READERS GUIDE

Questions and Topics for Discussion

INTRODUCTION
The mental institution occupies a shadowy place in today’s world: it is as old, as cold, and as foreign as Bedlam, and as hot and new as the latest pop star’s latest breakdown. It’s a world unto itself, hard to enter, harder to leave, and shut off from the flow of everyday life. This is the world that Norah Vincent decided to explore from the inside out in Voluntary Madness, the follow-up to her bestseller, Self-Made Man. Little did she know at the outset that she would be exposing not just the inner workings of the mental health system, but the deepest recesses of her own mind and soul.

Vincent describes herself as an “immersion journalist,” one who obliterates the barriers of simple observation and instead reports from the trenches on the sounds, smells, fear, and elation of real life. It was this full-throttle approach that lead to her remarkable first book, Self-Made Man, an account of the eighteen months she spent living, working, and dating while disguised as a man. At the end of that identity-warping year and a half, however, Vincent found herself suffering from a crippling depression and, fearing for her own safety, she voluntarily entered a mental institution. She immediately regretted it. The place seemed inhuman, the staff uncaring, the medication toxic. In other words, it was the perfect subject for a new book.

After leaving “the bin,” Vincent set about recovering her health and re-admitting herself—this time undercover, alert, and taking notes—to three different facilities: Merriweather, a public institution that temporarily houses some of the inner city’s poorest and most disturbed residents; St. Luke’s, a private Catholic clinic catering to the depressives and drug addicts of a middle-class, Midwestern suburb; and Mobius, a luxurious, spa-like facility in the south that promotes hands-on therapy over medication. Her goal was to report, as she had in her previous book, from inside an unfamiliar world on the lives of the natives, by passing herself off as one of them. But in this case the thin line between reporter and subject went from thin to indistinguishable almost immediately.

While she chronicles her encounters with the patients, Vincent is engaged in an increasingly desperate battle with her own demons. And it’s one she has to fight with mood-altering drugs that are aggressively marketed to a medical community that doesn’t entirely understand their effects by a pharmaceutical industry that doesn’t entirely care.

Through her visits to three very different facilities in the enormous mental healthcare system, in her conversations with fellow sufferers, arrogant doctors, and a few diligent therapists, Norah Vincent unlocks both the door of the mental asylum and the deeply buried secrets of her own mind.

Norah Vincent is the author of the New York Times bestseller Self-Made Man. Previously, she wrote a nationally syndicated op-ed column for the Los Angeles Times. Her work has also appeared in The New York Times, The New Republic, The Village Voice, and The Washington Post. She lives in New York City.

I’ve thought about this question long and hard, and had trouble coming up with an answer. I guess this means that most of my expectations were confirmed. I expected that going back into the bin would be hard and it was. I expected that it would get personal and it did.

The only thing that did shift for me unexpectedly was the emphasis from the institution to the individual. I went in blaming the institutions, expecting to point out their inefficiencies and missteps, and how often they tended to make people worse rather than better. I saw these expectations confirmed and wrote about them. But I also saw a lot of personal refusal and choice, and I came away laying quite a bit of the responsibility to heal chronic dysfunction at the feet of the patients themselves—myself included. In the beginning, I thought, like most of us, that mental illness just happens, and we have to just lie there and take it, or seek sole refuge in drugs and locked doors. But now I think it’s more complicated than that and that we do have a significant role to play in our own distress as well as our own healing.

Q. Did you ever confess your real reasons for being at these institutions to fellow patients, or to staff? Did anyone figure out that you didn’t need to be there?

At Merriwether, I think the docs had begun to speculate a bit, though I’m pretty sure this only happened at the tail end, at least that’s what the med student assigned to me told me right before I was discharged. They thought I was genuinely depressed, but they also wondered whether I wasn’t going to write something. I had a notebook with me almost all the time, after all. I tried to pass it off as graphomania most of the time, but I don’t think everyone bought it.

At St. Luke’s I wrote in my notebook a lot, too, and didn’t bother to hide it really at all. One of the patients said, only half jokingly, “What? Are you writing a book or something?” Another said, “What are you doing here? You look fine.” I didn’t admit anything until the end, when I did tell my doc and my psychiatrist what I planned to do. The doc didn’t know whether to believe me or not. Delusions of grandeur and all that. I told him to Google me, but I think that only made it worse.

Q. What do you think accounts for the difference in the quality of the support staff at these three facilities?

Partly funding, or efficient versus inefficient use of funding, how much they could pay the staff, and what kind of job or career opportunity they could offer them. Partly clientele—i.e. how dangerous or disturbed the patients were, and how hard or risky it could be to reach them and work among them. Partly culture or mission, that is, what role the institution saw itself playing in the community, what hopes it held out for healing, and the kind of staff it hired in this context. Were they babysitters, jailers, or healers? Were they hired as such? How did they see themselves? Were they punching a clock or pursuing a vocation? All of these things depended a lot on location: urban versus rural versus suburban; status; public versus private; and class, under, middle, or upper-middle. These are many of the factors as I see them, but I don’t think any of them is really insurmountable. It’s not impossible to make an urban public hospital into something more than a holding pen. It’s just harder.

Q. You don’t mention many outside visitors—family or friends—who come to see patients at the institutions, so we really get that sense of being shut off from the rest of the world. How difficult is it to have visitors as a patient at one of these places?

Not particularly difficult if your family lives nearby, or if you have family, though there are usually only a couple of hours set aside per day for that. Still, because you’re locked in, and because you can’t have access to a lot of items the staff consider potentially dangerous, it’s a lot more like getting visitors in prison than like getting them in a normal hospital ward, which only adds to the sense of alienation, fear, and loneliness that you, the patient, feel.

Q. Have you caught up with any of the other patients you met while researching the book?

Only one. Gary from Mobius, who seems to be doing quite well. Otherwise, as I did after I finished Self-Made Man, I’ve preferred to separate myself from the experience, and that means leaving behind the people who were part of it as well. It’s just something I need to do for my own mental health, to let go of the baggage of the immersion, or to, so to speak, emerge from the immersion.

Q. What kind of reactions do you expect from the three institutions you profile once the book is published? What about the mental health community at large? Are you worried about offending anyone?

Oh sure. I expect to be ignored. I also expect pretty nasty backlash from some quarters. I think most people in the profession, with the exception of psychologists and other therapists, will dismiss it out of hand as unscientific, conjectural, and out of sorts, or they’ll attack me as being an unreliable narrator, none of which is entirely untrue, but of course, it doesn’t make everything I say off the mark either. I say in the introduction that this is my story. I wasn’t trying to be an investigative reporter. I was trying to tell a story and poke at some unpleasant assumptions and status quos through the lens of my own experience. If I’ve done that, some people will be offended, and that’s okay, so long as other people—especially the public—are talking, even arguing, and questioning.

Q. Why have you chosen to be an “immersion journalist,” rather than erecting the more traditional journalistic barriers of distance and objectivity?

Objectivity is an illusion, especially in journalism. Look at Fox News and CNN, two sides of the same partisan coin. Besides, I find reports rather boring and all too commonplace. I like the first person. I think it has an immediacy and, for me, a purgative effect that’s indispensable. Rather than deny that you, the reporter, are part of the story, embedded in it even, why not explore that embeddedness as a means of learning something about the culture at large and yourself. There is no separating the individual and society/culture, so why pretend? Why not dive in and see what the murk can tell you?

Q. Like a lot of people, you have some complicated feelings about anti-depressant and anti-psychotic drugs. Do you wish you had never been exposed to them to begin with?

I wish that I had been told at the time, fully and honestly, what I was getting myself into. I may still have chosen to take them, had I known that they’d be very hard to quit, and that they’d have all kinds of side effects. They changed my life for ten years, but they did so by painting a veneer over it and me, by glossing over the problems, the very real, justified, and normal discontents and entanglements that I was dealing with. I have never disputed the fact that they helped me. They do help. But at what cost and by what means? They help by masking, not correcting, and they may very well do so by permanently changing or even damaging brain chemistry. We just don’t know enough, and I think it’s time doctors and big pharma were honest with patients about this and stopped trying to pathologize everyday life and suffering to turn a profit.

Q. It seems you knew a lot more about some of the drugs being prescribed at Merriweather in particular than did the people writing the prescriptions. Why do you think this is?

Most doctors don’t have the time to keep up with the particulars of new drugs, or old drugs that are being used for new purposes. Sometimes they learned it in med school and have forgotten. Sometimes the exact mechanics of how the drugs work is unknown. They might know that it works on a certain neurotransmitter, but they don’t really understand how that brings about the desired effect.

I did quite a lot of reading before I embarked on this project. There’s a lot out there, but the people who’ve debunked the common wisdom about drugs and modern mental health care are either pariahs in the profession—MDs who have testified against pharmaceutical companies in court, while their colleagues are taking money from those same companies. Or journalists who’ve been marginalized—i.e. they’ve been published only by university presses, or their books have not garnered nearly as much public attention as the mega-confessional bestsellers about mental illness, almost all of which have robustly advocated copious use of medication.

The bottom line is, doctors aren’t ipso facto humanitarians or gods, or even particularly smart. They’re often careerists, or clock-punchers, or mediocre people who just get by, and they’re subject to intellectual and cultural fashion just like everybody else. Some are hypercompetitive, some are lazy and just going through the motions, some are overworked and behind or taking shortcuts, and some are just dumb or don’t care. And then some are incredibly smart and kind and giving. But like everywhere else, they’re in the minority and we tend to forget that.

That may actually be one of the biggest surprises of this book. Uncovering our absolute and unquestioned reverence for doctors. If the doctor told us, then it’s so. It’s fact. The doctor has our absolute best interests at heart. The doctor knows best. That’s a pretty stunning assumption, and one that is widely, widely shared even among people who are otherwise quite skeptical and well informed. What this has often led to, especially when it comes to the corrupt relationship between doctors and pharmaceutical companies and the overmedication of the populace that has resulted, is an enormous violation of the public trust.

Q. The final chapter of your book deals with some very personal and difficult issues from your past—you reveal some extremely intimate stuff. How hard was it to write that section knowing that lots of people would read it?

Terribly hard. I had a big crisis of conscience and confidence over it. What will my family think? What if all the creepy people come out of the woodwork? What will it be like to be somewhere in public, have someone recognize me, and think, “They know way too much about me, and they’re a total stranger?” In the end, I chose to say the hardest things, the least flattering and sometimes vulgar things, because I wanted other people out there—no, let’s just say it—other molested kids, to know that they’re not alone, even in their worst and most violent thoughts, and that they’re not crazy because they have them, or because they’re depressed and suicidal as well. I said the things I said precisely because I was afraid to say them. Because I’m still ashamed.

Aside from the help I hope this will give to other people, I also followed the advice of a very smart friend who said, “Go toward the shame. When you feel really uncomfortable, you know you’re on the right track.” Hard as it is to live by this in my work, and take all the mean criticism that people throw at you about very personal information you’ve disclosed, I don’t know any other way to be. Call it freak show journalism. Call it lurid navel gazing. It’s what I know, and they tell you to write what you know, right?

Q. The book’s conclusion is that individual will is the key component in any recovery program, regardless of that program’s other methods. Do you think there’s a way for an institution like Merriweather or St. Luke’s to strengthen that will in its patients?

That’s a biggie. No politician ever got elected telling people what they didn’t want to hear. Namely, that not everything is somebody else’s fault. Getting people to step up to the plate, getting them to take a long, withering look at their choices, is a tall order indeed.

It’s cultural. I know I keep coming back to this, but that’s really one of the most interesting things I learned from writing this book. America, and we are not alone in this, though we may be among the worst offenders, is a very self-indulgent culture. We think freedom means that we can do whatever we want and not pay the piper. We think that actions don’t have consequences, or when they do, that we should be able to take a pill or get a check that clears those consequences up.

Can culture and ingrained attitudes be changed? I think so. Over time. I don’t think we were always the way we are now. Arguably, the current self-indulgence is not a manifestation or natural outgrowth of the Protestant ethic the country was founded and built on. But perpetuating it is making a lot of people a lot of money, so when that changes, attitudes and then behaviors probably will as well. To use a topical example: When gas prices get and stay high enough, people will go green, and not before.

Q. Now that you’ve been through this experience, what advice would you give to a friend who was considering checking herself into a mental institution?

If you can avoid it, don’t go. At least not to the hospital. If you can find a private group like Mobius, and you feel that you’re an immediate and serious danger to yourself or others, or that being in a protected environment separated from the world would help you, then by all means have a go. You’re bound to get something out of those kinds of places, precisely because they’re built around the idea of personal growth. The best advice I can give in this regard is to never let it get that bad. Try to organize your life in such a way, fill it with supportive people and groups, healthy, healing, and happy-making activities, and regular vigorous exercise, so that you don’t get to the point where you’re on the brink. Lead, as one friend of mine wisely said, a prophylactic existence. Sometimes things get out of hand, I know, no matter what you do, but unless you’re past the point of being able to make decisions on your own behalf, I’d avoid the cold grasp of the institution if I were you, and enlist private help instead.