A century ago, Clifford Beers published A Mind That Found Itself, an autobiographical account of his mental illness and of the abusive treatment of the hospitalized insane. Hailed by pre-eminent psychologist William James, Beers' landmark book sparked a social movement for the reform of insane asylums and led to the founding of the first American outpatient psychiatric clinic, creating an alternative to incarceration for the mentally ill. Psychiatry, psychiatrists, and psychiatric hospitalization have come under scrutiny many times since then, most notably in the 1960s and early 1970s in such works as Ken Kesey's One Flew Over the Cuckoo's Nest, Thomas Szasz's The Myth of Mental Illness, Erving Goffman's Asylums, and David Rosenhan's "On Being Sane in Insane Places." Mental illness, it was argued, was not a medical disturbance like physical illness but a social construction that enabled society to control deviant behavior by labeling it as pathology and sequestering it. (Szasz also argued that it was a means of evading individual moral responsibility.) The movement for deinstitutionalization of the mentally ill—which contributed to the increase in homelessness among people labeled by psychiatrists as sick—took inspiration from such critiques. More recently, Susannah Kaysen's story of her adolescent hospitalization, Girl, Interrupted, which also became a popular film, reprised the earlier themes in the tradition.
The newest addition to this genre is Voluntary Madness: My Year Lost and Found in the Loony Bin, by journalist and author Norah Vincent, a book that powerfully illustrates—in ways not always intended by the author—not only the deficiencies but the outright dangers of psychiatric hospitalization while again raising disturbing questions about mental illness, psychiatry, and psychiatrists. Vincent's method of "immersion journalism" distinguishes this work from its predecessors and poses questions of its own regarding the validity of her findings and the wisdom of our current penchant for playing around with our identities.
As she approached completion of the research for her earlier book, Self-Made Man, in which she went undercover as a man in order to experience male life, Vincent suffered from worsening depression and had thoughts of suicide. At the recommendation of her longtime psychiatrist, she was admitted to a psychiatric hospital as a voluntary patient. Once there, she had the therapeutic realization that her next book would explore mental illness and its treatment and would involve getting herself institutionalized under false pretenses. She was discharged within four days—a quick recovery—and began her journey.
Vincent's subtitle is misleading: She did not spend a year in the loony bin. Instead, she spent just more than a month in three institutional settings—10 days in a large public psychiatric hospital; another 10 in a small, private Catholic rehab and dual-diagnosis ward (i.e., substance abuse coupled with mental illness); and two weeks in an open alternative wellness center. She dubs these institutions Bedlam, Asylum, and Sanctum—the first driven by an ideology of pharmacological custodialism, the second by Catholic pastoralism, and the third by New Age rebirthing. She experiences the cold if not cruel treatment given to the poor, uninsured, and psychotic in Bedlam; the well-meaning but generally ineffectual care afforded the middle-class, insured, and addicted in Asylum; and the loving, empathic understanding available to the young, self-paying, and wayward in Sanctum. She gets worse in Bedlam, is stabilized by Asylum, and improves in Sanctum.
Vincent encounters neglect and demeaning treatment, especially in the public hospital. Surely such hospitals would benefit from increased resources, more highly trained staff members, and a stronger ethos of service. What public (or private) institution wouldn't? In the other settings, she encountered cold detachment and benign neglect as well as genuine commitment and caring. But spending 10 days or two weeks in an institution of any kind—psychiatric or nonpsychiatric, medical or nonmedical—is insufficient even to begin to explore and understand it. Vincent keeps herself on the razor's edge between virtual and real—this, after all, is part of her point in playing fast and loose with her identity, demonstrating that our categories are not fixed while revealing the perils of such self-manipulation. She doesn't belong in Bedlam, since she is not severely depressed or psychotic on admission. Hospitals are for people who are sick enough to require the environment and therapies that are not possible in other settings. But hospitalization is contraindicated for people who do not need it. Hospitals are loci of biological contagion, emotional regression, and—like all human organizations—social malfunction.
The fact that Vincent got worse in Bedlam may reflect the therapeutic failure of the institution—or it may reflect the fact that she shouldn't have been there in the first place. Perhaps a melancholically depressed person, a terrified paranoid person, or an out-of-control adolescent would find the routine and dullness of the ward therapeutic compared with the stimulation of the outside world.
Vincent returns throughout the book to the vexing question of the nature of mental illness. Is it a biological phenomenon like other medical diseases? Is it the result of an individual's emotional life? Is it, as the critics of the 1960s maintained, a social construct for stigmatizing and controlling deviant patterns of thought and behavior? Is it illness or an existential condition? Vincent tacks back and forth among these, explaining her own behavior and the behavior of those she meets along the way sometimes in one framework, sometimes in another.
At their best, psychiatrists are agnostic on the true nature and causes of mental illness. They are trained to think about their patients heuristically, along three dimensions: the biological, the psychological, and the social. At points during its history, psychiatry has been dominated by biological conceptions of mental illness; in other periods, psychology has reigned; and at still other times, social determinants have taken precedence. After the long postwar hegemony of psychoanalysis, the past 25 years in American psychiatry have witnessed a so-called biological revolution. This revolution, like so many others, took a tyrannical turn with the professional, cultural, and commercial triumph of serotonergic antidepressants. Prozac leached the psychology out of psychiatry, as psychiatric residencies taught psychotherapy less and pharmacology more, to the point where many programs stopped altogether training future psychiatrists in psychotherapy. Although the advent of the new medications was a great benefit to psychiatrist and patient alike, the loss of psychological modes of thinking within the profession has impoverished the skill of practitioners and the treatment of patients by psychiatrists. Although she doesn't tell us much about her decade of treatment prior to undertaking the research for Voluntary Madness, I wonder whether Vincent and perhaps her psychiatrist were not themselves casualties of this biological revolution with its almost exclusive focus on symptoms, diagnosis, and pharmacology. Only in the New Age Sanctum does Vincent encounter therapists who show any interest in addressing deeper emotional matters. Perhaps the failure of contemporary psychiatry to take emotional life seriously accounts for the current proliferation of alternative treatments.
Although in this day of budgetary constraint there are far fewer resources for such therapies, the nonverbal treatments that psychiatric hospitals were once renowned (or despised) for, such as physical recreation, dance, art, and music, do allow people who are so isolated from others and from themselves to become aware of and express what they are feeling and to reconnect in safe ways. In our pharmacological age, such human aspects of care should be neither forgotten nor contemned. For all its shortcomings, psychiatric hospitalization serves an essential role in contemporary treatment. The hospital provides a protective environment for people who are unable to protect themselves from themselves (or protect others from themselves). Hospitalization can also protect manic patients from harming themselves or others by preventing promiscuous sexual binges or ruinous spending sprees. Many a family of a manic patient—and many a patient after recovery from a manic episode—regrets that the law, out of concern for civil liberties, makes it so difficult to be hospitalized against one's will.
In psychiatry as in our culture, the tide may be turning once again, as we become disillusioned with the overuse of medications, more aware of their side effects and disappointed by their results, which could not possibly have met our inflated expectations. Although medications can help with symptoms—at times dramatically, saving lives that could have been lost—they will not treat underlying conflicts. For that, we need some kind of psychological therapy. In my practice, it is a rare patient who feels well enough from medications alone to forgo exploratory talk therapy.
In the end, Vincent concludes that the fault is less with our institutions and professions than with each of us individually: "[T]he vast majority of people don't want to participate in their own recovery. They are unwilling to try, even when they are given every advantage, every freedom, and an abundance of what was lacking in Meriwether [Bedlam], namely, compassion and the human touch." Much ink has been spilled over the question of resistance to change in psychotherapy, and most people are conflicted, whether consciously or unconsciously, about giving up their neuroses. But that is about internal conflict and unconscious motivation, not, as Vincent would have it, "because people—patients—are the way they are, often lazy, stubbornly self-indulgent, passive, and irresponsible." The therapeutic life lesson of her experience at the Sanctum is individual responsibility and self-discipline: "You want to be happy? You want to be well? Then put your boots on." Back to bootstraps. The New Age meets the Protestant ethic and discovers they have a lot in common.