The key ideas

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

Susannah Cahalan, 2019

In 1973, eight healthy people complained of hearing voices, and every one of them was admitted to a psychiatric hospital. David Rosenhan's article about the experience turned psychiatry upside down. Journalist Susannah Cahalan, who was nearly written off as mentally ill herself, set out to find the people in the experiment and discovered that much of the famous story does not match the records.

Who it is for

For anyone who wants to understand how psychiatric diagnoses are made and why it is so hard to be sure of them. And for everyone who loves investigations and wants to know how to test famous scientific stories.

We are never only one thing: the insane are not always insane, and the sane are not always sane.

The month she cannot remember

In 2009, Susannah Cahalan was twenty-four and working as a reporter at the New York Post. First the world began to seem too bright and too loud. Then came paranoia, insomnia and hallucinations, and after that seizures in which she screamed and thrashed. One by one, doctors blamed exhaustion, partying and alcohol withdrawal, and a psychiatrist suspected bipolar disorder. Later another diagnosis came up: schizoaffective disorder.

She was saved by a neurologist, Souhel Najjar. He found the real cause: encephalitis, a condition in which the immune system attacks the brain itself. Cahalan recalls that while she carried a psychiatric diagnosis, people treated her coldly, as if it were her own fault. As soon as the illness was recognized as neurological, her care got noticeably better. She wrote about this in her first book, Brain on Fire.

But one question would not let her go: how do you tell an illness of the brain from an illness of the mind, and why are some patients pitied while others are feared? Looking for an answer, Cahalan came across a famous 1973 experiment that seemed to describe her own story. Healthy people pretended to be ill, and the doctors believed them.

At first she simply wanted to write about the people in that experiment. Instead she spent years investigating and found that the story of the famous study itself does not match the records. This book is about how one article changed psychiatry, what in it turned out to be false, and what still holds true.

Three words that opened the hospital doors

In January 1973, the journal Science published an article called "On Being Sane in Insane Places". Its author, David Rosenhan, a professor of psychology and law at Stanford University, described a bold experiment. Eight people with no mental illness at all went to psychiatric hospitals. According to Rosenhan, they included three psychologists, a pediatrician, a psychiatrist, a painter, a housewife and a psychology graduate student.

Each of them made the same complaint: they heard a voice saying the words "thud", "empty" and "hollow". The only things they were allowed to make up were their names and jobs. All eight were admitted. Seven were diagnosed with schizophrenia and one with manic-depressive psychosis.

Once inside, these people, whom Rosenhan called pseudopatients, behaved completely normally and said the voices had gone. But getting out was not easy. In twelve hospitals across five states, they stayed anywhere from seven to fifty-two days, nineteen on average. Nearly all of them were discharged with a diagnosis of "schizophrenia in remission". Remission means the illness has not gone away, only quieted down.

The idea had a long history behind it. In 1887, the journalist Nellie Bly pretended to be ill and got herself committed to the asylum on Blackwell's Island in New York to expose what went on there. Cahalan, a journalist herself, places Rosenhan in this tradition: someone undercover gets into a place where outsiders are not allowed.

Read in Livria

About the author

Susannah Cahalan is an American journalist and a former New York Post reporter. In 2009 she survived autoimmune encephalitis and told the story in her bestseller Brain on Fire.

All books by this author: Susannah Cahalan

Terms from the book

  • Stanford
  • DSM
  • remission
  • Schizophrenia
  • Schizoaffective disorder: A psychiatric diagnosis in which a person has signs of psychosis together with severe mood swings.
  • Najjar: Souhel Najjar, an American neurologist. He gave Cahalan the right diagnosis when other doctors could not find the cause of her condition.
  • Encephalitis: Inflammation of the brain. Cahalan had anti-NMDA receptor encephalitis: the immune system mistakenly attacks proteins on nerve cells, and this can look like a mental disorder.
  • Science: One of the most respected scientific journals in the world. Rosenhan's article appeared in it in 1973.
  • Rosenhan: David Rosenhan (1929 to 2012), an American psychologist, a professor at Stanford University and the author of the pseudopatient experiment.
  • Manic-depressive psychosis: The old name for the disorder now called bipolar disorder: periods of elation alternate with periods of severe depression.
  • Pseudopatient: A word from Rosenhan's article: a healthy person who pretended to be ill in order to get into a psychiatric hospital.
  • Bly: Nellie Bly, an American journalist. In 1887 she pretended to be ill to get into the asylum on Blackwell's Island and describe how people were treated there.
  • Blackwell: Blackwell's Island, an island in the East River in New York, home to a large asylum for the insane in the nineteenth century. Today it is called Roosevelt Island.
  • Spitzer: Robert Spitzer, an American psychiatrist and the chief critic of Rosenhan's article. He led the creation of the DSM-III manual.
  • Deinstitutionalization: The closing of large psychiatric hospitals and the move of patients to life in the community. In the United States it took place in the second half of the twentieth century.
  • Doubleday: A major American publisher. It signed a contract with Rosenhan for a book about the experiment, which he never finished.
  • Haverford: Haverford State Hospital, a psychiatric hospital in Pennsylvania where Rosenhan was admitted under a false name in 1969.
  • Bartlett: Frank Bartlett, the psychiatrist at Haverford State Hospital who admitted Rosenhan in 1969.
  • Lando: Harry Lando, an American psychologist. As a graduate student at Stanford, he became the ninth pseudopatient, whom Rosenhan left out of the article.
  • Underwood: Bill Underwood, a Stanford graduate student and one of the two experiment participants Cahalan managed to find.

All terms

Similar books