The Center Building at St. Elizabeths Hospital in Washington, D.C., where psychologist David Rosenhan once conducted experiments exploring the validity of psychiatric diagnosis.

An Undercover Journey Into the Heart of Madness

When she was 24, Susannah Cahalan developed a sudden psychosis. She grew paranoid — convinced her apartment was infested with bedbugs, that people were spying on her, that her boyfriend was cheating. She started to believe she could age people with her mind. As she recounted in her 2013 bestseller, “Brain on Fire: My Month of Madness,” she received several misdiagnoses (bipolar disorder, schizoaffective disorder) before an alert doctor discovered the true culprit: autoimmune encephalitis.

The moment her illness was deemed neurological, ”as in physical, in the body, real,” rather than psychiatric, “in the mind and therefore somehow less real,” the quality of her care drastically improved, Cahalan writes in her new book, “The Great Pretender.” Sympathy and understanding replaced the detached attitude that had defined her treatment as a mental patient, “as if a mental illness were my fault, whereas a physical illness was something unearned, something ‘real,’” she writes.

Cahalan, a journalist, recovered from her brief psychosis, but the distinction between physical and mental illness continued to perplex her. “What does mental illness mean, anyway, and why would one affliction be more ‘real’ than another?” she asks. These questions form the backbone of “The Great Pretender.”

The book centers on the work of David Rosenhan, a Stanford psychologist whose paper, “On Being Sane in Insane Places,” was an instant sensation when it was published in the journal Science in 1973. The paper begins with a question: “If sanity and insanity exist, how shall we know them?”

Rosenhan went on to describe what happened when he sent eight healthy volunteers to psychiatric hospitals with a script. They were to say that they heard voices saying, “thud,” “empty,” and “hollow.” This single complaint was enough to get each of these “pseudopatients” diagnosed with a mental illness (usually schizophrenia) and admitted into 12 different psychiatric hospitals across the country. Once inside, they ceased the charade and resumed their normal behavior, yet none were ever detected as frauds. (According to Rosenhan, they were released when their mental illnesses were deemed “in remission.”)

“Having once been labeled schizophrenic, there is nothing the pseudopatient can do to overcome the tag,” Rosenhan wrote. His paper described the stigmatization and what today would be called “othering” that psychiatric patients faced.

The paper was, in the words of a eulogizer at Rosenhan’s funeral in 2012, “a proclamation, a moral outcry, a scream of pain, and a demand that the world bear witness.” That call to action was Rosenhan’s intention. He viewed the American psychiatric hospital system as a “state-sponsored travesty.” To draw public attention to the problem, “He had to create an account that could not be dismissed,” Cahalan writes. “It needed to be solid, quantifiable. It needed to be scientific.” Hence the study, which had a long-lasting influence on how researchers, psychiatrists, and the public viewed mental illness.

An “old electric shock machine,” circa 1920, once used for patient therapy at St. Elizabeths, one of the sites of the Rosenhan experiment, in the early 20th century. Visual: National Archives and Records Administration/National Building Museum

“On Being Sane in Insane Places” was one instigating factor in the widespread closure of U.S. psychiatric facilities, and it spurred a push to make psychiatric diagnoses more rigorous. “Any diagnostic process that lends itself so readily to massive errors of this sort cannot be a very reliable one,” Rosenhan had written.

Columbia University psychiatrist Robert Spitzer was a fierce critic of Rosenhan’s paper but he recognized that the publicity storm created by Rosenhan’s work could help him get traction for his effort to improve the American Psychiatric Association’s approach to diagnosing mental illness.

In 1974, Spitzer was tapped by the APA to oversee a new edition of the Diagnostic and Statistical Manual of Mental Disorders — the organization’s guide to diagnosing mental illness. He oversaw a revamping that was characterized by “literal boxes — doctors were provided diagnostic criteria to tick off one by one,” Cahalan writes. She learns that he had held back on publicly discussing some of the most troubling shortcomings of Rosenhan’s Science paper, perhaps because it served his argument that the DSM needed revising to make it more reliable.

“Having once been labeled schizophrenic, there is nothing the pseudopatient can do to overcome the tag.”

Cahalan’s book is a sharp investigation into how human self-interest, weaknesses, and egos can shape the way that science proceeds. Rosenhan’s study was small — only eight subjects — and as Cahalan digs deeper into the details, she finds that not all was as Rosenhan reported it. She could only locate two of the pseudopatients that Rosenhan had recruited for the study, and the accounts of their experiences that they share with her differ in meaningful ways from what Rosenhan had written.

She also learns that Rosenhan himself was one of the pseudopatients, and his description of his own experience in the psychiatric hospital diverges from the accounts she finds in medical records and other documents that she found among his collection of files, which include a book manuscript about the study that Rosenhan never finished. (His publisher eventually sued Rosenhan to recoup the large book advance they had paid him.)

“The Great Pretender” reads like a detective thriller, as Cahalan tries to reconcile what Rosenhan wrote in his paper and unfinished book manuscript with the facts she finds in the documentation and first-hand accounts of his work that she tracks down through her research. Rosenhan was beloved for his teaching, but his famous Science paper was the last time he published on the subject, and Cahalan discovers more than a little whispering and distrust of him among his colleagues.

A patient at St. Elizabeths Hospital in 1955. Visual: National Archives and Records Administration/National Building Museum

But even though she ultimately concludes that Rosenhan misrepresented and probably even fabricated some of the data reported in his study, Cahalan is more interested in exploring the repercussions of Rosenhan’s work than in tearing down the man himself. Even as she decides that he’s an unreliable narrator, she considers him the bearer of a worthy cause.

“In the end I believe that [Rosenhan] exposed something real,” Cahalan writes. This something was the ways that psychiatric conditions are dismissed as less legitimate than physical ones, the stigmatization of the mentally ill, and the limitations of psychiatry’s diagnostic tools. These problems remain worthy of attention, she writes, even if “the messenger was not.”

Cahalan’s book is a reckoning of psychiatry’s past and present. Nearly five decades after Rosenhan’s landmark study, our understanding of the biology underlying mental illness remains in its infancy, she writes. Psychiatry is at the point that infectious disease research was at when the microscope had just been invented, Lancet Psychiatry editor Niall Boyce tells Cahalan.

Ultimately, the book ends where it started, with questions: What is mental illness and why do we insist on treating it as separate from other medical conditions?

Christie Aschwanden is an award-winning science journalist. She’s the author of “Good to Go: What the Athlete in All of Us Can Learn from the Strange Science of Recovery” (Norton) and co-host of the podcast “Emerging Form.” Find her on Twitter at @CragCrest.