The Great Pretender

Susannah Cahalan

Canongate, £16.99

Review by Alastair Mabbott

For good or ill – but really both – American psychiatry was never the same after David Rosenhan. In 1969, the Stanford professor faked hearing voices to gain admittance to a mental hospital and experience the system from the inside.

Over the next three years, under his guidance, seven more sane people bluffed their way into psychiatric institutions across the US. All were diagnosed with schizophrenia, except one, who was assessed as manic-depressive. The results, when published under the title “Being Sane in Insane Places”, exposed an inconvenient truth: the American psychiatric system couldn’t distinguish between the sane and the insane. That they also highlighted widespread dehumanisation and neglect didn’t help either.

Susannah Cahalan, who researched their story more than 40 years later, has a personal stake in it. Aged 24, she fell into a psychotic state and was on the verge of being institutionalised when one bright doctor suggested that her symptoms might have a physical cause. Her condition turned out to be a brain inflammation caused by an autoimmune disease, and Cahalan doesn’t doubt that her doctor saved her from a grim and hopeless existence in an institution.

The story of David Rosenhan and his “pseudopatients” was bound to resonate with her. But researching the background to his hugely influential article raised not only difficult questions about mental illness but also doubts about the veracity of Rosenhan’s work.

The Great Pretender recounts her attempts to track down the pseudonymous pseudopatients, check the accuracy of Rosenhan’s claims and tackle the question of why he later cooled off on the subject, failing to deliver a promised book to Doubleday, who sued him to get their advance back. She meets Harry Lando, the subject excluded from the final study, whose reports of a “benign atmosphere” and “genuine and caring” environment at the hospital he infiltrated didn’t fit the picture Rosenhan ultimately presented.

But more interesting still is her account of the part Rosenhan’s article played in the reshaping of American psychiatry. Inadvertently, “Being Sane in Insane Places” lent weight to DSM-III (the Diagnostic and Statistical Manual of Mental Disorders), which “remedicalised” mental health as a standardised box-ticking exercise. As well as leading to an explosion of diagnoses of ADHD and autism in children, DSM-III ushered in an era when monolithic psychiatric hospitals fell from favour. Unfortunately, the funds promised to facilitate care in the community never materialised, and the mentally ill were pushed further into the margins, towards homelessness and prison. “Rosenhan did not create these outcomes,” she writes, “but his study enabled them.”

Nevertheless, however much he may have fabricated, and whatever the negative effects of his work, he “touched on a truth”, exposing a flaw at the heart of psychiatry, and somehow Cahalan finds herself able to end on a positive note. “I believe in all the excitement emerging from neuroscience,” she claims, and sees progress in such areas as the weakening of Big Pharma and the current psychedelic revival. But coming at the end of a book depicting American psychiatry as a series of shambolic lurches from one disastrous state of affairs to another, her optimism can’t help but feel forced.