The BookBrowse Review

Published September 16, 2020

ISSN: 1930-0018

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The Great Pretender
The Great Pretender
The Undercover Mission That Changed Our Understanding of Madness
by Susannah Cahalan

Paperback (14 Jul 2020), 400 pages.
Publisher: Grand Central Publishing
ISBN-13: 9781538715277

From "one of America's most courageous young journalists" (NPR) and the author of the blockbuster #1 New York Times bestselling memoir Brain on Fire comes a propulsive narrative history investigating the 50-year-old mystery behind a dramatic experiment that changed the course of modern medicine.

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?


Psychiatry, as a distinct branch of medicine, has come far in its short life span. The field has rejected the shameful practices of the recent past—the lobotomies, forced sterilizations, human warehousing. Today's psychiatrists boast a varied arsenal of effective drugs and have largely dropped the unscientific trappings of psychoanalytic psychobabble, the "schizophrenogenic" or "refrigerator" mothers of yesteryear who had been blamed for triggering insanity in their offspring. Two decades into the twenty- first century, psychiatry now recognizes that serious mental illnesses are legitimate brain disorders.

Despite all these advancements, however, the field lags behind the rest of medicine. Most of our major innovations—better drugs, improved therapies—were in play around the time we first walked on the moon. Though the American Psychiatric Association reassures us that psychiatrists are uniquely qualified to "assess both the mental and physical aspects of psychological problems," they are, like all of medicine, limited by the tools at hand. There are not, as of this writing, any consistent objective measures that can render a definitive psychiatric diagnosis—no blood tests to diagnose depression or brain scans to confirm schizophrenia. Psychiatrists instead rely on observed symptoms combined with patient histories and interviews with family and friends to make a diagnosis. Their organ of study is the "mind," the seat of personality, identity, and selfhood, so it should not be surprising that the study of it is more impenetrable than understanding, say, the biology of skin cancer or the mechanics of heart disease.

"Psychiatry has a tough job. In order to get the answers we need, the truth about what's really going on, we need to understand our most complex organ, the brain," said psychiatrist Dr. Michael Meade. "To understand how this physical organ gives rise to the phenomenon of consciousness, of emotion, of motivation, all the complex functions we humans see as possibly distinguishing us from other animals."

Diseases like the one that set my brain "on fire" in 2009 are called the great pretenders because they bridge medical worlds: Their symptoms mimic the behaviors of psychiatric illnesses like schizophrenia or bipolar disorder, but these symptoms have known physical causes, such as autoimmune reactions, infections, or some other detectable dysfunction in the body. Doctors use terms like organic and somatic to describe diseases like mine, whereas psychiatric illnesses are considered inorganic, psychological, or functional. The whole system is based on this distinction, on categorizing illness as one or the other, and it dictates how we treat patients up and down the scale.

So what is mental illness? The question of how to separate sanity from insanity, of how to even define mental illness, rises above semantics, and above deciding what kind of specialist will care for you or your loved one during a time of intense need. The ability to accurately answer this question shapes everything—from how we medicate, treat, insure, and hospitalize to how we police and whom we choose to imprison. When doctors diagnosed me with an organic illness (as in physical, in the body, real) as opposed to a psychiatric one (in the mind, and therefore somehow less real), it meant that I'd receive lifesaving treatment instead of being cordoned off from the rest of medicine. This separation would have delayed or even derailed my medical team's efforts to solve the mystery in my brain and would have likely led to my disablement or death. The stakes couldn't be higher, yet, as psychiatrist Anthony David told me, "the lay public would be horrified to realize how flawed and arbitrary a lot of medical diagnosis is."

Indeed, this "flawed and arbitrary" diagnostic system has life- altering ramifications for the one in five adults living in the United States who will experience symptoms of mental illness this year. It even more urgently affects the 4 percent of Americans who contend with serious mental illness,1 a segment of the population whose lives are often shortened by ten to twenty years. Despite all of our medical progress—of which I'm a direct recipient—the sickest among us are getting sicker.

Full Excerpt

Excerpted from The Great Pretender: The Undercover Mission That Changed Our Understanding of Madness. Copyright © 2019 by Susannah Cahalan, LLC. Reprinted with permission of Grand Central Publishing. All rights reserved.

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Please be aware that this discussion guide may contain spoilers!

  1. Discuss the book's title. Does the term "the great pretender" change meaning for you over the course of the book, and if so,how? What different things does it represent to you by the end of the book versus the beginning?
  2. In chapter 1, Susannah encounters a woman whose disease was similar to her own, but her fate was drastically different. She begins to refer to her as her "mirror image." How does this figure—and the author's awareness of her background presence—help shape the rest of the book? What would such a person look like in your own life?
  3. Why do you think "On Being Sane in Insane Places" hit such a nerve in American culture in 1973, and caused such a sea change in the history of psychiatry? How was it different from the work done by Nellie Bly and other brave pseudopatients and reporters in previous decades?
  4. Try to imagine what mental health care in this country would look like now if Rosenhan had never published his work. Would we be in a better place? A worse one? Why?
  5. Dr. Levy described Susannah as a ninth pseudopatient. In what ways do you feel that Susannah fills this role in the book?
  6. The central mystery of the book propels Susannah down a number of rabbit holes, and to a frustrating series of dead-ends, before she discovers the truth. Once she does, she realizes that the answer has been staring her in the face the whole time. How did you feel about this revelation? Have you had any experiences in your own life that have been similarly surprising?
  7. From the beginning, psychiatry has struggled with identifying the divide between the body and the mind, between the biological and the psychological, between the "real" and the idea that something is "all in your head." Do you agree that this line needs to be drawn, and if so, where would you draw it and why? Is there a better system of diagnosis than the one we have currently?
  8. If you had to write policy for revamping the mental healthcare system in this country, what would you tackle first? What approach do you feel is the most likely to succeed long-term?
  9. What was the most exciting, dramatic twist, or piece of evidence, that stuck with you over the course of the book?
  10. Susannah describes herself as in awe of Dr. Rosenhan, early in the book, and her drive to understand his study is fueled by her admiration for him; his students frequently describe him as "charismatic" and "charming." But of course,the secrets she uncovers considerably complicate her—and our—portrait of him as a man and a scientist. Have you had any experiences in your own personal or professional life with the fall of a hero, someone you admired who, in one way or another, failed to live up to your expectations? Discuss.
  11. If you were Rosenhan's student and he recruited you to participate as a pseudopatient in the study, would you have done it? Why or why not?


Unless otherwise stated, this discussion guide is reprinted with the permission of Grand Central Publishing. Any page references refer to a USA edition of the book, usually the trade paperback version, and may vary in other editions.

In this engrossing read, journalist Susannah Cahalan untangles the complicated truth behind one of psychology's most widely cited and reprinted studies while tackling broader questions about the very meaning of mental illness.

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Susannah Cahalan's The Great Pretender is a fascinating deep-dive into one of the most influential studies in the history of psychology, Stanford University professor David Rosenhan's 1973 paper "On Being Sane in Insane Places." In an era of growing doubts about the validity of psychiatry, Rosenhan—the "great pretender" of the book's title—undertook to put the discipline to the test with a daring experiment. He and seven other volunteers pretended to be mentally ill and went undercover in institutions across the nation to see whether doctors and staff could tell the difference between the sane and the insane. Apparently, Rosenhan reported in his bombshell study, they could not.

As Cahalan's book explains, Rosenhan and the other "pseudopatients" arrived at a psychiatric hospital complaining of just one vague symptom—hearing voices that said "empty," "hollow" and "thud," language meant to evoke an existential crisis. All eight were admitted and diagnosed with either manic depression or schizophrenia. Although they behaved entirely normally once they were admitted, all eight remained institutionalized for at least a week. In fact, one pseudopatient was hospitalized for a full 52 days. "The facts of the matter are that we have known for a long time that diagnoses are often not useful or reliable, but we have nevertheless continued to use them," Rosenhan concluded. "We now know that we cannot distinguish sanity from insanity."

The study sent shockwaves through the field of professional psychiatry. "It was a landmark study that shook us all—it created a crisis of confidence," Cahalan quotes one psychiatrist as saying. Largely in response to Rosenhan's challenges, the American Psychiatric Association completely revamped its diagnostic manual, replacing the vague psychobabble of the Freudian tradition with itemized checklists and strictly defined criteria meant to standardize diagnoses and preclude the sort of embarrassing mistakes doctors had made in the pseudopatient study.

But while the extent of Rosenhan's influence on the field is clear, it turns out that little else about his story is straightforward. As the book unfolds, it becomes evident that there is yet another layer of meaning to its title—neither Rosenhan nor the details of his study are quite what they appear to be. "The harder I fought to make sense of it, the more I realized that Rosenhan and his study were like quicksand," Cahalan writes. "Whenever you felt that you were on solid ground, the support would fall away, leaving you in the dark muck and sinking fast."

The Great Pretender recounts Cahalan's dogged efforts to pin down the details of the story. It's a task complicated by secrecy: All of the pseudopatients are identified only by pseudonyms, even in Rosenhan's notes. Matching Rosenhan to his pseudonym proves easy, but uncovering the real identities of the other pseudopatients takes on the proportions of a detective case. Fortunately, Cahalan, a former investigative reporter for the New York Post, is both an able sleuth and a gifted writer with a knack for holding the reader's interest.

She tracks down Rosenhan's son, former students, friends, associates, colleagues and secretaries, spending hours on the phone and sending hundreds of emails. She sifts through notes, letters, diary entries, medical records and a 200-page unfinished book manuscript. In the process, she uncovers some troubling discrepancies—details in Rosenhan's published paper that don't seem to square with his notes, numbers that don't add up. Some may be sloppy errors or oversights. Others seem like deliberate attempts to deceive.

Cahalan makes a convincing case that, at the very least, Rosenhan's study was seriously flawed. Yet at the same time, she concludes, his work contains a core of truthfulness. "I believe that he exposed something real," Cahalan writes in her epilogue. "Rosenhan's paper, as exaggerated, and even dishonest as it was, touched on truth as it danced around it." That truth has to do with larger questions about how to draw the line between mental illness and physical disease; about the urgent need to rethink how we treat people with psychiatric conditions; about how the labels we use to describe illness color our perceptions of patients.

These are issues that Cahalan has thought deeply about because of her personal history with an illness that blurred the boundary between the mental and the physical. As a young woman in her twenties, Cahalan was misdiagnosed with schizophrenia after falling ill with autoimmune encephalitis, an inflammatory disease in which the body's immune system attacks brain cells and causes symptoms that mimic those of a mental illness—an experience she chronicled in her first book, Brain on Fire.

Cahalan's personal investment in her topic gives her writing a passion and sense of urgency that is refreshing. In places, however, the book can feel unfocused. "This was not the book I initially intended to write," Cahalan notes in her Acknowledgments. At times, that shows. Cahalan weaves Rosenhan's story into larger digressions on the vexed history of psychiatry, from the horrors of the insane asylums of the past to the anti-psychiatry movement that led to the shuttering of mental institutions across the nation. There is much that is thought-provoking in these discussions. However, the different strands of the book don't always feel like they fit together—as if Cahalan didn't want whatever original research she started out with to go to waste and so decided to throw it all in anyway.

This lack of focus is especially noticeable towards the end of the book, where she discusses today's failed health care system, which all too often funnels the mentally ill into prisons and homeless shelters. While the issues she raises here are tremendously important, they don't connect neatly with the overarching themes raised by the Rosenhan study, which have to do with the validity of psychiatric diagnoses. Perhaps, however, this messiness is fitting for a book about psychiatry, a field where few concepts or categories are neat and tidy.

Reviewed by Elisabeth Herschbach

New York Times
The Great Pretender reads like a detective story, with Cahalan revealing tantalizing clues at opportune moments so we can experience the thrills of discovery alongside her. Her voice is warm and often charming, though she has a weakness for whimsical asides...But such amiability was probably what got some reluctant sources to talk. One man sent her some crucial information while he was in the last stages of pancreatic cancer; another source agreed to an interview at her nursing home just before her 100th birthday. Without Cahalan’s intrepid reporting, the truth of Rosenhan and his paper might have been lost.

Cahalan seems at sea at this end of this book. I think she went in intending to write one kind of book — about a reformer and his crusade to expose the tyranny of psychiatric labels — and then inadvertently ended up writing an exposé about the faulty policing of scientific research papers and the professionals who publish them. The Great Pretender is still worth reading because it illuminates a game-changing moment in the history of psychiatry in the U.S.; it just isn't as satisfying a book as Brain on Fire because it ends in the muddled middle of things.

New York Journal of Books
Cahalan's research is dogged and her narrative riveting, leading us from red herring to clue and back with the dexterity of the best mystery novelists. Then she builds her case like a skilled prosecuting attorney.

Publishers Weekly
Fascinating...Cahalan sets a new standard for investigative journalism...Her impeccable inquiry into the shadowy reality of Rosenhan's study makes an urgent case that the psychological and psychiatric fields must recover the public trust that 'Rosenhan helped shatter.

Kirkus Reviews (starred review)
Cahalan draws a vivid and critical picture of Rosenhan and the ramifications of his most prominent work. A well-told story fraught with both mystery and real-life aftershocks that set the psychiatric community on its ear.

Library Journal (starred review)
[B]rilliant...Indispensable reading for aficionados of Cahalan's Brain on Fire and Merve Imre's The Personality Brokers.

Author Blurb Ada Calhoun, author of St. Marks Is Dead and Wedding Toasts I'll Never Give
Breathtaking! Cahalan's brilliant, timely, and important book reshaped my understanding of mental health, psychiatric hospitals, and the history of scientific research. A must-read for anyone who's ever been to therapy, taken a brain-altering drug, or wondered why mental patients were released in droves in the 1980s. And a thrilling, eye-opening read even for those who thought they weren't affected by the psychiatric world.

Author Blurb Andrew Scull, author of Madness in Civilization: A Cultural History of Insanity
The Great Pretender is an extraordinary look at the life of a Stanford professor and a famous paper he published in 1973, one that dramatically transformed American psychiatry in ways that still echo today. The book is fast-paced and artfully constructed—an incredible story that constitutes a tribute to Cahalan's powers as both a writer and a sleuth.

Author Blurb Luke Dittrich, New York Times bestselling author of Patient H.M.
The Great Pretender is a tight, propulsive, true-life detective story which somehow also doubles as a sweeping history of our broken mental health-care system...It is an amazing achievement, and there is no question it will go down as the definitive account of one of the most influential psychology experiments of all time.

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Fake Science

The Stanford Prison Experiment In The Great Pretender, former New York Post investigative reporter Susannah Cahalan uncovers evidence that Stanford University psychologist David Rosenhan fabricated at least some of the details in his famous 1973 paper "On Being Sane in Insane Places."

If true, this certainly wouldn't have been the only time a high profile researcher's work has turned out to be flawed or even downright fraudulent. A particularly brazen example is that of repeat offender Diederik Stapel, a former professor of social psychology at Tilburg University in the Netherlands. Stapel rose to prominence in his field with a series of studies that gained media attention around the world. One study purportedly showed that carnivores are more selfish than vegetarians. Another claimed to show a correlation between dirty, trash-filled environments and racist attitudes. His fame came crashing down in 2011, however, when the university determined that he had been faking his data. So far, a whopping 58 of his publications have been retracted because of fraudulent research.

An even more famous example hits closer to home—in fact, it involves one of Rosenhan's own colleagues at Stanford University, psychology professor Philip Zimbardo. The so-called Stanford Prison Experiment, conducted in 1971, was supposed to test how social roles affect people's behavior. Zimbardo recruited 24 students and randomly assigned them to be either guards or prisoners in a simulated prison on the Stanford campus. The results were shocking, apparently showing that ordinary people could behave with extraordinary cruelty in situations of power.

The prison experiment turned Zimbardo into an instant academic celebrity. The study generated big headlines, and to this day it remains one of the most famous psychological studies of all time, a staple of undergraduate psychology courses. Like Rosenhan's pseudopatient study, Zimbardo's experiment became a catalyst for professional reforms, prompting the American Psychological Association to revise its ethical guidelines for research on human subjects precisely to prohibit the type of research Zimbardo had conducted.

Also like Rosenhan's study, Zimbardo's prison study is now under a cloud of suspicion after new evidence has called into question its scientific integrity. In 2018, journalist Ben Blum published a thoroughgoing exposé based on interviews with study participants and previously unpublished recordings from the experiment. These sources provide convincing evidence that the "guards" were coached to behave more aggressively and the "inmates" were putting on an act—in other words, that the experiment was a fake.

Research fraud is not limited to the field of psychology. Allegations of academic misconduct are rampant across the sciences, from stem-cell research to genetics to food science. In fact, Richard Horton, editor of the prestigious medical journal The Lancet, caused a splash in 2015 when he suggested that perhaps as much as half of the world's scientific literature may be untrue. "Afflicted by studies with small sample sizes, tiny effects, invalid exploratory analyses, and flagrant conflicts of interest, together with an obsession for pursuing fashionable trends of dubious importance, science has taken a turn towards darkness," he wrote.

The consequences of research fraud can be far-reaching and devastating. In 1998, a British doctor named Andrew Wakefield published research that suggested a link between autism and the measles, mumps and rubella (MMR) vaccine, a routine vaccination given to millions of children around the world every year to prevent these highly contagious diseases. Wakefield's research was later found to be fraudulent, and the journal retracted his paper, but not before it helped to fuel a vocal anti-vaccine movement still raging today. As vaccination rates drop, cities around the world have seen increased outbreaks of infectious diseases. Indeed, in 2019, the World Health Organization listed vaccine hesitancy, the decision to forego life-saving vaccines despite their availability, as one of "ten threats to global health."

The Stanford Prison Experiment, via Teodorvasic97/Wikimedia Commons

Filed under Medical, Science and Tech

By Elisabeth Herschbach

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