Susannah Cahalan

“No one can improve without the bare minimum—shelter, clothing, and food—but they also need care: intelligent medical intervention, personal contact, community, and meaning.”

If you ever developed a passing interest in psychology, you have likely learned about David Rosenhan’s watershed study published in 1973 “On Being Sane in Insane Places”. Rosenhan, a psychology (and law) professor at Stanford University, and eight other ordinary, well adjusted people faked symptoms of show more mental illness in order to be committed to mental asylums across America. Rosenhan was essentially looking to prove that psychiatry had no reliable way to tell the sane from the insane, and the results of the experiment appeared to confirm his theory.

The eight subjects (one having been excluded from the results), including Rosenhan, told the same story -they were hearing voices- and, all but one who was labelled with manic depression, were committed with a diagnosis of schizophrenia. The eight pseudopatients were then required to stay until they were medically released. The length of hospitalization, Rosenhan reported, ranged from seven to fifty-two days, with an average stay of nineteen days.

Rosenhan’s paper appeared to be a damning indictment of the psychiatric field, not only were these pseudopatients incorrectly diagnosed they were, by and large, subject to ill-treatment while in the ‘care’ of these institutions. “On Being Sane in Insane Places” became a major factor in changes to the psychiatric discipline going forward, contributing to public distrust of the field, the widespread closure of hospitals for the mentally insane, and the 1974 update of the Diagnostic and Statistical Manual of Mental Disorders.

The author of The Great Pretender, Susannah Cahalan has herself made a major contribution to the discipline of psychiatry. At the age of 24 Susannah, a journalist, suddenly began exhibiting signs of acute mental illness, and was variously diagnosed with bipolar and schizoaffective disorders until a neurologist discovered that Susannah’s brain was under attack from a rare autoimmune disease resulting in her psychotic behaviours. Treatment of the disease resolved any sign of mental illness. Cahalan wrote about her ordeal in Brain on Fire (later adapted by Netflix as a feature film).

Cahalan’s experience of being wrongly diagnosed with a mental illness is what prompted her interest in Rosenhan’s study. Cahalan’s investigation and research appears meticulous and exhaustive but the results are disturbing. It seems likely that Rosenhan, was a ‘Great Pretender’ in that he manipulated and/or fabricated much of the data, and therefore the conclusions he presented in “On Being Sane in Insane Places”. I was convinced by Cahalan’s discoveries, and shocked by the implications of Rosenhan’s fraud.

“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.”

While I remained absorbed in the story of The Great Pretender, I did think that Cahalan’s occasional sidestep into related, but not perhaps not particularly relevant, areas drew focus from the main narrative, though I did find them interesting in their own right.

I found The Great Pretender to be an accessible and compelling read. I imagine that the psychiatry field will not be pleased to learn that yet another ‘breakthrough’ thesis is probably fraudulent, and I’ll be curious to learn what, if any, effect this may have on the future of mental health care (and if Rosenhan’s study will be removed from textbooks).

“And this fraud, played out every day in our academic journals and our newspapers (or more likely our social media feeds), breeds an anti-science backlash born of distrust.” show less

About the author’s experience with a health issue that severely affected her brain. The onset was gradual and confusing- at first Cahalan thought she just had the flu. Then she started having problems with motor skills, visual perception and emotional control- breaking into sobs over nothing or displaying extreme aggression and suffering from vivid paranoia. Her behavior become so erratic she was finally convinced to see doctors but got different answers: alcohol abuse withdrawl, side show more effects from medications, a mental illness such a schizophrenia or bipolar disorder. Her family got her checked into a hospital when she started having seizures. She was nearly at the catatonic stage when a different doctor was assigned to her case and finally came up with the answer- a rare infection had attacked her brain tissue. The rest of the story is about her treatment and recovery. She describes struggling with language and memory afterwards, bu her recovery was complete enough that she was able to return to work and of course, write this memoir, in the hopes that it would help others who suffered from the same frightening illness. That’s the part that struck me most, after reading this book. More than the alarming symptoms and interesting information about the brain, how very narrowly she avoided being put in an institution for the rest of her life, misdiagnosed with a mental illness. A lot of her symptoms very closely resembled schizophrenia, her inarticulate vocalizations and stiff body movements in later stages were just like those depicted in horror films about people being “possessed”. It is horrifyingly sad to think how many hundreds of people in the past probably had the same illness and were condemned as being possessed by demons or shut up in mental hospitals. Nowadays it’s treatable but still only if it gets recognized quickly enough- the testing was not at all cheap, author was so very lucky to have affluent parents who didn’t give up on her and insisted on more answers. I can’t stop wondering how many other mental afflictions are due to pathological causes that could be treated if we just knew more about them. show less

In "The Great Pretender," Susannah Cahalan gives us a brief overview of how the mentally ill have been treated throughout the centuries. This does not make for pleasant reading. Among the remedies in vogue at one time or another were beating people to chase out their demons; placing them in ice baths; restraining or caging them in confined spaces for long periods of time; performing lobotomies that sometimes obliterated their personalities; and dosing them with drugs that caused them to show more drool, shake, and walk around in a stupor. On the other hand, some visionaries placed the emotionally disturbed in cheerful environments, gave them nourishing food, engaged them in wholesome activities, and hired humane doctors and nurses to tend to their needs. However, the latter was the exception, not the rule. To this day, many of us fear men and women who hear voices, speak or scream unintelligibly, neglect their hygiene and appearance, and more and more frequently, live on the streets. Cahalan says, "There is something profoundly upsetting about someone who does not share our reality."

The author goes on to discuss the work of Stanford University psychologist David Rosenhan who, in the 1970s, allegedly managed to get himself and seven other healthy individuals (all of whom feigned their symptoms) admitted into various asylums. Based on their experiences, Rosenhan wrote a groundbreaking paper, "On Being Sane in Insane Places," that appeared in 1973 in the prestigious journal, "Science." Rosenhan's findings gave a black eye to psychiatric institutions—depicting them as "authoritarian and degrading," and their employees as cold, incompetent, and uncaring. This widely-read study may have, to a small extent, helped hasten the deinstitutionalization of thousands of sick people who, in many cases, ended up in jail or on the streets.

In an unexpected twist, Cahalan looks into Rosenhan's background and discovers, much to her surprise, that this charismatic teacher and researcher may have falsified at least a portion of the data that he used to critique mental hospitals. She interviews men and women who knew and worked with Rosenhan, examines his unpublished notes, and locates discrepancies and anomalies that cast doubt on his data and methodology. Although "The Great Pretender" has quite a few tangents that seem like filler, it is a compelling and persuasive warning that so-called scientific studies may be misleading or fraudulent. In addition, Cahalan makes a convincing case that, although skilled psychiatrists alleviate suffering every day, psychiatry still has a long way to go when it comes to diagnosing mental illness and providing safe and effective treatments. show less

This is the memoir of an illness. Susannah Cahalan sank into a severe psychotic state, most of which entirely escapes her memory. With the help of the memories of her family, friends, coworkers, and medical team, she reconstructs the suspenseful unfolding drama of finding a diagnosis and then a treatment. Her story is a page-turner as we watch the entire sequence of events unfold, one test at a time, and the two-steps-forward, one-step-back progress of her recovery.

Cahalan fell victim to a show more little-known brain disease with the tongue-tangling name of anti-NMDA-receptor autoimmune encephalitis. Her first doctor diagnosed her with alcohol withdrawal and accused her parents of denial when they refused to accept the diagnosis. Fortunately, her next neurologist was certain that alcohol was not involved in her illness before he ran out of ideas and passed her on to yet another neurologist who became the hero of the tale.

Cahalan's story would make a whopping good suspense film, a true-to-life Dr. House search-for-the-truth, where time is of the essence. Her doctors knew that delay could mean death or a lifetime of profound disability.

Her gratitude to those who fought so long and hard to save her life and restore her quality of life has given her new focus. In addition to her book, which contains enough scientific information to be of use to physicians, she has established a foundation to underwrite the cost of the required high-level care (the kind of care she received) for those diagnosed. She is determined to make a difference for others who have been or may be condemned to death or locked away in a mental hospital as a result of a misdiagnosis. show less