A Q&A with Susannah Cahalan
1. What drew you to this topic? Did you go looking for such an explosive story, or was it luck?
It started from a highly personal place. When I first read David Rosenhan’s study, his experience with depersonalization and labeling rang so true to my own experience. But chancing upon that explosive story (as you describe it!) was total luck. When I was writing the book, I didn’t see these issues as a positive thing for the narrative—I worried that this book was done with!
2. Why do you feel it is important or urgent for readers to be discussing Rosenhan and his work?
Even though Rosenhan’s study is now almost fifty years old, so many of the questions that he raises in it—how to distinguish “sanity” from “insanity,” how to treat serious mental illness, the role of context in diagnosis—have remained with us. Rosenhan’s study crystalizes the importance of asking these questions and the importance of being honest and open about the limitations in answering them.
3. What was your favorite part of researching the book? Of writing it? What was the biggest surprise?
I had such a joyous time writing this book—mostly because of the extraordinary people I met—among them David’s close friend and confidant Florence Keller and his son, Jack Rosenhan, both of whom are now close friends. I loved mining Rosenhan’s personal files and getting access to his mind. I loved learning about the history and digging through archives. And I loved discussing these impossible topics with some great thinkers. The whole experience, as difficult and dark at times as it was, was such a gift.
4. You were a journalist before you were a bestselling memoirist. In what ways do you think Brain on Fire influenced your writing of The Great Pretender? Would this be a different book if you were just coming in as a pure outsider, a journalist curious about the mysteries Rosenhan left behind?
Brain on Fire touched every page of this book. The Great Pretender is not only informed by my experience with misdiagnosis; it’s also a reaction to the reader responses and my own shifting views on what happened to me. Without the experiences chronicled in my memoir, I would not have been able to write the book as it stands. Even though most of the book is not about me, my interests, my fears, my obsessions are all over the narrative.
5. What do you want readers to take away from the book?
I hope that this book raises questions that you may feel more comfortable discussing, even if you don’t (and you won’t) have all the answers. I hope that it provides an education and that it gives some insight into the terrible ways we’ve dealt with these issues in the past. I hope that the book both makes you more skeptical about modern medicine and mental health care but also more optimistic. I hope that people who live with serious mental illness or people who have family members or friends who do, walk away with a deeper understanding of our shared history—a history we need to fully understand if we expect to move forward.
6. What three books would you recommend to readers interested in learning more?
This is a tough one! There were so many books that informed my thinking (check out the notes for a full list). I particularly love Ron Powers’s No One Cares About Crazy People, which is rallying cry in the form of a deeply moving memoir. I found Andrew Scull’s Madness in Civilization indispensable. And although I wasn’t lucky enough to read this miraculous book when I wrote The Great Pretender, I highly recommend Esme Wang’s The Collected Schizophrenias to anyone interested in hearing a gorgeous writer discuss what it’s like to live with a serious mental illness.
PERMISSIONS
Here: Excerpt from Haverford State Hospital medical records. David Rosenhan’s private files. Permission granted by Florence Keller and Jack Rosenhan.
Here: Excerpt from Haverford State Hospital medical records. David Rosenhan’s private files. Permission granted by Florence Keller and Jack Rosenhan.
Here: Excerpt from Haverford State Hospital medical records. David Rosenhan’s private files. Permission granted by Florence Keller and Jack Rosenhan.
Here: Excerpt of questionnaire. David Rosenhan’s private files. Permission granted by Florence Keller and Jack Rosenhan.
Here: Handwritten excerpt of John Fryer’s speech. John Fryer, “Speech for the American Psychiatric Association 125th Annual Meeting,” undated, John Fryer Papers, Collection 3465, 1950–2000, Historical Society of Pennsylvania (Philadelphia). Permission granted by Historical Society of Pennsylvania.
Here: Excerpt of David Rosenhan’s outline. Reprinted with permission from Jack Rosenhan.
Here: Excerpt from yearbook. Stanford University, Stanford Quad, 1973. Print, Stanford University Archives. Reprinted with permission from Stanford University.
Here: “William Dickson” medical record. Permission granted by Bill Underwood to publish.
Here: Excerpt from Haverford State Hospital medical records. David Rosenhan’s private files. Reprinted with permission from Florence Keller and Jack Rosenhan.
Here: Excerpt from Haverford State Hospital medical records. David Rosenhan’s private files. Reprinted with permission from Florence Keller and Jack Rosenhan.
Here: Excerpt from Haverford State Hospital medical records. David Rosenhan’s private files. Reprinted with permission from Florence Keller and Jack Rosenhan.
Here: Excerpt from Haverford State Hospital medical records. David Rosenhan’s private files. Reprinted with permission from Florence Keller and Jack Rosenhan.
Here: Excerpt from Harry Lando, “On Being Sane in Insane Places: A Supplemental Report,” Professional Psychology, February 1976: 47–52. Reprinted with permission from Harry Lando.
Here: Excerpt of David Rosenhan’s outline. Reprinted with permission from Jack Rosenhan.
NOTES
I relied on a treasure trove of materials to put together this book—most notably from Florence Keller’s file of “On Being Sane in Insane Places”–related documents. Stanford Special Collections also provided eight banker’s boxes’ worth of documents from David Rosenhan’s three-decade career. I relied on his diary entries, his unpublished book, audio and video recordings of his interviews and lectures, newspaper interviews, and television and radio appearances, and I interviewed hundreds of people who knew him. Research on the history of psychiatry came from a wide variety of sources, many listed here, including interviews with experts in the field, site visits to psychiatric hospitals, and archival research. Still, I’ve only scratched the surface of the history of mental health care. Take a look at notes below for references to other, more in-depth sources. And if the spirit moves you, read them.
PREFACE
Patient #5213’s… Details like this one in the preface came from medical records found in David Rosenhan’s private files.
“Do you recognize the voices?”… Direct quotes are from Rosenhan’s unpublished book, Odyssey into Lunacy, chapter 3, 5–6.
“The history of psychiatry”… Edward Shorter, A History of Psychiatry: From the Era of the Asylum to the Age of Prozac (Hoboken, NJ: Wiley, 1996), ix.
PART ONE
Much Madness is divinest Sense… Emily Dickinson, The Poems of Emily Dickinson (Boston: Roberts Brothers, 1890), 24.
1: MIRROR IMAGE
“assess both the mental and physical”… American Psychiatric Association, “What Is Psychiatry?,” https://www.psychiatry.org/patients-families/what-is-psychiatry.
“Psychiatry has a tough job”… Dr. Michael Meade, email to Susannah Cahalan, March 17, 2019.
called the great pretenders… For a discussion of these disorders, see Barbara Schildkrout, Masquerading Symptoms: Uncovering Physical Illnesses That Present as Psychological Problems (Hoboken, NJ: Wiley, 2014); and James Morrison, When Psychological Problems Mask Medical Disorders: A Guide for Psychotherapists (New York: Guilford Press, 2015).
“the lay public would be horrified”… Dr. Anthony David, phone interview, January 28, 2016.
the one in five adults… “Mental Illness,” National Institute of Mental Health, https:
//www.nimh.nih.gov/health/statistics/mental-illness.shtml.
urgently affects the 4 percent… “Serious Mental Illness,” National Institute of Mental Health, https://www.nimh.nih.gov/health/statistics/prevalence/serious-mental-illness-smi-among-us-adults.shtml/index.shtml.
“mental, behavioral or emotional disorder”… “Serious Mental Illness,” National Institute of Mental Health.
whose lives are often shortened… World Health Organization, “Premature Death Among People with Severe Mental Disorders,” https://www.who.int/mental_health/management/info_sheet.pdf.
“Insanity haunts the human imagination”… Andrew Scull, Madness in Civilization (Princeton: Princeton University Press, 2015), 10.
your blue may not be my blue… For more on the variability of color perception, see Natalie Wolchover, “Your Color Red Really Could Be My Blue,” Live Science, June 29, 2014, https://www.livescience.com/21275-color-red-blue-scientists.html.
“medically unexplained”… For more on the so-called medically unexplained, see Suzanne O’Sullivan, Is It All in Your Head?: True Stories of Imaginary Illness (London: Vintage, 2015).
how everyday drugs like Tylenol work… Carolyn Y. Johnson, “One Big Myth About Medicine: We Know How Drugs Work,” Washington Post, July 23, 2015, https://www.washingtonpost.com/news/wonk/wp/2015/07/23/one-big-myth-about-medicine-we-know-how-drugs-work/?utm_term=.1537393b19b4.
what exactly happens in the brain during anesthesia… Susan Scutti, “History of Medicine: The Unknown Netherworld of Anesthesia,” Medical Daily, March 5, 2015, https://www.medicaldaily.com/history-medicine-unknown-netherworld-anesthesia-324652.
a condition like anosognosia… “What Is Anosognosia?” WebMD, https://www.webmd.com/schizophrenia/what-is-anosognosia#1.
“They seem to blame my son”… The father who wrote this email to me prefers to maintain his privacy. Email to Susannah Cahalan, March 7, 2018.
2: NELLIE BLY
To re-create Nellie’s preparation and hospitalization, I relied on her own writing: Ten Days in a Mad-House (New York: Ian L. Munro, 1887), https://digital.library.upenn.edu/women/bly/madhouse/madhouse.html. Other sources include Stacy Horn, Damnation Island: Poor, Sick, Mad & Criminal in 19th-Century New York (Chapel Hill, NC: Algonquin Books, 2018); and Matthew Goodman, Eighty Days: Nellie Bly and Elizabeth Bisland’s History-Making Race Around the World (New York: Ballantine, 2013).
“The strain of playing crazy”… Bly, Ten Days in a Mad-House, chapter 2.
“plain and unvarnished”… Bly, Ten Days in a Mad-House, chapter 1.
two broad categories of “idiocy” and “insanity”… For a concise summary of the government’s tracking of mental illness in America, see Herb Kutchins and Stuart A. Kirk, Making Us Crazy (New York: Free Press, 1997).
seven categories of mental disease… Allan V. Horwitz and Gerald N. Grob, “The Checkered History of American Psychiatric Epidemiology,” Milbank Quarterly 89, no. 4 (2011): 628–57.
something called unitary psychosis… For more on unitary psychosis and the history of diagnosis, see Per Bergsholm, “Is Schizophrenia Disappearing? The Rise and Fall of the Diagnosis of Functional Psychoses,” BMC Psychiatry 16 (2016): 387, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5103459.
“Compulsive epilepsy, metabolic disorders”… Patton State Hospital Museum, Patton, California, October 29, 2016. Thank you to curator Anthony Ortega for the enlightening tour.
Other hospital records show… The “other hospital” is Agnews State Hospital. The reference to “habitual consumption of peppermint candy” and “excessive tobacco use” came from Michael Svanevik and Shirley Burgett, “Matters Historical: Santa Clara’s Hospital of Horror, Agnews,” Mercury News, October 5, 2016, https://www.mercurynews.com/2016/10/05/spdn0916matters.
were diagnosed with “insurgent hysteria”… Marconi Transatlantic Wireless Telegraph to the New York Times, “Militant Women Break Higher Law,” New York Times, March 31, 1912, https://timesmachine.nytimes.com/timesmachine/1912/03/31/100358259.pdf.
A nineteenth-century Louisiana physician… Dr. Cartwright, “Diseases and Peculiarities of the Negro Race,” Africans in America, PBS.org, https://www.pbs.org/wgbh/aia/part4/4h3106t.html. Thank you to Dominic Sisti and Gary Greenberg for calling my attention to these disorders.
Throw a rock into a crowd… For a great summary of the literature coming out of England focusing on fears about institutionalization, see Sarah Wise, Inconvenient People: Lunacy, Liberty and the Mad-Doctors in England (Berkeley: Counterpoint Press, 2012).
There was Lady Rosina… For more on Lady Rosina, see Scull, Madness in Civilization, 240–41.
“Never was a more criminal”… Rosina Bulwer Lytton, A Blighted Life (London: Thoemmes Press, 1994).
Elizabeth Packard continued… For more on Elizabeth Packard, see Linda V. Carlisle, Elizabeth Packard: A Noble Fight (Champaign: University of Illinois Press, 2010); and “The Case of Mrs. Packard and Legal Commitment,” NIH: US National Library of Medicine, October 2, 2014, https://www.nlm.nih.gov/hmd/diseases/debates.html. For context, see Scull, Madness in Civilization, 240.
“Poor child,” mused Judge Duffy… Bly, Ten Days in a Mad-House, chapter 4.
or mocked as “bughouse doctors”… Andrew Scull, Madhouse: A Tragic Tale of Megalomania and Modern Medicine (New Haven: Yale University Press, 2007), 14.
Psychiatrist would become… Scull, Madness in Civilization, 12.
The word asylum comes… Thank you to Arizona State classics professor Matt Simonton for explaining the Greek and Roman origins of the word asylum.
The first asylums built… Andrew Scull, “The Asylum, the Hospital, and the Clinic,” Psychiatry and Its Discontents (Berkeley: University of California Press, 2019).
towns in Europe, the Middle East, and the Mediterranean… Greg Eghigan, ed., The Routledge History of Madness and Mental Health (New York: Routledge, 2017), 246.
there weren’t many differences among… The rise of asylums (and their relationship to prisons and jails) is covered beautifully in David J. Rothman, The Discovery of the Asylum: Social Order and Disorder in the New Republic (New York: Little, Brown, 1971).
In eighteenth-century Ireland… Shorter, A History of Psychiatry, 1–2.
Europe’s oldest psychiatric hospital… Thank you to Bethlem Museum of the Mind for providing an in-person history of their hospital and of mental health care in general. https://museumofthemind.org.uk.
a “stout iron ring”… Roy Porter, Madness: A Brief History (Oxford: Oxford University Press, 2002), 107.
American activist Dorothea Dix… For more on Dix, see Margaret Muckenhoupt, Dorothea Dix: Advocate for Mental Health Care (Oxford: Oxford University Press, 2004). For the loveliest description of her work and legacy, read Ron Powers, No One Cares About Crazy People (New York: Hachette, 2017), 102–3.
thirty thousand miles across America… “Dorothea Dix Begins Her Crusade,” Mass Moments, https://www.massmoments.org/moment-details/dorothea-dix-begins-her-crusade.html.
“the saddest picture of human suffering”… Thomas J. Brown, Dorothea Dix: New England Reformer (Boston: Harvard University Press, 1998), 88.
a woman tearing off her own skin… Brown, Dorothea Dix, 89.
“sacred cause”… Dorothea Dix, “Memorial to the Massachusetts Legislature, 1843.”
thirty-two new therapeutic asylums… “Dorothea Dix Begins Her Crusade,” Mass Moments.
“beacon for all the world”… Horn, Damnation Island, 7.
located on 147 acres… Horn, Damnation Island, xxii.
“The mentally sick, far from being guilty people”… John M. Reisman, A History of Clinical Psychology, 2nd ed. (Milton Park, UK: Taylor & Francis, 1991), 12.
Connecticut physician Eli Todd… The description of his philosophy came from Stephen Purdy, “The View from Hartford: The History of Insanity, Shameful to Treatable,” New York Times, September 20, 1998, https://www.nytimes.com/1998/09/20/nyregion/the-view-from-hartford-the-history-of-insanity
-shameful-to-treatable.html.
and its “lounging, listless, madhouse air”… Charles Dickens, American Notes for General Circulation (Project Gutenberg eBook), July 18, 1998, https://www.gutenberg.org/files/675/675-h/675-h.htm. Thank you to Stacy Horn, Damnation Island, for making me aware of this quote.
six women were confined to a room… Horn, Damnation Island, 45.
“the onward flow of misery”… Horn, Damnation Island, 52.
give birth in a solitary cell… Horn, Damnation Island, 52.
and another woman who died… Horn, Damnation Island, 53.
“I talked and acted just as I do”… Bly, Ten Days in a Mad-House, chapter 1.
“Compare this with a criminal”… Bly, Ten Days in a Mad-House, chapter 8.
“the crib”… Horn, Damnation Island, 24.
“A human rat trap”… Bly, Ten Days in a Mad-House, chapter 16.
According to an 1874 report… Horn, Damnation Island, 16.
“more I endeavored to assure them”… Bly, Ten Days in a Mad-House, chapter 16.
“What are you doctors here for?”… Bly, Ten Days in a Mad-House, chapter 16.
The Manhattan DA convened a grand jury… Goodman, Eighty Days, 34.
“these experts cannot really tell”… “Nellie Brown’s Story,” New York World, October 10, 1887: 1, http://sites.dlib.nyu.edu/undercover/sites/dlib.nyu.edu.undercover/files/documents/uploads/editors/Nellie-Browns-Story.pdf.
3: THE SEAT OF MADNESS
For great summaries of the early treatments of madness, see Scull, Madness in Civilization; Porter, Madness: A Brief History; Richard Noll, American Madness: The Rise and Fall of Dementia Praecox (Cambridge, MA: Harvard University Press, 2011); Jeffrey A. Lieberman, Shrinks: The Untold Story of Psychiatry (New York: Little, Brown, 2015); and of course Shorter, A History of Psychiatry.
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