The Great Pretender: The Undercover Mission That Changed Our Understanding of Madness Audible Audiobook – Unabridged
For centuries, doctors have struggled to define mental illness - how do you diagnose it, how do you treat it, how do you even know what it is?
In search of an answer, in the 1970s a Stanford psychologist named David Rosenhan and seven other people - sane, normal, well-adjusted members of society - went undercover into asylums around America to test the legitimacy of psychiatry's labels.
Forced to remain inside until they'd 'proven' themselves sane, all eight emerged with alarming diagnoses and even more troubling stories of their treatment. Rosenhan's watershed study broke open the field of psychiatry, closing down institutions and changing mental health diagnosis forever.
But, as Cahalan's explosive new research shows, very little in this saga is exactly as it seems. What really happened behind those closed asylum doors, and what does it mean for our understanding of mental illness today?
Preface and epilogue read by the author.
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|Listening Length||12 hours and 16 minutes|
|Whispersync for Voice||Ready|
|Audible.com Release Date||January 02, 2020|
|Best Sellers Rank|| #378,011 in Audible Books & Originals (See Top 100 in Audible Books & Originals) |
#4,222 in Mental Health (Audible Books & Originals)
#9,342 in Psychology (Audible Books & Originals)
#61,580 in Mental Health (Books)
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Cahalan had access to Rosenhan’s unpublished manuscript of a book, and his detailed notes of his own stay as a fake patient on a psychiatric ward in 1969. She tracked down two other fake patients. She uncovered numerous things that Rosenhan fabricated and lies he told. Much of Rosenhan’s famous paper could be neither supported nor discounted because many of the key players have passed away after more than 40 years, but Cahalan makes an interesting case that Rosenhan may have fabricated even more than what she was able to document.
She uncovered the fascinating side story about psychiatrist Robert Spitzer, who was perhaps Rosenhan’s fiercest critic. Spitzer obtained a copy of Rosenhan’s hospital record and may have used it to his own advantage towards the development of the revolutionary Diagnostic and Statistical Manual, Third Edition (DSM-III).
Weaknesses of the book include how Rosenhan described his experiences and the experiences of other fake patients as almost entirely negative because they felt bored, neglected, and dehumanized. He never seemed to be able to view it from the experiences of real patients who were helped by being hospitalized. The inability to view life from the perspectives of others, and Rosenhan’s know-it-all dismissiveness of other viewpoints, sounds like a narcissist. The author never seemed to question Rosenhan’s one-sided negative view of hospitals. This appears to view real patients as passively allowing themselves to be mistreated. The sections on her own medical illness that was mistaken briefly as a psychiatric illness, the history of insane asylums, and other history about psychiatry placed a focus on the history of psychiatry instead of on Rosenhan’s lies, which made the book feel like two different books. These topics might have been discussed more dispassionately in the context of how easy it is for nefarious things to happen when dealing with the human mind.
Cahalan’s disparagement of the DSM is worthy of note. Her criticism of the DSM is naïve for repeating many of the criticisms about how it artificially creates categories, creates too many disorders, and how psychiatrists supposedly blindly embraced the DSM as a bible. Much could be said in response but I think the best response is that despite a lot of smart people criticizing the DSM for years, no one has proposed a better classification system. The DSM was never meant to provide a perfectly unassailable view of the human mind. Criticizing the DSM for not doing everything perfectly seems like criticizing a car because it can’t fly.
If Cahalan had stuck to the facts of the Rosenhan story, I may have rated it five stars, but it felt like she could not remove her personal beliefs from the narrative. Cahalan writes well, and she did a good job of investigating and finding perhaps everything that was possible to find after more than 40 years. She found quite a lot. However, even though Rosenhan lied about the most central aspects of his study, the author still seems to find some validity in Rosenhan’s central premise that the doctors in his study were the ones who got it wrong. On her Today Show interview (Nov. 5, 2019), she said, “I still think there is a lot of validity in it (Rosenhan’s study) even though there are problems. He actually identified a lot of true things.” Like what?
This is one of the stories that are found in Cahalan’s book. The other is about a young woman who was diagnosed and treated for schizophrenia when, in fact, she was suffering from autoimmune encephalitis. That woman was Susannah Cahalan.
This book contains twists within twists, and plots within plots, except that they are true stories based on Cahalan’s investigation into a psychiatric experiment carried out by a Stanford University psychologist, David Rosenhan. Rosenhan wrote a paper published in ‘Science’, about how he and seven other volunteers pretended to have mental problems and were admitted into a psychiatric hospital. The aim was to show that it was impossible to objectively distinguish the sane from the insane. That paper was titled, ‘On Being Sane in Insane Places’.
As Cahalan dug deeper, she found that a psychiatrist, Robert Spitzer was highly critical about the method used by Rosenhan. But Spitzer did not go all out to bring his criticism to the full light of academic review. Could it be that Rosenhan’s article which had become famous, supported Spitzer’s own views that psychiatric illnesses required objective diagnosis? Spitzer went on to revolutionise the DSM manual in psychiatry and produced the most objective version in DSM- III. That was the edition that removed homosexuality as a psychiatric problem.
The truth about the Rosenhan experiment is uncovered by Cahalan like a detective, but you be the judge. In the course of her research, Cahalan also revealed that DSM-5, the current edition, came under severe criticism, including a book, ‘Saving Normal’, by Allen Frances, the editor of DSM-IV.
What is clear is that mental illness and normality are difficult to differentiate, and that in most cases, psychiatrists are split, 50-50 in their diagnosis of the same patient. Furthermore, it takes time for a psychiatrist to distinguish a true patient from a pseudopatient, yet many psychiatrists spent only a fraction of the time required when make their diagnosis.
In the 1970’s a Stanford psychologist, David Rosenhan, set out to show that anyone could get themselves admitted to an asylum by changing just a few of their answers on an evaluation, and to show how they were treated once admitted even if they acted completely “normal”. The results of his study had a broad impact on the world of psychiatry. But as the author looked deeper into his study, she found that not all may have been as it was presented.
This book brings to light questions we should all be asking ourselves about psychiatry. About how patients are diagnosed and treated, and how we should all keep looking for solutions and answers rather than allowing the ones seeming to need treatment to disappear or remain on the outsides of society as other. I really would recommend this book to anyone. It was informative and interesting. It asks the tough questions. I give it 4.5 stars.
Top reviews from other countries
Reviewed in the United Kingdom 🇬🇧 on January 15, 2020
But was it really what it claimed?
Susannah Cahalan has produced an investigation that I can only describe as riveting. She tracked down everyone who knew Rosenhan, everything he wrote. She spoke to family, friends and colleagues. In particular she set her sights on the eight subjects, anonymous in the paper. Were they still alive? Could she locate them? Could she ask for their memory of their experience?
The author claimed an interest for her curiosity. She had herself been misdiagnosed with schizophrenia and has written about this. She is not a psychiatrist but is respected in the medical community, frequently lecturing to professional audiences.
She addresses the wider questions raised by Rosenhan’s paper. Can we really not tell sanity from insanity? Is there a such a thing as mental illness? Her answer to the second is unequivocal – mental illness is a reality. Closing down hospitals did not solve the problem. Psychiatry has generally failed to offer a solution at least not in the way we manage cancer or heart failure. It has had some success though and we must continue to hope for advances. Her optimism somewhat tempered she concludes the book with “I believe”.
It is a great book with a couple of caveats. She puts a lot of her own experience into the account, which we could understand. Her style of writing is a bit free at times – “throw a rock into a crowd in the 1800s and there’s a good chance you’d hit someone who’d spent time in an asylum”.
Set against this is the reach of her investigation – determined and detailed. Her background in news helped her to get people to talk about things both personal and painful. How upfront has she been though? It becomes clear that among leading psychiatrists Rosenhan did not command respect. There were doubts about his research, serious questions were raised. By and large these were not publicised. By 2015 most of those who led the field in 1970 had either died [Rosenhan deceased in 2012] or long retired. Was now the time? Did someone drop a hint to the author?
The author’s experiences of mental ill health add weight to her investigation and her concerns as she wrestles with the stories she uncovers.
It is a fascinating and thorough investigation and it has certainly made me reevaluate mental distress and the ways we treat those who are suffering.