This is a well-crafted, gripping narrative that succeeds on many levels. Cahalan, who gained the trust of Rosenhan’s family, is meticulous and sensitive in her research; compelling and insightful in her writing. She accurately conveys the troubles that have haunted psychiatry over the past half-century, embodied by Rosenhan’s famous critique, as it struggled to transform itself into an objective science. She interrogates important academics from that time, such as Allen Frances; her book, which I hope wins awards, has immense value as a historical account.
Some five years ago, three years after Rosenhan’s death, the New York-based investigative journalist Susannah Cahalan came across his work. ‘On Being Sane in Insane Places’ was the only significant scholarship he ever produced, and he lived off this famous paper throughout his career. It occurred to her that it would be fascinating to track down as many of the pseudo-patients as she could, and to explore the circumstances under which Rosenhan had come to undertake his study. The Great Pretender recounts the remarkable investigation that she undertook. The book reads like a fascinating real-life detective story, one whose denouement is only hinted at in its title.
This book, choppily organised but passionate, is a warning against easy answers. The truth is we are strangers to each other. Sanity and love are the abilities we need to live with this. Insanity is, in these terms, easily understandable but hard to cure, perhaps because, even in its worst excesses, it is ever present as a possibility in our sane selves.
I wasn’t really prepared for the story Cahalan ends up telling. That she discovered the truth about Rosenhan is a testimony to her dogged research. That this truth was inconvenient for her own outlook on psychiatry is a compliment to her integrity. She writes it all very well too, with clarity, economy and style.
And the truth is that Rosenhan was a fraud. What Cahalan’s research showed was that there were probably only two “pseudopatients” (Rosenhan himself and one other), that the accounts of their hospitalisation were fabricated, and that in one case where a genuine pseudopatient had experiences that did not fit with Rosenhan’s thesis, he was then excluded from the study.
By the end of the book, she has adopted a more optimistic view, looking forward to new brain-scanning technologies and genetic research that might enhance our understanding of what can go wrong within the brain, the most complex object in the known universe. She does also finally concede that modern psychiatry helps untold numbers of ordinary people: psychiatric drugs “help many people lead full and meaningful lives”, she writes. “It would be folly to discount their worth.” But by the time of this grudging admission, pages from the end, this book might have been happily seized on by cultists and fearmongers who want to dismiss the discipline as a conspiracy cooked up by Big Pharma and the authoritarian state. The truth is that psychiatry, along with medicine in general, remains a highly imperfect science – but the book’s polemical implication that it has not moved on much since 1973 has the potential to be truly harmful to anyone thinking about seeking help now.
Given her own experiences, and her twitchy investigative reporter’s nose, Cahalan was drawn to re-examine the case and its repercussions in the practice of psychiatry. The result of that inquiry is this compulsively readable book, in which she tries to track down the eight anonymous “pseudopatients” and examine the facts of their hospitalisation. Rosenhan died in 2012, the obituaries noting his famed experiment; with access to his original field notes, Cahalan was able to piece together the untold stories of his research and test them against reality... Cahalan, having unearthed these damning caveats, is not as damning as she might be. “Rosenhan’s paper,” she argues, “as exaggerated and even dishonest as it was, touched on truth as it danced around it.” That truth was the exposure of “the role of context in medicine”, the importance of diagnostic doubt as well as faith. Is it possible, as Chief Bromden observed in One Flew Over the Cuckoo’s Nest, that Rosenhan’s findings represented “the truth even if it didn’t happen”? Cahalan is honest enough as a writer to leave that question hanging, having presented important and spirited cases both for the prosecution and the defence.