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The Not-So-Loony BinVoluntary Madness doesn't have a new prescription for psychiatric treatment.

By Leonard GroopmanPosted Wednesday, Jan. 7, 2009, at 7:11 AM ET

Voluntary Madness: My Year Lost and Found in the Loony Bin, by Norah Vincent. 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.

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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.

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Leonard Groopman practices psychiatry in New York and is on the faculty of Weill Cornell Medical College, where he teaches psychiatry and medical ethics.

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