Sun, Jan 25, 2009 page14

• [ HARDCOVER: UK ]: Undercover and overlooked in the psychiatric ward

  • By Alexander Linklater / THE OBSERVER
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  VIEW THIS PAGE To produce her first book, Self-Made Man, lesbian author Norah Vincent embarked on an adventure in “immersion journalism,” spending a year disguised as a man. She emerged with a best-selling account of American masculinity and some unresolved mental-health issues. Though she does not clarify whether the strain of adopting a fake identity was a trigger, she suffered a depressive collapse towards the end of her research and wound up in a locked psychiatric ward.

  Where Self-Made Man ended, her new book, Voluntary Madness, begins. After her breakdown, Vincent decided to re-enter the psychiatric system as a journalist, posing as a patient with a serious mental disorder. Unsurprisingly, as her immersion-narrative deepens, the distinction between Vincent as journalist and Vincent as patient dissolves. It turns out she has long suffered from depressive episodes that date back to a childhood trauma, the precise nature of which is revealed towards the end of her story.

  This blurring of roles creates an interesting ambiguity. Vincent attempts to speak both with the authority of a commentator who has researched the American psychiatric system from the outside, and with the psychic vulnerability of someone experiencing it from within. To give the reader a feeling of what happens to disordered minds in an institution, she has to be mad enough herself to render the experience, but not so mad as to lose the plot. She must, to tell a sane story, maintain her perspective on other patients whose experiences of the world are defined by far more profound distortions and psychoses.

  It is a problematic balancing act, but one that captures the fundamental dilemma of psychiatry — how to reduce subjective experience to the objective classifications of medical science. The precedent is the famous 1972 experiment by American psychologist David Rosenhan, who sent researchers into a dozen psychiatric institutions with instructions to report phony hallucinations. The fact that all of them were admitted with formal diagnoses exposed the central difficulty of the profession (one that remains as real today as it was then): that the only test for even the most extreme psychiatric illnesses is a patient’s own report of his or her state of mind. Vincent is not exactly faking it, but she plays up to what she knows her doctors need to hear to achieve the level of admission appropriate to her task.

  The shallow, anti-psychiatric conclusions that might be drawn from this — that mental illnesses do not really exist or that diagnostic classifications are meaningless — are not, however, ones that Vincent indulges (though she certainly questions the categories). She begins her journey in a New York public hospital where the reality of diseased minds presses upon her with irrefutable force. Nor does she shy away from the paradox that lies behind the stigma — that to care for the mentally ill means confronting a potential abhorrence of the sufferer. “Good intentions,” she writes, are “the casualty of contact.”

  While recognizing the social need for incarceration as safety net, she provides potent criticisms of entrenched medical habits — the grim realities of bureaucratic inertia and lazy diagnosis in which the sickness of patients is reflected in, and reinforced by, the nature of the institution. “Did the people make the place or did the place make the people?” she wonders. The question should be asked by every doctor in every institution.

  After two weeks in the closed ward, she goes to a private hospital in the Midwest, run according to the same psychiatric model but in a better environment with more caring staff. The difference for the patients is palpable, with the added irony that the insurance costs are no more than they were for the public institution.

  Finally, Vincent arrives as a patient at an alternative center with high-quality facilities, programs of both medication and psychotherapy, and a distinctively American blend of cognitive, behavioral, spiritualist and psychoanalytic jargon. And it’s here that she comes to her own, personal resolution.

  The originality of Voluntary Madness lies in the fact that Vincent is reporting from inside the system at its three cardinal levels: a hard-core public institution, a more congenial private equivalent, and an intensively personalized therapeutic realm. As near as is possible in a single account, this presents the full spectrum of psychiatry in operation. Vincent’s observations veer between the insightful and the trite, but in a field dominated by antagonistic professional specialisms of brain and mind, it can take an informed generalist to see the big picture. VIEW THIS PAGE
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