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A defining antipsychiatry text comes under fire

The Great Pretender: The Undercover Mission That Changed Our Understanding of Madness

Susannah Cahalan
Grand Central Publishing
2019
400 pp.
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The past decade has not been kind to psychology. Researchers have been unable to replicate some of its best-known experiments, leading many to now speak of a “replication crisis.” Of greater concern is the discovery that some of the field’s most eye-catching experiments were fraudulent (1, 2). In a new book, The Great Pretender, journalist Susannah Cahalan reports on her extensive efforts to learn more about another famous experiment that appears to crumble under closer scrutiny: David Rosenhan’s 1973 study that claims to have reported on the harrowing experiences of eight volunteers who were admitted to mental hospitals after feigning symptoms of mental illness (3).

The eight pseudopatients who supposedly presented themselves at various mental hospitals reported mild auditory hallucinations, such as hearing voices saying “empty,” “hollow,” and “thud.” All, according to Rosenhan, were diagnosed with schizophrenia. After being admitted, they behaved normally. Yet it took up to 52 days for the pseudopatients to be released, all but one with the diagnosis “schizophrenia—in remission.”

The volunteers reportedly initiated contact with psychiatrists a total of 185 times and with nurses and attendants 1283 times, with responses received in just 4 and 0.5% of those instances, respectively. Average daily contact with health personnel ranged from 3.9 to 25.1 minutes, with an average of 6.8 minutes. The lesson, as articulated by Rosenhan, is obvious: Once someone is placed in a mental hospital, he or she will be considered insane regardless of their behavior. Moreover, psychiatrists are not able to distinguish the sane from the insane, implying that psychiatric diagnosis is arbitrary. Lastly, concluded Rosenhan, mental hospitals are degrading institutions. Purportedly reinforcing the conclusions of Erving Goffman’s ethnographic observations (4), Rosenhan’s “On Being Sane in Insane Places” became one of the defining texts of the antipsychiatry movement.

Cahalan provides an engaging account of her efforts to track down the pseudopatients who participated in Rosenhan’s experiment. Rosenhan died in 2012 and was not interviewed for the book, but using his notes and 200 pages of an unpublished manuscript he had prepared on the experiment (secured from former colleagues), diaries (secured from his son), interviews with former associates and research assistants, and patient records, she discovers that he embellished the experience of his own committal.

A second volunteer, who Cahalan interviews, spent 8 days in a mental hospital, yet only the 2 days he spent in the acute ward were difficult—and not because of poor treatment. (Despite taking precautions, he accidentally swallowed a dose of the antipsychotic medication Thorazine and experienced a host of unpleasant side effects.) The next 6 days were uneventful and ended when he remembered that he wanted to attend an off-road motocross event. He tells Cahalan he left without much ado—and without any diagnosis.

A third volunteer with whom Cahalan meets was committed to what turned out to be a pleasant and well-run institution in San Francisco. He had, by his own account, a wonderful experience.

Rosenhan decided to exclude this individual’s experience in the end, arguing that the volunteer had not followed protocol during the admission process. Yet when Cahalan discovers an early draft of Rosenhan’s paper, which contained the ninth pseudopatient, she notes that the numbers in both versions of the paper were exactly the same. Furthermore, neither of the volunteers she interviewed recalled being asked to quantify encounters with staff.

Cahalan could not find any trace of the six remaining pseudopatients, if indeed there were six others. (Rosenhan, in one of his notes, indicated that one of the volunteers had himself committed on four separate occasions.) His notes about these individuals were sparse—or in some cases entirely absent—and not even an eye-watering advance from a publisher was enough to get him to finish what would surely have been a best-selling book about his experiment.

In illuminating chapters, Cahalan explores the repercussions of Rosenhan’s article. It encouraged Robert Spitzer to publish the third edition of the Diagnostic and Statistical Manual of Mental Disorders, for example, which he hoped would make psychiatric diagnosis objective, scientific, and therefore less arbitrary. Although he was a fierce critic of Rosenhan’s experiment (5), Spitzer never disclosed his suspicions that at least part of it was fraudulent. Was this because it constituted one of the most compelling justifications for his own project?

Rosenhan’s article also provided considerable impetus for the deinstitutionalization movement, which was already proceeding rapidly in the United States and elsewhere. While acknowledging the many flaws of mental hospitals, Cahalan argues that de­institutionalization has made the lives of many individuals with severe mental illness worse.

Questions remain. Would such a “study” pass muster now? What would happen to pseudopatients presenting with similar symptoms today? Whatever the answers may be, with The Great Pretender, yet another well-known and rhetorically powerful experiment in psychology bites the dust.

References and Notes:
1. C. Romm, “Rethinking one of psychology’s most infamous experiments,” The Atlantic, 28 January 2015.
2. G. Toppo, “Time to dismiss the Stanford Prison Experiment?” Inside Higher Ed, 20 June 2018.
3. D. L. Rosenhan, Science 179, 250 (1973).
4. E. Goffman, Asylums: Essays on the Social Situation of Mental Patients and Other Inmates (Anchor Books, 1961).
5. R. L. Spitzer, Arch. Gen. Psychiatry 33, 459 (1976).

About the author

The reviewer is at the School of History and Philosophy of Science, University of Sydney, Sydney, NSW 2006, Australia.