Friday 24 January 2020

The Great Pretender: Brain on Fire author tackles 'flawed and arbitrary' nature of psychiatry and diagnostics

Psychology: The Great Pretender

Susannah Cahalan Canongate, hardback, 400 pages, €23.79

Bloodhound pursuit of truth: Susannah Cahalan
Bloodhound pursuit of truth: Susannah Cahalan
The Great Pretender by Susannah Cahalan
Stella O'Malley

Stella O'Malley

Cahalan shines a welcome light on the many flaws in our current psychiatric care approach in this book. The opening pages powerfully set the scene; David Lurie, patient #5213, has been admitted to hospital for the first time with a diagnosis of schizophrenia, schizo-affective type because he reports hearing voices. It soon emerges that David is a fake; he doesn't hear "thud, empty, hollow" noises and he has gained entry into this psychiatric hospital under false pretences.

It is as a direct result of her own experiences that Cahalan was inspired to present a comprehensive analysis of our understanding of psychiatry. When Cahalan was 24, her life was devastated by an illness that was initially misdiagnosed as possible bipolar disorder but then shifted to a diagnosis of schizo-affective disorder. Cahalan was eventually correctly diagnosed with autoimmune encephalitis whereupon she received the appropriate treatment and made a full recovery. Although she is considered a success story, Cahalan is aware that there are many others, just like her, who were not so lucky and remain misdiagnosed and receiving inappropriate care.

Cahalan has already catalogued this experience in 2012 in her memoir Brain on Fire: My Month of Madness and her latest book focuses instead on what is the "flawed and arbitrary" nature of psychiatry and diagnostics. This book reads like a riveting detective story as Cahalan becomes like a bloodhound in her pursuit of the truth behind Dr David Rosenhan's 1973 seminal paper 'On Being Sane in Insane Places'.

Rosenhan was a warm, charismatic character and yet he is also puzzling. The premise of his study was that eight 'pseudo-patients' gained entry into various psychiatric hospitals and reported back on their findings. According to Rosenhan, it turned out that doctors could not tell the difference between the sane and the insane and that psychiatric hospitals "make the sick sicker". As the book progresses, the reader eventually learns of the litany of falsehoods that shadow Rosenhan's work. Cahalan steadfastly follows every lead - even going as far as hiring a private detective in her bid to find the various participants of the study. What she finds is a mess of obfuscation, conjecture and fraudulence.

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Although Rosenhan's study was hailed as an influential paper that shaped the DSM, the bible of psychiatrists worldwide, Rosenhan ultimately sidestepped his most prestigious study and neglected to capitalise on its potential. It seems telling that even though Rosenhan had written 200 pages of a proposed book about the study, and his publishers Doubleday were very supportive and encouraging, eight years later Doubleday eventually sued Rosenhan who couldn't - or wouldn't - produce the finished manuscript. Nonetheless Cahalan points out that although Rosenhan's methods were unreliable, "Maybe it's as Chief Bromden says in One Flew Over the Cuckoo's Nest: 'It's the truth even if it didn't happen'."

Cahalan identifies this era as a pivotal point in modern psychiatric treatment. Psychologists such as RD Laing and Thomas Szasz challenged the mental health practices of the day, while Ken Kesey's One Flew Over the Cuckoo's Nest, first published in 1962, shaped many lay-people's attitudes to psychiatric drugs. The subsequent film, released in 1975, was the third-highest-grossing film in the US. The anti-psychiatry movement promoted the idea that these hospitals were ran by blindly arrogant doctors who had a delusional level of certainty about the drugs they prescribed. The 'Stanford Prison Experiment', led by the psychology professor Philip Zimbardo at Stanford University in 1971, was another part of the same narrative although Zimbardo's prison experiment has since been criticised as unscientific. Now, as a result of Cahalan's work, Rosenhan's study is also called into question.

Cahalan captures not only the details and the complexities surrounding academic fraud but also the far-reaching consequences of hubristic and unsound studies. The destructive impact of Andrew Wakefield's paper that fraudulently links vaccines with autism is well-known, however, Cahalan argues succinctly the Rosenhan's paper had even further-reaching consequences as this study shattered the public's trust in psychiatry.

It is arguable that this atmosphere of distrust is well-earned as Robert Whitaker's more recent Anatomy of an Epidemic, describes how poorer countries such as India and Nigeria have much better outcomes for schizophrenia than the US or other rich countries - and yet only 16pc of patients in the poorer countries are regularly maintained on anti-psychotic medications. However, an unfortunate consequence of the anti-psychiatry movement is that there are 90pc fewer psychiatric beds available in the US today compared to 1963 and a "shadow mental health system" has been created where many people who would have been admitted to hospital are now languishing in prison or living on the streets.

Cahalan's book leaves the reader wondering what would have happened if there hadn't been such a backlash against psychiatry? Did Rosenhan and his ilk inspire the necessary corrective action that needed to be taken or did they inhibit a fallible but promising treatment approach?

This is an essential read for anyone who wishes to understand the context of psychological and psychiatric care in the 21st century; it is also a compelling read. The author ends on an optimistic note as she welcomes the dawning of a new era in psychiatric care. There have been far too many lives devastated as a result of psychiatric illness and inappropriate treatment so hopefully her optimism is well-founded.

Stella O'Malley is a psychotherapist and author of 'Fragile: Why We Feel More Anxious, Stressed and Overwhelmed Than Ever, and What We Can Do about It'

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