You likely know Susannah Cahalan as the author of the bestselling memoir Brain on Fire, in which the author details her terrifying experience with anti-NMDA receptor encephalitis. Now she’s back with The Great Pretender, a deeply reported story about one of the most famous studies in the field of psychiatry: David Rosenhan’s experiment where healthy patients went undercover in mental institutions. They documented their treatment and kept track of how long it took for them to be released. His findings would forever change the way people think about psychiatric diagnoses. Cahalan sat down with Bookish to chat about The Great Pretender, how this book feels even more personal than Brain on Fire, and the collapsing line between physical and mental illness.
Bookish: How did you first become fascinated by David Rosenhan’s study? How did you decide it would be the subject of your next book?
Susannah Cahalan: It really happened when I was on tour for Brain on Fire. I was doing an event, and there was someone in the audience I had previously interviewed—she works with children with serious mental illness and with the NMDA receptor. I went to dinner with her and another psychiatrist who also works in that area, and we were chatting. Watching these two people talk, it was like watching a puck in a hockey game because their minds are way more advanced than mine.
We were talking about all these illnesses that blur the line between mental and physical. At one point I told them the story that kind of galvanized me, angered me to be honest. It’s the story of what I call my “mirror image,” a woman who was misdiagnosed for several years who had the same autoimmune disease that I did, and she ended up in a psychiatric hospital instead of a hospital like I did. I told them this story and one of them said to me, this reminds me of this study on being sane in insane places. She mentioned David Rosenhan and I vaguely remembered him from Psych 101. I went home and looked at the study, and I was just floored.
Bookish: Do you see this book as a continuation of Brain on Fire?
SC: I think so. That book raised some questions that I wasn’t ready to dive into at the time. I wrote that book a year after I was sick, so I didn’t have any distance from it. It was so interesting because after my book came out, I noticed that if someone would describe my illness as psychiatric or mental or “she had a breakdown,” I’d get really angry and defensive. I started to ask myself as time went on, “Why am I so defensive about this?” “Why are we making these stark definitions between psychiatric conditions and physical ones?” Those questions plagued me and when I found Rosenhan’s study, it seemed to crystallize everything for me.
Bookish: This book deals extensively with the somewhat arbitrary dichotomy between mental illness and physical illness. How do you hope readers think about mental illness after reading this book?
SC: I’m of the mindset that it’s complicated. I don’t necessarily think we’re going to find all the answers in the neurotransmitters. I think there’s art and there’s science, and both those things come together in our understanding of all illnesses. But I do hope that we break down these things we think we know. Like, we think of schizophrenia as this monolithic entity, and I’m hoping that this book provides some insight into the limitations of that approach. If a doctor’s not treating you correctly, search for a new one. I hope this book gives people knowledge, basically. Knowledge, not to be cheesy, is a very powerful thing. I think that sometimes, in all of medicine and in psychiatry, there’s a leaning on labeling and jargon that can be very confusing. I hope that this book gives some insight into the origins of that labeling and jargon that isn’t as objective or scientific as it’s purported to be.
Bookish: The Great Pretender left me with competing feelings: I felt glad that medicine has made incredible strides in treating mental illness, but also amazed at how much more work the medical field has left to do. What feelings were you left with as you finished this book?
SC: I’m glad you had that response! That was my intention. Sometimes I’m angry at the field, so a lot of anger came out. But researchers are so excited right now, and I’m an optimist by nature, and I’m leaning on that. I really do feel that things are turning around. I love that the young psychiatrists are completely willing to say “this field is messed up and we have to change things.” I think that acceptance will move the field forward. That’s what I’m hoping readers will take from it too.
Bookish: Brain on Fire was an intensely personal book, and in some ways, this one is too. Did it feel different to write a book where you were not also the subject?
SC: This book is more personal to me than Brain on Fire. I don’t remember a good deal of what happened in Brain on Fire. It was reported from a distance and I feel like I’ve always had an emotional remove from what happened to me. So there’s that. But I also think that my experience was backed by studies and by doctors, so there was no questioning what happened to me. There are a lot of things in The Great Pretender that people are going to disagree with or people are going to want to debate, and that’s very exciting, but it’s also scary, too.
Now, I also think that my condition was a psychiatric condition with a cause. If you would have asked me when Brain on Fire came out, I would have doubled down and said “this is neurological.” Now I don’t feel that way. I had psychosis. I experienced what people with serious mental illness experience, and once you have that experience you can’t turn away from it again. That’s basically why I wrote this book.
Bookish: Over the course of doing research for this book, what surprised you most?
SC: I think what surprised me is how subjective a lot of diagnosis is. That was shocking to me. It’s also shocking to me how we’re reaching into the past to move forward, which is kind of cool. I always thought, especially with my experience in Brain on Fire, that medicine is just linear progress and you move forward at every step. Now I’m realizing it’s not true: It swings back and forth and it’s not always taking steps forward. That was a hard thing to know because it’s not just psychiatry, it’s medicine in general that doesn’t necessarily follow that linear path.
Bookish: One of the most striking revelations in this book is that once institutionalized, even “healthy” patients had trouble getting released even though they stopped exhibiting symptoms. Why do you think this is?
SC: There was this whole labeling theory of mental illness and I think it’s definitely still the case. Once you’re given a mental illness diagnosis, all of your behaviors are under that banner. All behaviors that in other contexts would be perfectly normal are suddenly seen as a function of their mental illness. I think that’s something that happens all the time. I toured a psychiatric hospital and heard this story, they kind of told me in a funny way, and it wasn’t funny. There was a man who was young, in his early 20s, who was psychotic. And he started complaining that he was lactating. And they were like, “oh he’s having delusions.” It turns out that the psychiatric medication he was on made him lactate. But no one would take him seriously until finally it was so obvious.
Bookish: Do you envision a future where psychiatry is less concerned with labels? How do you think we might get there?
SC: There’s an interesting call to get rid of these clunky labels like schizophrenia and break them down into their component parts—whatever is actually affecting that person in a very specific way. And I agree with that, and I think that’s where we’re headed. My doctor who treated me said that schizophrenia [as a diagnosis] is basically on life support. He said he thinks it’s going to be gone in ten years. Can you imagine? I think it will change the field.
Bookish: For readers who love this book, what else would you recommend they read?
SC: There are so many great books. I love everything by Andrew Scull. He did Madness in Civilization—it’s a history of madness and it’s so good, it’s phenomenal. I loved Richard Bentall’s book about madness, Madness Explained. I loved Edward Shorter’s A History of Psychiatry, it’s the book every psych med student reads. Fabulous. No One Cares About Crazy People by Ron Powers was so powerful. Insane by Alisa Roth and Insane Consequences by D.J. Jaffe. Insane Consequences is more policy-driven and Insane talks about the prison system and the ridiculous things that are going on with the mentally ill there.
Susannah Cahalan is the award-winning, New York Times bestselling author of Brain On Fire: My Month Of Madness, a memoir about her struggle with a rare autoimmune disease of the brain. She lives in Brooklyn with her family.