The Great Pretender review – defending Rosenhan #1

 

I have always had reservations about David Rosenhan’s On Being Sane in Insane Places; its inferiority to the way a (qualitative) sociologist might have approached the same topic is evident.[1] And now Susannah Cahalan’s The Great Pretender has exposed Rosenhan as a fake: he made it all up (well – some of it).[2] However, reading her account of Rosenhan’s unpublished writing, fieldnotes in particular, has been more interesting. He should have had the courage to follow through his insights into power relations and produce a rich ethnographic account of life in a mental hospital. His inability to do so, and what that tells us about the doing of research, rather than any dishonesty on Rosenhan’s part is what we might more usefully take away from this sorry tale.

There’s at least one good review out there (if you ignore the headline)

I discovered this new book when reading a Guardian review, one that, predictably, failed even to summarise the case accurately.[3] Rosenhan describes the experience of pseudopatients, a small group of people admitted to hospital as schizophrenics when they claimed to be hearing voices. However, in its first paragraph, the Guardian review says they were institutionalised against their will, an odd mistake for even the most careless reader to make. A bit later we’re told Rosenhan’s study led to the first edition of the DSM, the classification system still used in the United States for diagnosing disorders. However, the first edition dates back to the 1950s; and so it’s left to a far better review in The Spectator to indicate the damage done by DSM-III. According to Andrew Scull, there is now a ‘rigidly biologically reductionist psychiatry, one that (falsely) claimed that the “diseases” the DSM identified and listed were akin to those that mainstream medicine diagnosed and treated’. Scull calls the case ‘a fraud whose real-world consequences still resonate today’, a conclusion the magazine then distorts for its misleading headline – ‘How a fraudulent experiment set psychiatry back decades’.[4]

If Rosenhan did set out to highlight misdiagnosis, such errors remain problematic today, and one might do better than blame the messenger whose message remains valid.[5]

Further, it’s worth pointing out here that Rosenhan’s modest little paper would have had a lesser impact had it not seemed to reinforce criticisms going back a decade or more.

Rosenhan’s nemesis?

On Being Sane in Insane Places was clearly of its time, the anti-psychiatry movement boldly dismissive of the pretensions of mainstream mental healthcare (summarised by Cahalan, 56-61). Nonetheless, Rosenhan’s study was rejected by the research community, ‘a chorus of hostile voices’ (175). By now Cahalan has anointed Robert Spitzer her hero and Rosenhan’s nemesis:[6] pouncing on Rosenhan’s claim that pseudopatients were released ‘in remission’, Spitzer points out that this term is seldom used – to do so would imply no symptoms of schizophrenia were being displayed.[7] Hence, the conclusion that, if pseudopatients were judged to be in remission, it must have been ‘a function of [their] behaviors and not of the setting (psychiatric hospital) in which the diagnoses were made’.[8] Rosenhan claims that, once the person has been labelled, all behaviours will be interpreted as evidence of their illness; Spitzer, pointing out that this cannot be so, questions the logic of Rosenhan’s argument – hence the sneering refrain, ‘logic in remission’.[9]

So far it is a conventional case of one professional researcher challenging the work of another, policing disciplinary boundaries, what Spitzer must have thought he was doing. However, he remains blissfully unaware that he has, inadvertently, done Rosenhan a favour. Cahalan makes the same mistake. When she starts to outline ‘sloppiness that seemed unprofessional and possibly unethical’ (173), she refers to pseudopatient Bill’s doubt that he had been released ‘in remission’ (see also Bill’s hospital record, reproduced on 160). On 231 another pseudopatient, Harry, also denies that he left hospital ‘in remission’, Cahalan again drawing attention to Rosenhan’s ‘outright fabrications’. Well, untruthful he might have been, but the absence of any ‘in remission’ statements here undermines, at the very least, Spitzer’s line of attack and suggests Rosenhan was right after all. If this is the case, why he chose to lie about it remains a matter for speculation (to be discussed later).

With the dismantling of Rosenhan’s study and reputation now underway, Cahalan appears to side with Spitzer when Rosenhan refuses to identify the hospitals pseudopatients had been admitted to (179). Spitzer can do little wrong.[10] However, one might pause here for thought. Ethical considerations would have to ensure that no participants were identifiable; it’s puzzling that anyone would expect Rosenhan to freely surrender such details, and this same reservation would cover some if not all ‘outright fabrications’. When Harry is quoted as saying ‘there are some basic factual inaccuracies that, I mean, don’t advance anything’ (231), one again wonders if, or how far, such ‘inaccuracies’ might legitimately be claimed as an attempt to maintain confidentiality. If a statement ‘doesn’t advance anything’, can it be said to be a significant distortion of research findings? At the very least, this is a question worth asking.

It’s certainly reasonable to ask for evidence that a researcher hasn’t lied – if legitimate suspicions have been raised. But is it also reasonable for the researcher to change details that don’t matter? With a strong emphasis on details that don’t matter – perhaps, if that means participants are protected. Cahalan says Rosenhan lied about the safeguards put in place to help pseudopatients if they were unable to get themselves released from hospital (145, 249). That would indeed be serious.[11] Changing details here and there might well be a lesser crime. I began by saying I have always had reservations about Rosenhan’s claim that his research could be called an experiment; and this, I suspect, the adherence to conventional methodological procedure, even when it means playing fast and loose with ‘the facts’, when he might have chosen a quite different route, is where Rosenhan got himself deeper into trouble.

To be concluded.

[1] David Rosenhan, 1973. Symposium: On Being Sane In Insane Places, Santa Clara Lawyer, 13/3, 379-399. Online: https://digitalcommons.law.scu.edu/cgi/viewcontent.cgi?article=2384&context=lawreview

[2] Susannah Cahalan, 2020. The Great Pretender, Edinburgh: Canongate Books. On the ‘replication crisis’ see 270-274.

[3] Stephen Poole, 2020. The Great Pretender by Susannah Cahalan review – psychiatry’s dubious past, The Guardian, 10 January. Online: https://www.theguardian.com/books/2020/jan/10/great-pretender-susannah-cahalan

[4] Andrew Scull, 2020. How a fraudulent experiment set psychiatry back decades, The Spectator, 25 January. Online: https://www.spectator.co.uk/2020/01/how-david-rosenhans-fraudulent-thud-experiment-set-back-psychiatry-for-decades/

[5] Since the 1970s research has continued to appear highlighting the problems of misdiagnosis and the role played by different kinds of bias; the problem isn’t going away. See:

Maureen R. Ford and Thomas A. Widiger, 1989. Sex bias in the diagnosis of histrionic and antisocial personality disorders, Journal of Consulting and Clinical Psychology, 57/2, 301-305.

Rebecca Pinto, Mark Ashworth and Roger Jones, 2008. Schizophrenia in black Caribbeans living in the UK: an exploration of underlying causes of the high incidence rate, British Journal of General Practice, June, 429-434.

Jolynn L. Haney, 2016. Autism, females, and the DSM-5: Gender bias in autism diagnosis, Social Work in Mental Health, 14/4, 396-407.

Michael A. Gara, Shula Minsky, Steven M Silverstein, Theresa Miskimen, and Stephen M. Strakowski, 2019. A Naturalistic Study of Racial Disparities in Diagnoses at an Outpatient Behavioral Health Clinic, Psychiatric Services, 70/2,: 130-134.

On gender bias one might also note that the only pseudopatient (supposedly) diagnosed as manic depressive was a female painter, Laura.

[6] Robert L Spitzer, 1975. On Pseudoscience in Science, Logic in Remission, and Psychiatric Diagnosis: A Critique of Rosenhan’s ‘On Being Sane in Insane Places’, Journal of Abnormal Psychology, 84/5, 442-452.

[7] Ibid, 444.

[8] Ibid, 445.

[9] On 200 an erstwhile colleague is found quoting Spitzer, basking in reflected glory. One wonders how long Spitzer himself dined out on his own recycled witticism. As I point out below, blinded by his own methodological assumptions, he missed a more obvious opportunity to put the boot in. Hubris, indeed.

[10] See for example the passage at the bottom of 178: ‘the drollest piece of academic literature I’ve ever read’ etc. Really?

[11] Rosenhan’s own take: ‘I was not sensitive to these difficulties at the outset of the project, nor to the personal and situational emergencies that can arise, but later a writ of habeas corpus was prepared for each of the entering pseudopatients and an attorney was kept “on call” during every hospitalization. I am grateful to John Kaplan and Robert Bartels for legal advice and assistance in these matters’ (On Being Insane, 382, fn6). According to Cahalan, when she spoke to him, ‘Bartels [Kaplan’s assistant] was a bit hazy on details’ (145); and there is nothing from Kaplan. Sometimes Cahalan’s witnesses readily recall events in detail; sometimes they just don’t remember.

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