What I'm reading: The Great Pretender .




The Great Pretender by Susannah Cahalan sets out to catalogue the centuries-old struggle to define mental illness, diagnose and treat it.

Now, as we come to terms with the impact of lockdown and isolation on our collective mental health, it resonates even more powerfully.

The scaffolding of the book is a research project by psychologist David Rosenhan in which he and other sane individuals persuaded psychiatrists to admit them into asylums to observe the psychiatric diagnosis in each case and examine whether this was truly an objective and scientific process.

All but one were diagnosed with schizophrenia in remission, leading Mr Rosenhan to claim “we cannot distinguish the sane from the insane in psychiatric hospitals”.

That they were able to do this with minimal training was astounding in its own right, but the treatments they had to undergo shone a spotlight on one of the less fashionable areas of medicine.

The impact of the Rosenhan paper, when published in 1973, was immediate and long lasting: mental health diagnosis techniques changed and asylums were closed.

And yet, as the book explains, it seems as if most of the evidence was made up to prove a conclusion that was written before the results were either collected or invented.

The temptation is to believe that our present is at a pinnacle of rational understanding and that our predecessors were ignorant, misguided or both.

But lest we feel tempted to cast the first stone, we continue to identify new problems which then become epidemics. For example, childhood bi-polar diagnoses multiplied 40 times between 1994 and 2002. The list of our current fixations and treatments is long.

Returning to the long-term consequences of the Rosenhan paper is to consider how these days the mentally ill are kept out of sight now there are very few shelters. A fair number seem to be in prison.

This is a book that poses perennial issues that are very much in focus in this extraordinary year of crisis; what defines normal behaviour, the fallibility of belief, and are treatments effective or mere quackery? Misjudgements happen because we are predisposed to fill in unknowns with theories and disregard anything that does not support our opinions. Logic is often in remission at times of stress.

As governments interact with academics in an attempt to understand and control this disease, the gaps in understanding are clear. Yet uncertainties have to become certain when speaking at a lectern.

An additional challenge is an analysis of research papers in many areas indicates that a substantial minority contain invented results or results that are simply untrue. This is worrying given that we closed the global economy this year and are now trying to safely restart it.

The Great Pretender was written to interest readers in the history of mental illness, but through the lens of our current health preoccupations, it has become much more.