Sunday, October 11, 2020

Book Review of The Great Pretender by Susannah Cahalan

 



 This is the second book review of this book on my blog.  I was asked by the editor of The Philosophy Special Interest Group of the Royal College of Psychiatrists - Dr. Abdi Sanati to write another review for this newsletter.  I looked at it as an opportunity to cover some things I may have missed in the first review.  I agreed to not put it on my blog until the newsletter came out.  The latest review follows:

The Great Pretender (1) is written as an exposé of a famous experiment conducted by Rosenhan (2) that purported to discredit psychiatric diagnoses.  The original article was published in in the journal Science in 1973.  Whether you we aware of the original article or not depended on when you were trained and the extent to which you followed that literature. I was just finishing my undergraduate degree at that point and did not complete psychiatric training until 1986.  We had a community psychiatry seminar for 6 months during my last year that was taught by some of the innovators in the field.  It was common to analyze and discuss controversial papers of the day.  A good example would have been the paper that suggested that people with schizophrenia had a much better outcome in the developing countries (3).  At no point did we hear about or discuss the Rosenhan paper.  In fact, for the next 24 years the paper never came across my desk. It was only when I started writing a psychiatry blog that I realized it played a major role in psychiatric criticism and antipsychiatry rhetoric.  At that point, I read the paper and the associated criticism and concluded independently that the methodology was extremely weak and that pseudopatients were not really a good test of medical or psychiatric diagnoses.  I thought it would just fade away on that basis.

I was as surprised as anyone when I heard that investigative reporter Susannah Cahalan had written a book about this experiment, the author, and the methods used.  The investigation begins with a visit to one of Rosenhan’s former colleagues. This colleague shows her a stack of anti-psychiatry books that he thinks “were the key to his thinking”. There is also a file labeled “pseudopatients” that contain the names of all eight pseudopatients and details surrounding their hospitalizations. All the names or aliases and the hospital names had also been changed.

Cahalan’s approach is to write about three parallel subjects.  The most thorough and objective analysis is about the pseudopatient experiment. She covers everything from the available remaining data and the problems with it to the likelihood that the experiment actually occurred the way it was described in the Science paper.  The second broad subject was a character study of Rosenhan.  How did people describe him?  What was he like? Did people especially his colleagues believe that he conducted the experiment.  And finally, the book is a vehicle for Cahalan to comment on psychiatry.  She comes to this work with the direct experience of having experienced autoimmune encephalitis and writing about that experience in the book Brain on Fire.

Reading the original paper is a good starting point for understanding the book.  If you do pull up that article, a few details are immediately evident. The author begins the introduction using the terms “sane” and “insane” as though this is technical language used by psychiatrists. That use of language is interesting because he is listed as a professor of both psychology and law at Stanford.  Since the days of my training, insanity is a strictly legal term and it is without meaning in psychiatry.  The use of these legal terms allows him to point out the unreliability of the “sane”-“insane” dichotomy based on expert witnesses disagreeing in adversarial court hearings.  That has nothing to do with the clinical diagnoses in psychiatry. To what extent were formal diagnoses used in 1973? Rosenhan refers to the Diagnostic and Statistical Manual in the body of his paper.  Interestingly, the authors of my community psychiatry paper (3) reported on the 2-year follow-up of patients from the International Pilot Study of Schizophrenia (1973) and concluded that schizophrenia could be reliably diagnosed so that international comparisons and follow up were possible.  A sanity metric during the same time frame is crude by comparison. There are many additional examples of a lack of objectivity toward the issue of psychiatric diagnosis in the introductory section of the paper (paragraphs 4-7) and the discussion. Excellent critiques of the scientific merit of the paper were available at the time most notably by Robert Spitzer. 

The author describes his pseudopatient experiment as consisting of 8 people – three women and four men of various occupations. Cahalan identifies Rosenhan as pseudopatient number 1.  Twelve hospitals in various locations were chosen.  One was a private hospital.  Pseudopatients were supposed to call the hospital, present for an intake appointment, and then complain that they were hearing voices. When asked to elaborate they were supposed to say the voices were unclear except for the words “empty”, “hollow”, and “thud”.  Rosenhan provides a rationalization for this symptom choice about how on the one hand these symptoms were supposed to have existential meaning and yet there was not a single report of existential psychosis in the literature. Once admitted, the patient was supposed to cease simulating any symptoms and give their actual social history and behave “normally”. They were to take notes and be as cooperative as possible to get discharged. The length of stay was 7-52 days with an average of 19 days. 

Rosenhan also claims in the body of this paper that a second experiment occurred at a “research and teaching hospital” where the staff were informed ahead of time that pseudopatients were going to seek admission during a 3-month period.  Staff were asked to rate whether a patient was a pseudopatient or not.  Of 193 admissions during that time 41 were ranked as likely being a pseudopatient. In this case, Rosenhan did not send any pseudopatients to the facility and claims this false experiment represents “massive errors”.  

One of the elements of the paper that is really never discussed is it structure. The primary data points were eight pseudopatients were admitted and discharged from psychiatric hospitals without being discovered. The secondary data points were a series of observations of the staff that is largely unstructured, highly anecdotal, and contrasted with other situations that seem to lack relevance. The bulk of Rosenhan’s discussion is judgmental and there is no discussion of the limitations of the experimental design or data. Instead the author leaps to clear-cut conclusions that are in some cases only peripherally connected to the data.

Cahalan expends a lot of effort to try to identify and find the pseudopatients and ask them what their experience was like. She locates the records of Rosenhan’s own admission as a pseudopatient. The first real sign of a departure from the research protocol described in Science, occurs in Rosenhan’s recorded admission interview. He recited the voices script and said the symptoms had been going on for four months. He was admitted on an involuntary commitment and discharged nine days later. The hospitalization ended in 1969 - four years before the article came out. The first major sign that the experiment described in Science was not quite the way it was described in the paper occurs when Cahalan looks at the record of the admission interview. In addition to the vague description of hallucinations, Rosenhan states that he believes he can “hear what people are thinking”, that he has tried to “insulate out the noises by putting copper over my ears”, and that he has “suicidal thoughts”. These are all more serious psychiatric symptoms than factitious “existential hallucinations”. Rosenhan also altered his occupational history during one assessment to say that his psychiatric illness led him to give up a job in economics 10 years earlier. At one point he stated that his wife is probably unaware of how useless he felt and that “everyone would be better off if he was not around”.  Considering the seriousness of his fake history, I was surprised that he was discharged in 9 days.

What about the other 8 pseudopatients?  Cahalan was able to locate two – only one of whom was part of the research protocol and shared Rosenhan’s experience. The second patient started out as a psychologist and co-authored a couple of papers with Rosenhan. The author was surprised at how little preparation went into the pseudopatient role. Patient 2 was taught to cheek medications and spit them out. He was reassured by Rosenhan that he had filed a writ of habeus corpus to get him out of the hospital at any time.  When Cahalan tracked down that attorney who said the writs had been discussed but never prepared and that he did not consider himself to be “on call” to get pseudopatients immediately released. Patient 2 was also in the hospital for 9 days and basically released upon his request.  There was no reason for discharge given on the official form but he recalled a psychiatrist approaching him prior to discharge and making remarks to suggest that there was still some concern that he may still be suicidal. Despite that concern there was apparently no discharge plan.

The third pseudopatient discovered by Cahalan was interesting in that he was eliminated from the original protocol and not counted by Rosenhan.  Cahalan discovered that the ninth uncounted pseudopatient was a research psychologist named Harry Lando.  Dr. Lando is well represented in the smoking cessation literature and had published an article in the Professional Psychologist (4) stressing the positive aspects of his pseudopatient experience.  His observations were in direct contrast to Rosenhan and he states as much in the observation: “My overall impressions of the hospital are overwhelmingly positive. The powerlessness and depersonalization of patients so strongly emphasized by Rosenhan simply did not exist in this setting.” He goes on to suggest that using better hospitals as models may be a way to improve the quality of care.  He also questions the ethics of placing pseudopatients in “already overcrowded and understaffed institutions”.  Lando does express a concern about the diagnostic process since all three pseudopatients received diagnoses of schizophrenia.

The key question about why the data of the ninth pseudopatient was omitted from the original paper is answered as a footnote number 6 on page 258 of the original paper:

“Data from a ninth pseudopatient are not included in this study because although his sanity went undetected, he falsified aspects of his personal history. Including marital status and parental relationships. His experimental behaviors therefore were not identical to the other pseudopatients.” 

That footnote is exactly what Rosenhan did when he was admitted as pseudopatient 1 as documented in the existing medical record.  Rosenhan’s lapses were discovered and discussed by Cahalan and are included in the following table.

 

 

Rosenhan’s Lapses

 

1.  Data was improperly recorded. The two pseudo-patients interviewed by Cahalan pointed out that their durations of stay in the hospital were not correctly recorded.

2.  His private notes indicated strong influence by Szasz and Laing. Prior to the pseudopatient experiment he assigned work to his students describing psychiatric hospitals as “authoritarian”, “degrading”, and “illness-maintaining”.

3.  He told a pseudopatient that a writ of habeas corpus was prepared and an attorney was on call to get them out of the hospital if necessary. That was not true.

4.  Professional and possibly “unethical” mistakes (p. 173) about length of stay in pseudopatient number two (7 days versus 8) and pseudopatient number 9 (26 days versus 9 days), patient population in the hospital 8,000 vs 1,510), the specific discharge diagnoses of pseudopatients 2 and 9, and details of staff behavior on the ward.

5.  Sending a pseudo-patient into a hospital that was in disarray because it was closing.

6.  Rosenhan at one point lied in correspondence to Spitzer about his stay in the hospital and said it was part of a “teaching exercise” that had nothing to do with research(p. 180). Cahalan describes this as “an outright lie”.

7.  During his admission Rosenhan “goes off script” and gives far more fabricated symptoms and history than the “empty, hollow, thud” existential hallucinations he described in the protocol. Additional symptoms suggest a significant psychiatric disorder. He describes suicidal ideation and significant conflict with his employer – the same falsification of personal history that led him to eliminate the data of the ninth pseudopatient.

8.  Rosenhan fabricated an excerpted portion of the medical record and both the original record and the excerpt are published for A - B comparison on page 190. Cahalan concludes that the facts “were distorted intentionally by Rosenhan himself.”

9.  Inadequate preparation of the research subjects. Patient 2 ended up taking a dose of chlorpromazine and patient 9 was given liquid chlorpromazine so it could not be cheeked as instructed.  Pseudopatient 9 estimated the preparation time for hospital admission by Rosenhan was about 15 minutes.

10.  When patient 9 was eliminated from the study none of the data about pills dispensed or staff contact time in the paper was changed.

11.  In an National Public Radio program that aired before the publication of his paper (December 14, 1972) he misstated his time in the hospital as a pseudopatient (several weeks versus 9 days) and the amount of medications dispensed to pseudopatients (5,000 pills versus 2,000 pills) while building to the conclusion that psychiatric hospitals are non-therapeutic and should be closed (p.234)

12.  Pseudopatient 9 commented that what Rosenhan had written about him in the experiment was “total fiction” (p.269)

13.  Rosenhan did not complete a book about the pseudopatient experience, despite an advance from the publisher, a subsequent lawsuit from the publisher and what is described as plenty of publicity around the time the paper came out in Science. He also never published on the topic again (p. 295). 

 

Rosenhan did continue to publish a description and discussion of his study in the text Abnormal Psychology (5). The discussion emphasized that the simple hallucinations described with nothing else being unusual would have been detected outside of a hospital. In the context dependent setting it was not.  In other words – he maintained one of the same themes as in the original paper.

One of the areas that really piqued my interest was why Science published this paper in the first place.  Cahalan got the opinion from an academic psychologist that the peer review in a non-psychology journal would be less rigorous.  When she approached the journal she was told that records were confidential and that they were not kept back that far.  Accessing Retraction Watch (6) demonstrated that there has been a total of 120 papers retracted from Science since 1963. The reasons for the retractions are given as data errors, errors in methods, result errors, errors in conclusions, errors due to contaminated experiments, falsification/fabrication of data, irreproducible results, misconduct by the author, ethical violations by the author, investigation by a company, institution, or third-party.  Only three of these papers had anything to do with psychiatry and those papers were primarily about the neurobiology of the brain. Cahalan’s investigation suggests that several of the reasons for retraction have been met.

Apart from the details of the Science paper, Cahalan also does a character study of Rosenhan. We learned that his brother had bipolar disorder and did well on lithium. It was suggested that was why he became interested in psychology. He was described as bright and charismatic. He was clearly influenced by the work of anti-psychiatrists and assigned work to his students that “describe psychiatric hospitals as authoritarian, degrading, and illness maintaining among other terms”. (p 73).  The title of the book highlights Rosenhan’s characteristics as a raconteur who would occasionally pretend to be someone who he was not. His son described an incident in New York City where he introduced himself as a professor of engineering at Stanford in order to get a tour of an interesting construction site with his son. In another scene he is joking about the wig he wore to get into the psychiatric hospital.  Cahalan finds the admission photo showing that he is bald without a wig. The people who knew him the best – acknowledge the he was difficult to know and just like Rosenhan’s arguments about psychiatric diagnoses being context dependent – his personality was as well.   

Apart from academic books about the history of psychiatry – most books review sensational history and arguments that by their very nature diminish the field.  This book is intermediate in that tone with those arguments interspersed through the investigative journalism about Rosenhan. They touch on the familiar themes of biological reductionism as opposed to a clinical psychiatry where patients are actually listened to with no reference to how clinical psychiatrists really practice every day. Some psychiatrists end up being caricatured and some are acknowledged as being highly motivated and humanistic. I am probably far too invested in clinical psychiatry and the good I have seen done to tolerate a journalist’s approach to the field.  I give Cahalan credit for touching on the current situation that has resulted in severely rationed care and the transinstitutionalization of patients in jails.  The overall concept that psychiatrists have little to do with the systems of care that are controlled by businesses and governments is not emphasized even though it was recognized as a problem by two of the pseudopatients.  She also points out that the pseudopatient experiment is irrelevant to psychiatric practice today but her resounding theme throughout the book was that it was extremely relevant irrespective of what actually happened.  The book also gives Rosenhan too much credit for psychiatric criticism. Like many books of this nature – there is little to no evidence that psychiatrists might be their own best critics or that outrage might be a legitimate reaction to outrageous criticism rather than defensiveness.

 In conclusion The Great Pretender identifies very specific problems with the original Rosenhan paper that have been listed in the narrative and table in this report. He gained initial celebrity status from the study and signed a book contract. Even though he was given an advance on the book and wrote a manuscript he never produced a book.  The author suggests that may have been due to the fact that Robert Spitzer was aware of Rosenhan’s nonadherence to the research protocol during his admission. As Rosenhan withdrew from the pseudopatient limelight he also stated that none of his research should lead to the conclusion that psychiatric hospitals were unnecessary and that represented a complete turnaround form earlier statements.

The controversy, the original paper and the book could be the subject of seminars in the history or philosophical aspects of psychiatry. It touches on a number of themes primarily the ethics of research and how it should be conducted. It also touches on psychiatric criticism and may be useful in discussing how future generations of psychiatrists can prepare to deal with it. 

 

George Dawson, MD, DFAPA

 

References:

 

1: Susannah Cahalan.  The Great Pretender. Grand Central Publishing. New York, 2019. 382 p.

2: Rosenhan DL. On being sane in insane places. Science 1973 Jan 19;179(4070):250-258.

3: Sartorius N, Jablensky A, Shapiro R. Cross-cultural differences in the short-term prognosis of schizophrenic psychoses. Schizophr Bull. 1978;4(1):102113. doi:10.1093/schbul/4.1.102

4: Lando, H. A. (1976). On being sane in insane places: A supplemental report. Professional Psychology, 7(1), 47–52. https://doi.org/10.1037/0735-7028.7.1.47

5: David E. Rosenhan, Martin E.P. Seligman. Abnormal Psychology- 2nd Ed. WW Norton and Company, New York City, 1984, 1989; p 181-183.

6: Retraction Watch: Retractions from Science.  Accessed on May 22, 2020: http://retractiondatabase.org/RetractionSearch.aspx#?jou%3dScience


Supplementary:

The review was written for Philosophy Special Interest Group of the Royal College of Psychiatrists September 2020 newsletter and it can be found starting on page 8.

 

 

 

 

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