long run.