A Conversation in Critical Psychiatry with Susannah Cahalan.
CONVERSATIONS IN CRITICAL PSYCHIATRY
Susannah Cahalan is an award-winning American journalist and author. She is best known for her New York Times bestselling memoir Brain on Fire: My Month of Madness (2012), a narrative account of her struggle with anti-NMDA receptor encephalitis, a rare autoimmune disease that often masquerades as psychiatric illness. Indeed, she was misdiagnosed initially as suffering from bipolar disorder and schizoaffective disorder before a correct diagnosis was made by a thoughtful and empathic neurologist. Her account of illness has been of great interest to psychiatrists as well as other medical specialists, and she spoke at the opening session of the 2017 annual meeting of the American Psychiatric Association.
Her second book is The Great Pretender: The Undercover Mission That Changed Our Understanding of Madness. It is an in-depth investigation into the famous Rosenhan experiment, the results of which were published in 1973 in a paper titled “On Being Sane in Insane Places”1 in the journal Science.
In Rosenhan’s study 8 healthy volunteers feigned hearing voices to gain admission to 12 psychiatric hospitals. Once admitted, the “pseudopatients” acted like their normal selves, but once labelled as psychotic even their normal behaviors were seen through a pathological lens by the hospital staff. Nearly all were diagnosed with schizophrenia and forced to take antipsychotic medications.
The study challenged the reliability of the notion of mental illness and highlighted the dehumanizing conditions of psychiatric hospitals, and it received tremendous attention throughout the country. Cahalan’s research for the book initially started off as a celebration of the study, however, the more she investigated, the more contradictions and discrepancies she found between the published paper and Rosenhan's unpublished documents as well as other study related materials. For instance, Rosenhan was the first pseudopatient in his own study and his medical records reveal that he had not merely feigned auditory hallucinations but had also reported suicidal ideation and behaviors such as putting a copper pot over his head. There were also various odd numerical inconsistencies in data. Added to this, despite years of searching, Cahalan was only able to identify and locate two other participants of the experiment, one of whom had in fact had a positive experience of his psychiatric hospitalization, but his experience was excluded from the study by Rosenhan.
After uncovering all this, Cahalan began to contemplate the possibility that some pseudopatients mentioned in the study may never have existed and the corresponding data may have been fabricated by Rosenhan. In addition to offering an in-depth investigation of the experiment and an illuminating discussion of the impact the published paper has had on psychiatry, The Great Pretender also provides a nuanced overview of psychiatry’s current struggles, going into issues such as the lack of validity and reification of DSM diagnoses, and the consequences of deinstitutionalization in USA which, coupled with lack of community care services, has resulted in a mass movement of individuals with serious mental illness from hospitals to prisons. Over-all it's a highly thought-provoking book, and I'm glad Ms Cahalan agreed to shed more light into her insights through this exchange with me.
Aftab: “If sanity and insanity exist, how shall we know them?” It’s clear that you were fascinated by this question posed by Rosenhan. Years of research and a book later, are you any closer to answering this question?
Cahalan: Oh, I don’t think so. Something I learned was the idea of “sanity” and “insanity” (of course inappropriate terms) being fixed or rigid conditions is just not the case. We all, or at least many of us, slide over these lines during the course of our lives.
Aftab: Based on the evidence you have uncovered do you think Science should retract Rosenhan's paper?
Cahalan: It has been so long now, what good would that do? Instead, I would love for a conversation to develop about how we allowed this to happen, what can we do with this information to move forward in a more honest direction.
Aftab: Is it possible that we may be overestimating the impact of Rosenhan's paper on subsequent history of psychiatry? The study was sensational, it was flashy, it got a lot of press, it provided a lot of ammunition to psychiatric critics, but even if the Rosenhan paper had never been published, major events such as deinstitutionalization and Spitzer’s development of DSM-III would still have happened. Andrew Scull, for instance, writes: “deinstitutionalization was driven in great measure by fiscal concerns, and in the United States by the ability to transfer costs between levels of government. And it suggested that the rhetoric of reform masked what was an emerging policy of malign neglect.”2(p3) I guess we can say that Rosenhan’s study provided fuel for the “rhetoric of reform” but to what extent was it responsible for any substantial change?
Cahalan: I think that you always have to follow the money—you’re correct. But I do think that the rhetoric of change became so extreme and so ham-fisted and I think that this study contributed to that extreme reaction. I also think that once you trace psychiatry’s reaction to the study—the embarrassment, the subsequent influence it had on the creation of the DSM, the effect on the growing distrust that the general public had about the field—I think when you stack all these elements up then you see the inflated influence that this study had and continues to have.
Aftab: What made you relate to Rosenhan’s study on a personal level? To be honest, I have not fully appreciated why you thought of yourself as a “modern day pseudopatient” when you heard about Rosenhan’s study. Your case of misdiagnosis—mistaking autoimmune encephalitis for schizoaffective or bipolar disorder—was very different from the scenarios of feigned psychotic symptoms orchestrated by Rosenhan.
Cahalan: I considered myself a modern pseudopatient in the way that my diagnosis tested the validity of psychiatry’s diagnoses. If someone who had the same presentation as I did was misdiagnosed for two years with schizophrenia, when she in fact had autoimmune encephalitis, what does that say about our understanding of schizophrenia? Rosenhan’s study revealed psychiatry’s limitations and I think that my story (or rather the story of my mirror image, the woman misdiagnosed) does, too. I also felt a difference in treatment between when my symptoms were caused by a “mental” condition, versus a “physical” one—and this was explored, though is often not focused on, in the Rosenhan’s study and it really struck a nerve with me.
Dr Aftab and Ms Cahalan have no conflicts of interest concerning the subject matter of this article.