The Ambivalence of the Asylum

I.

Ten years ago, in Washington, D.C., I stopped taking my medication. I knew the consequences. Eighteen months earlier, a psychiatrist in Chicago had told me that even if I stopped seeing him, I could not stop swallowing these pills. If I did, I would begin to imagine poisons, assassins, hidden cameras, and demons again; I would become erratic, unpleasant, unstable, even dangerous. I could hear that doctor, like an embodied superego who had stalked me from the Midwest to the coast, reminding me that I’d nearly stabbed my roommate in his sleep last time. Did I want to find myself in the kitchen of my new apartment with a knife again? I had a job now, an editorial position at a real news organization. Did I want to lose my job again, having lost so many other jobs? Did I want to lose my mind?

The trouble was that under the haze of psycho­pharmacology, I wasn’t sure if I really had a mind to lose. I worked in a dull stupor. Moving, even standing, felt like an incredible labor. I had stopped reading. I wanted to sleep. I ordered Chinese food every night and shoveled it in and none of it ever came out, just built up like an immense festering airbag in my gut, pressing out and leaving me shuffling and stupid in what was left of my life in this new city. I couldn’t write. I was twenty-five years old and stable and medicated and newly employed. People expected things of me. Before, when I was sick, many people hated me, but they didn’t expect anything from me at all.

I stopped. A few weeks later I was florid, working, energized. I came to work on time and did my job and remained many nights in the empty office producing my own work at an unprecedented pace. I walked around Washington for hours, sometimes in heavy rain, stoked about moving. I made calls, I made plans. I saw people, sent essays off, began to get a little strange and insistent and intense about it all. Six months after the last pill, I was suspended from my job because I would not stop using Twitter.

There was a hospital a few blocks from my apartment with prominent signage for psychiatric services. When I passed it on my walks, I thought, I have to keep it together or they’ll send me there and they’ll make me take my medication. I didn’t want to take my medication again. I couldn’t. But after a few months, I walked by the hospital and thought, If I go in there, they’ll make me take my medication—they’ll make me—and one evening in the early summer, I went in.

Two days later, I came out with a new prescription for a more tolerable drug, and a plan to seek real ongoing psychiatric care. I went back to my apartment, where for the first time all weekend I could see by non-fluorescent light. I took my pills and waited for the comforting descent of nothingness and bloat-gut and mental clarity to come.

II.

We have two visions of the asylum, two stories. The old vision, the one that pervaded the eighteenth and nineteenth centuries and that has begun to re-assert itself here in the twenty-first, is of a refuge. The asylum is a place of healing where the mad—once left to the precarities of fortune, murder, suicide, poverty, locked closets and jailhouses and chaining to the pillars of churches—could instead be treated by doctors. They could take a break from the vagaries of life, be given medicine and therapy, be restored to life itself. In the asylum either the insane are protected from the cruelties of the world or else the world is protected from the insane, who are contained before they become the cruelty, the disorder of the streets. Those visions are the same: the asylum as salvation, either of the mad or from them.

The second vision, more familiar to us for its domination of the twentieth-century imagination, is of a vampire’s castle. The asylum is a forbidding tower on a hill, shrouded in darkness and silence, interrupted only by the irregular wails of terror emanating from within. It is a place of oppression and abuse, both conceptual—it was in the asylum itself, says Foucault, where madness was invented by reason to silence the irrational—and literal, where beatings and shocks and prefrontal lobotomies are carried out against unwitting patients left to fester in padded rooms. This asylum is a prison, designed not to cure our sick or protect our cities but to warehouse our great shame, a place where life is not restored but suspended.

Like all contradictions, these visions mingle freely in our cultural imagination so long as they remain in its periphery. But in debate—which is to say, in any situation where we are forced to look directly at our own views, to clarify and articulate our intuitions—they become fixed, mutually unintelligible, and the basis of violent indignation. Partisans of both visions ask why we don’t do something about the “mental health crisis” in this country, but the meaning of this question depends entirely on the vision behind it. For one visionary, doing something means locking the mad up, forcing them into care for their own good and for the common good, doing what needs to be done. They cannot see why such an obvious problem, the source of so much suffering for patients, for their families, and for society at large, has ceased to avail itself of the dedicated mental institution. The mad are afflicted. They are an affliction. How can we propose allowing them to go on untreated? But for the other visionary, to do something means abolishing our ignorant and violent impulses. It means abandoning the warehouse, actually helping the insane. If you see the vampire’s castle, it is impossible to understand how that blighted place—that place that invents madness, that drives people mad, that has been so thoroughly discredited by its own long history of abuse—could solve the very problem it embodies. These people are sick, they say, or misunderstood. How can you propose warehousing them? Forcing them? Punishing them?

These questions go unanswered. As in all conflicts that reveal themselves, at bottom, to concern the primitive meaning of some object that has transcended its physical reality and become the center of a whole symbolic nexus of ideas, metaphors, social relations, theories of mind, and hierarchies of obligation, there can be no real debate. Only the constant, grinding tension of two hard, incommensurable visions, hardened into stone, pushing up against each other, bloodying the mad between them.

III.

I keep my vision of the asylum out of sight and unresolved, but my experience of the asylum, which encompasses numerous stays in several states, is that it is very tense and somehow, at the same time, very dull. I have never been in any mental hospital where I was not acutely and irritatingly aware of every moment, every cough, every ache of eyes awake too long, every buzz of the big fluorescent lights that have been keeping me awake. The asylum is a strange place, filled with strange people. The rooms and halls are unfamiliar, labyrinthine by design, haunted by odd sounds at all hours and all the more mysterious for the fact that movement is often tightly controlled. Nearly everybody there is insane, and being insane yourself does not lessen the unsettling effect of other lunatics and their particular lunacies. The sane residents, meanwhile, are engaged in secret ceremonies: They are always watching, taking notes, conferring, then disappearing behind closed doors to decide your future. You wait for hours in crowded triage rooms, or in soft, dull two-patient singles upstairs. You attend bromidic group therapy sessions or engage in mutual make-believes with harried junior clinicians whom you have never met before and will never meet again on the pretense that some significant work can be accomplished in the legally mandated seventy-two hours, lest the mandate extend indefinitely. Everything, in short, appears like nothing so much as the manifestation of the psychotic fantasy: a haunted place, shabbily disguised by its insistent sterility, dedicated to a malevolent and persecutory end. The asylum is a machine for inducing paranoia.

After I left the hospital in Washington, and after several years and several more visits to psych wards mainly in the Midwest, I moved to New York in the summer of 2020 with the ambition to stay out of the asylum forever. The plan was diligent, built upon guardrails: half a dozen medications designed to produce tolerable side effects, taken under the supervision of a psychiatrist whose appointments I kept. Weekly therapy for the purposes of monitoring my affect. A job, a routine, an apartment in a quiet part of Queens. Sufficient sleep. I moved to New York with the woman whom I would marry shortly after. She was the first partner from whom I did not conceal my diagnosis and whose opinion of my sanity I was (usually) willing to accept.

We brought two cats. One was an aging Siamese who had belonged to my wife’s late father. Mine was a black short-haired ten-year-old with an uncertain past. I named him Fyodor, not for Dostoevsky, but for his character Fyodor Pavlovich Karamazov, who was fat and lazy and loved to gaze lecherously from high windows, and who, despite his wickedness, was possessed of a simple heart, just like my boy. My wife was still in Paris. I lived in Iowa, alone, on the upper floor of an old Victorian converted into apartments with jury-rigged plumbing and ugly, tight carpets over aging wood floors. I adopted Fyodor from a pound there. They weren’t sure where he’d come from—he’d been feral, or possibly abandoned. They gave him to me eighty percent off. They seemed relieved that anyone would take him. When I brought him home, he hid for three days. But on the third night, after I turned out the light next to my irregularly washed sheets, he snuck into the room and curled against the side of my face and slept.

The eyes of small animals are alert. Fyodor watched me: in bed, in the living room from his perch on the back of the couch, from where he hid on a shelf above my kitchen counter. I became self-conscious about his gaze, then comforted by it. He didn’t cure me of the executive dysfunction that characterizes the day-to-day business of psychotic disorders, but when I ran the faucet in the bathroom every morning he leapt onto the counter and I took my medication on his reminder. He was not the most important part of my new life by the time I reached New York, but I hadn’t been to the hospital once since he’d arrived.

My guardrails were designed to be nearly invisible, to allow me to remain sane to the degree that I largely forgot the daily mechanisms needed to maintain my equinamity. I wanted to be held in place, a tenant of the soft asylum of the superego, rather than the real hospital. My work and routine and apartment would be just that, my marriage just a marriage, my cat just a cat. I logged into Zoom to see therapists and psychiatrists for appointments otherwise unremarked on and unremarkable. I swallowed my medication automatically, adjusted my medication, swallowed more and then moved on. I accepted feedback from my wife. I watched Fyodor jump onto my desk and knock my books onto the floor for attention, held his tail gently between my fingers and followed behind while he trotted from room to room.

But while these structures were preferable to the asylum—they allowed a life, not merely a suspension of time—I found myself, more and more as months turned into years, regarding their totality with the same feelings inspired by the hospital: tension, resentment, paranoia, and chiefly dread. I loathed their delicate arrangement, the deliberate regularity of their purpose, their watching me, too closely.

IV.

Our two visions of the asylum have produced two schools of asylum autobiography: the recovery memoirists and the survivors. The survivors span centuries and continents. They include Elizabeth Packard, John Perceval, Mary Jane Ward, Susanna Kaysen, Shulamith Firestone, and Janet Frame. Some are explicit anti-psychiatrists, some are not. Some conceded that they really were insane, but not most of them. Their books may concern madness, but their subject is the treatment of insanity. Survivor memoirs document the labyrinthine strangeness of their institutions, the perverse tendency of treatment to worsen the disease, the ways in which these patients were severed—sometimes maliciously, sometimes despite the best intentions—from the social reality of the exterior world. The plot of the survivor memoir is inaugurated not by the arrival of madness but by the arrival of police, or paramedics, or a family member saying, “Get in the car. I am taking you somewhere that’s for the best.” The survivors often begin as optimists, naïvely expecting the hospital to help them, or at least for some sympathetic expert to quickly realize that this has all been a mistake and release them with apologies. The action follows their disillusionment. This was not a mistake, and nobody is coming to help. We follow them through a drama of tortures and indignities. Doctors and nurses are incompetent, or sadistic. Abuses are rampant, and even the treatment as prescribed is baffling, ineffective, or actively counterproductive. The asylums themselves—their physical reality, their institutional logic—are opaque, threatening; the memoirs often distort time and spatial orientation in an effort to convey all this menacing strangeness by mimesis. If any solace or solidarity is to be found, it is found in other patient discontents. The survivors learn to subvert the therapeutic ambitions of their prison, to resist, or to ameliorate their madness despite the doctors. The plots terminate, almost every time, when they win their freedom and return to life.

The recovery memoir, meanwhile, largely blossomed at the end of the twentieth century. De-institutionalization combined with advances in psychopharmacology produced Lori Schiller, Kay Redfield Jamison, and Elyn Saks, patient-memoirists who were capable of appreciating their incarceration, and of producing memoirs that mainstream publishing believed might be more palatable to the general public than the radical survivors. The recoverees were not severed from social life by the asylum. They were severed by insanity, and it is the hospital that offers them a way back. They are not naïve. In their memoirs, they tend to enter the asylum skeptical and resistant, either persuaded that they are not mad or persuaded that the “medicine” will only make them worse. The action sees them overcome their own resistance, separate the good doctors from the bad, do the work, and save themselves. The Quiet Room, Lori Schiller’s recovery memoir, refers to a place where disobedient patients are confined and ignored. Schiller initially regards the quiet room as the inner sanctum of the vampire’s castle. But by the end, she embraces it; it is indeed therapeutic, a place of profound peace. Like the survival memoirs, the recovery memoirs often end shortly after release, but the recoverees are grateful. Many of their books are dedicated to named psychiatrists.

Not every mad memoir is set in a mental hospital, of course. In Operators and Things, the pseudonymous lunatic Barbara O’Brien tells us that her “story of mental institutions is short. I couldn’t get into one.” But the asylum is just a vision, a metaphor. The asylum is the whole business of waking up one day and discovering that you have a disability not of the eyes or legs but of the mind, that the coherence of human subjectivity itself is the target of your disease. It is waking up and being told, whether you believe it or not, that you cannot trust who you are, what you want, or what you think, and that you must rely on others—others who might help you, or might abuse you, or might, maddeningly, do both—in order to keep on living, forever. Operators and Things is one of the most detailed accounts of delusional content ever recorded in English.

V.

Plans fail. Three years after I arrived in New York, I locked myself in my bedroom with a kitchen knife, determined to stab myself through the heart. I had been raving for hours, and unsteady for weeks. Fyodor was hiding, waiting for the commotion to end.

I am reliably suicidal several times each year, but I have not succeeded. “A successful suicide,” Susanna Kaysen observed in her memoir Girl, Interupted, “demands good organization and a cool head, both of which are unusually incompatible with the suicidal state of mind.” My head was not cool on this occasion, but I was sufficiently organized—a usable weapon, a locked door—that my wife called 911, and soon the police came and were very sweet as they coaxed me out of the bedroom, then very brusque as they handcuffed me and put me in an ambulance and took me to the hospital.

Police lie. They lie so routinely that they lie without much expectation that you will actually believe them. In the apartment they told me that they would remove my handcuffs in the ambulance. In the ambulance, they told me that procedure required they keep them on until we got to the hospital. Where are we going? Nearby. How long will I be there? They’ll probably just check you out; a couple hours tops. We rattled on for a while, then stopped, and an officer helped me, still handcuffed, out of the back. It was dark and I didn’t see any signs. Two officers escorted me through a back door and down a nondescript tunnel to a small room with a few gurneys. A hospital employee put a wristband on me, gave me a gown and socks, and waited for me to change. I’m sure they just want to check you out and you’ll be home soon, one of the cops said. They finally removed my handcuffs.

An hour later, a nurse instructed me to lie back on my gurney-bed and then wheeled me down the hall to psychiatric triage. The room was full: forty or fifty patients in makeshift rows of mobile beds with a nurse’s station in the center, phone ringing nonstop. The din of the room was mainly murmuring and moaning, all of us in identical gowns, fidgeting in and out of consciousness. There was a row of patients behind me, all catatonic. To my left was a woman still handcuffed to her bed. There were two women in uniform in chairs beside her. She had come from Rikers for psych eval. She told her guard, who had never met her before, how she’d wound up in prison just because she kicked a guy in the ass. Her other guard, who knew her, said, Sure, but he flew. To my right an old man said excuse me, excuse me, excuse me toward the nurse’s station until one of them looked up and he had nothing to say.

An hour went by, then two. Nobody said anything to me. A young man with cropped blonde hair woke and started yelling. He wouldn’t stay in his bed. He didn’t say anything unreasonable. He wanted to leave. An orderly told him he needed an escort for the bathroom. Eventually, three nurses came over. Two held him down and the other “B-52ed” him—fifty milligrams of Benadryl, five milligrams of Haldol, two milligrams of Ativan; the standard psych ward one-shot sedative—and he howled until he shut up. The old man beside me said, Now, that’s not legal, but it was. A middle-aged woman with an Indian accent asked her husband, who was by her bed, if he’d fed their cat. The nurses took the now-sedated man to a small, sealed room in the corner of the ward.

The whole room was bright under rows of fluorescent lights. Somebody on the far side of the room would not stop coughing. I stood up and took two steps toward the bathroom sign. You need an escort to use the bathroom. Okay. I don’t need it. Never mind. I sat back down and didn’t sleep. Hours passed. I took an escort to the bathroom.

A doctor came, a tall young woman with straight black hair. She told me she’d send a psychiatrist soon to assess me for admission to a bed upstairs. The psychiatrist did not come. I began pacing in wider and wider circles from my gurney; the nurses told me to lie down. I yelled this isn’t right and you are making me worse between bouts of weeping.

Patients kept coming in and out. Some of them were screaming. My head burned. I watched a man covered with boils wake up listless and start coughing. The young man with the cropped hair, still under sedation, was wheeled back semi-conscious. Several middle-aged women gossiped somewhere out of sight, but I could smell them, somewhere past the dozen or so men on my row who rocked and mumbled and whispered when the nurses came by. The old man to my right was manic and joking with the orderlies. He knew several on a first-name basis. They played along until he got too close, and then they threatened a shot if he didn’t go back to bed. The psych triage must have been close to an exterior wall; when the din of patients subsided, I could sometimes hear car horns. The vampire’s castle is not usually so close to the city. When the first doctor came around again to check on another patient, I intercepted her. She was exasperated and dismissive and told me to stay in my bed. I said, I’ve missed my meds and I’ve been up all night in this room. Do you think this is good for my mental health? She didn’t say anything. I said, I don’t think you got into medicine to hurt people, because I thought this would hurt her. She walked away.

Freud did not treat psychotics. The difficulty, he argued, was that psychosis resulted from the total abdication of the ego in its duty to contain libidinal and unconscious forces. With no remaining self to speak of, there was nothing for the analyst to attach to, no possibility of transference, and no coherent subject to recover. Better to send them to the hospital. But in 1918, Freud wrote that the trouble with hospitals is that they “make everything as pleasant as possible for the patient, so that he might feel well there and be glad to take refuge there again from the trials of life.” He may have been envisioning the old asylums for the European bourgeoisie, clinics with tennis courts on great blue lakes in Switzerland; certainly, he was not envisioning the triage room of a busy hospital in Queens. But even when the hospital has not made anything pleasant—when it is so unpleasant that one cannot possibly feel well there and is not glad at all—it is still possible to be seduced by the promise of refuge. I felt as if I had been kidnapped: by my wife, by the police, by the doctors and this hospital. But I also wondered if I hadn’t given myself up too easily. Why take the knife into the bedroom? Why make a big show of it? Why do this over and over if you really don’t want it at all?

A nurse came by and told me that the psychiatrists had all gone home hours ago. Somebody would come by in the morning. I didn’t know what time it was. The appeal of the hospital is that it doesn’t matter because you have nowhere to be and nobody expects you to know what time it is, or to care if time goes on in here at all.

VI.

In both the survivor and the recovery memoirs, a scene arrives: The asylum, once hated, is now longed for; the asylum, once longed for, is now hated. The hospital is good for the narrator but terrible for others; it is terrible for the narrator but good for someone else. The lunatic discovers an opportunity to escape, or does, or simply considers the possibility of leaving the institution, and he implodes. The two visions collide, and the result is a crumpling of the prior logic of the text, a contradiction that arises in the interstices.

In her memoir Reluctantly Told, published in 1926, Jane Hillyer recounts an attempt at escape. She unlocks an upstairs door by slipping her hand through the wire netting. “I walked down the hall,” she writes. “I was going out.” Downstairs she finds the reception area empty. She goes outside. Nothing is stopping her from leaving the hospital for good. But “there was a certain restfulness” about the scene, she remembers, “a quiet that was almost country.” She decides to sit down on an old rocking chair on the porch and rest. Not long after, two nurses discover her and return her to her room. She doesn’t put up a fight. But upon finding her door newly reinforced, she explodes: “I was locked in! I was locked in,” she wails. “I had given up; I had done it to myself.”

Forty years later, in Cambridge, Massachusetts, Susanna Kaysen is trapped in the “parallel universe” of McLean Asylum. She isn’t crazy, she tells us in Girl, Interrupted. Some doctor had committed her after a fraudulent fifteen-minute exam. She dedicates chapter after chapter to an assault on psychiatry: on her therapist, her doctors, and her diagnosis, which was delivered in the form of patronizing, vaguely sexist psychobabble. At one point, she and her friends try to help another patient, a woman named Torrey, escape before she can be sent back to her parents. They give her a little money and tell her to jump out of her taxi at a red light and go to Boston. But the plan is foiled when, before the trip, a nurse gives Torrey Thorazine, a powerful antipsychotic. She becomes hazy, slow, compliant—unable to execute her escape, and worse, uninterested in even trying. Later that night, a restless Kaysen becomes preoccupied with her hand. She thinks there are no bones inside. She starts scratching, trying to peel the skin away. Then she bites down hard, drawing blood. “What the fuck are you doing?” her roommate asks. A nurse rushes over, giving Kaysen her first ever shot of Thorazine. As she’s carried off, Kaysen asks if it’ll be okay. “My voice was far away from me and I hadn’t said what I meant,” she writes, “What I meant was that now I was safe, now I was really crazy, and nobody could take me out of here.” Then the chapter ends. On the next page, Kaysen is eating meatloaf when she realizes she has a toothache.

In 1998, in Airless Spaces, Shulamith Firestone tells us about Rachel, who feels “so imprisoned” in the hospital that “had she had a calendar she would have scratched off the days.” But to what? Her “date of discharge was always unresolved.” When she does come out, she is “fat, helpless, unable to make the smallest decision, speechless, and thoroughly programmed by the rigid hospital routine.” She eats and exercises and sleeps at precisely the times she had on the inside. Then Firestone tells us about Mrs. Brophy. She is happy to be released, but “once the initial Welcome Home had been exhausted of any love or care therein, and it all became too much for her again,” she “began to long for a hospital to bottom out in. . . . She began to find excuses to hang around in the vicinity of [her hospital] Beth Abraham.”

What is notable about these moments, and others like them littered throughout the memoirs of the mad, is not the extent to which they reflect the conflicting motives of their authors as they stagger through the fog of mental illness. It is not merely mimetic of the strangest part of madness, that impairment of subjectivity itself, still echoing through the self-translating act of autobiography. Nor is it even, as notable as this may be, how universal such moments are in mad memoir, how they appear across centuries and countries and contrary ideologies. What is remarkable is that they are unremarked on. They arrive without warning, and depart without ceremony or reflection. They occur in passing, or end chapters; they do not form part of the conscious dialectic of the asylum narrative, nor inaugurate a wrinkle to be explored through character development or plot. They appear because they are essential to the mad experience.

VII.

I knew it was morning when the nursing shift changed. The prisoner and her escorts had gone; in her place was an enormous man, asleep or sedated, with boils on his face and some kind of scarring on his hands, whose eyes shot open every fifteen minutes or so as he let out several thunderous coughs before settling back down on his pillow. I hadn’t slept at all. I paced. I took an escort to the bathroom just for something to do, but it reeked. I still had not seen a doctor, but they let me make a phone call. I called my own cell phone—the only number I knew—and my wife picked up and promised to come soon.

She arrived an hour or two later. I cried, and apologized for the night before. I wanted, like anyone who finds himself among the dead, to be assured they are still welcome among the living. I was terrified. I assured her that I was feeling better. Nothing about the twelve or fourteen hours in the hospital—nothing about the seventy hours that could still come—had altered the desires that had brought a knife to my chest, but the feel of the handcuffs and the bumps of the ambulance ride and the sleepless night among coughs and moans had inspired the sharp, adrenaline-edged feeling of reality that I imagine other suicides must feel when they leap from rooftops and begin hurdling toward the ground. The psychiatrist finally arrived mid-morning. He asked me the standard questions: Are you going to kill yourself? Are you going to try to kill somebody else? If you do want to try, will you come back? I said no, no, yes, and he walked away. When the first doctor passed through the ward again, she avoided me. The old man still to my right mumbled bullshit, bullshit, bullshit and went back to sleep.

Hours passed. The intervals between my outbursts got short. I lay down when I could until I began crying, then stood and began heckling the orderlies again. I had not slept in thirty hours. My wife was nervous; she asked me, please just try to calm down. The psychiatrist and the other doctor came back in the afternoon and asked to speak to her alone. I don’t know what was said. But she must have told them that I had a home and she could vouch for me and she thought that I’d be fine, because when the psychiatrist came back, he told me I’d be discharged right away. I waited another two or three hours. The man with the boils disappeared; the man with the cropped blonde hair, able to stand and walk again, was escorted upstairs. Two nurses discussed their difficulty identifying a small woman with scrunched features and long hair who did not speak and had come in without identification. I harangued the nurses. Eventually, one of them handed me a Ziploc bag with my clothes and shoes, and we went out into the sour orange light of the late afternoon.

Now secure, I was furious with my wife. Before we were married, I had made her promise me that she would never have me committed to a hospital. She told me that she had had no choice. I’d had a knife. I’d locked the door. She tried. I stayed angry because it is easier to be angry than ashamed. It is terrible to be a bother and a terror, to know that you are dependent and to resent those you are dependent on. It did not occur to me then that when the doctors took her aside and spoke to her, she must have known that I had gotten no actual treatment there, that I was angrier and more desperate and deranged than I had been the night before. She felt guilty for calling the ambulance—I had made her feel guilty for calling the ambulance—and had been forced to choose between my safety and my wishes, had to gamble that my freedom was more important than the possibility that I would go home and end my life, had to fear how I would react if she told them to hold me for a couple days. I don’t think any of that occurred to me until just now.

When I arrived home, I buried my face in Fyodor’s gut. I lay down on my bed, and he stood on my nightstand and stuck his chin out to be scratched. I put him on my chest, but he went and curled up between my knees, the same place where he liked to sleep at night. We have a vision of cats as independent creatures. but this is an act of projection. Like all mammals, like us, cats are social animals. They trust us. But they are incapable of understanding why we do anything we do. He loved to be kissed, but if I kissed him one too many times, he would punch me right in the eye.

A few months after I left the hospital, Fyodor was diagnosed with a mild infection. He received antibiotics, then seemed better, then stopped eating. Further blood tests revealed nothing. He went from twenty to twelve pounds from mid-summer to mid-fall. The vet shaved his gut, leaving a pale white patch of lumpy flesh in his black coat, and scanned, but found only some mild inflammation of the pancreas. He stopped drinking. Then he drank only from a human cup. Then he stopped. Then he ate only plain poached chicken, which my wife and I prepared for him, then he ate only treats, until he stopped with those. He seemed to get worse after every visit to the veterinarian; at home, he hid under the bed for hours. I am sure that he believed that the pain and terror he felt in those months was the result of the care—the torture—that we put him through. But perhaps that is just projection too.

When he finally refused to eat for three straight days, I took him to an animal hospital. He hated the car and cried all the way there. They’d keep him overnight, give him fluids and nutrients by I.V., and run tests in the morning. At home I was relieved that for the first time in months, I did not have to watch him from the corner of my eye and pray that he would eat, pray to see his chest rise and fall with his breathing. I suppose that this is how my wife felt while I paced around the crowded psychiatric ward.

VIII.

The ambivalence of the asylum is not a result of confusion but of clarity. The trouble is that madness is not a misunderstanding or a mere category of identity, but a species of disease. You may need the asylum, but it really is a vampire’s castle: They really did those lobotomies, really locked men in padded rooms and dunked them in freezing water. You may need the asylum, you may depend on care, but the caretakers really are sadists to be survived sometimes, and there is nothing worse than being hurt by those whom you depend on.

The trouble is that you may need the asylum, and even if it doesn’t hurt you, who among the dependent does not hate to know the extent of their need? Anyone would rebel against being told—or worse, against knowing for a fact—that they need to be minded forever, and there is nothing worse than knowing the true extent of your dependence.

The trouble is that we want to live our lives in real time, among the living, but the world really can persecute—disdain and stigmatize and even kill—the palpably insane. Even mundane things can be utterly overwhelming to the diseased mind. The newspaper sees homeless schizophrenics on the street and wonders why they don’t get help, as if there is anything appealing in all the difficulty and time of the hospital, the appointments, the medication forever, all in service of—what? Getting a job and owing taxes? There is nothing worse than living free and dying of bigotry or boredom.

The trouble, most shameful of all, is that sometimes we want to depend. After the hospital, after the medication, after the therapy, the lunatic finds the world that up until this point has been so fervently insisting upon the vision of the asylum as sanctuary now expects him to get back to the business of living. You’re granted the freedom you’ve been asking for only to curl into a ball and weep for comfort, and have those caretakers, whom you have just finished resenting for their care, resent you for asking to be taken care of.

The ambivalence of the asylum—which is to say the ambivalence of all treatment, of the whole condition of lunacy—is not the hazy ambivalence of feeling conflicted, of not yet being clear, of not having thought things through, but the ambivalence that comes from seeing the situation plainly and finding it impossible. This can be tolerated with discomfort when it is not forced to the surface by crisis, or by the demands of putting one’s experience to words, but the analyst knows what happens when two incommensurable visions are forced before our eyes at once: The patient implodes, or explodes; goes catatonic or murderous or suicidal, or passes into stunned silence, or develops a sudden toothache.

IX.

I was home alone when the veterinarian called. They had run some tests that morning, and although a scan of Fyodor’s abdomen had revealed nothing just a month before, it now showed multiple tumors and fluid filling his intestines. I went to the hospital and picked him up. In the car I opened up the top of his carrier and scratched him behind his ears. I told him, You never have to go in the car again, buddy. You never have to go to the doctor again.

He lived in our apartment for three days. We made him a bowl of whipped cream, which he barely touched, taking just a couple licks off of my finger. He hid behind our bed frame, or slept in a little orange cat bed in our office. He still purred when I brushed his head with his little green plastic brush, and pushed his cheeks into the bristles when he could. On the third day, a veterinarian came to our home. He examined our other cat in the kitchen while I sat with Fyodor next to his orange bed, stroking his back and weeping. You saved my life, I said. I said it over and over and I believed it. The vet gave Fyodor an anesthetic and said it would take ninety seconds to kick in. My wife and I held him in the corner, beneath a window where he’d liked to sit and hiss at birds. I stroked his cheeks with his brush, and he fell asleep for good. I carried his limp body back to the vet, who administered a barbiturate overdose, and I spent the rest of the day out of my mind. The next morning, I forgot to take my medication.

A mile from my apartment there is a park on the East River, and across the river is an island with two towers: Manhattan Psychiatric Center, an ordinary mental hospital, and the twelve-story Kirby Forensic Psychiatric Center, a maximum-security institution for those once called the criminally insane. This is the vampire’s castle, although the drab, yellowing-brown stone walls, the gaggle of satellite dishes and metal receiving towers sticking out from the roof, the runs of indistinct windows have always put me more in mind of the satellite cubicles of a large insurance corporation than two of the oldest bug houses in New York. I have never been to either of these hospitals, but they are where, in my fantasies, I would go if I had to go into asylum again: Manhattan Psych if I’m lucky, Kirby if I’m not. I have stayed out of the asylum for years now. I am in remission. I have gone back to accepting my dependence on my wife, on my psychiatrist, on my therapist, on my friends. But I still resent it. And I am still possessed—when faces or rooms seem wrong, when my wife asks me whether I feel okay, when I am overwhelmed by small things, when I miss my cat—by a longing for the island, by a desire to be cradled and protected and soothed by people who expect nothing of me, even if they keep me up all night and hurt me.

The mad, like cats and everyone else, are social animals. We are all utterly dependent, in birth and in death and at an interminable number of points in between. We all have visions of the sanctuary asylum and the resentment that comes with it. We are all struck by the sight of the vampire’s castle, the vision of our own need, and admit, in quiet moments, to the longing it inspires. The sane are only different from the mad—or perhaps the healthy are different from the young and old and variously ailing; that is to say, different from themselves, at different times in life—in that it is easier to let these visions intermingle in the periphery, to never really force the issue and be stricken dumb.

The most abiding and productive fantasy of Western culture is the individual. I do not mean this as a matter of attitude—the rugged individual man who relies on himself in all things and votes conservative—but the notion, in total, that particular lives exist as historical phenomena unto themselves, self-sufficient, with the narrative unity ordinarily reserved for fiction. We are, it is almost too obvious to say, preoccupied with our belief in our own freedom as agents of a personal history. Perhaps less obvious is how this is true not only in our ambitions but in our fears. We live in an era defined by a particular sense of dependence, of helplessness, of reliance, at all times and in all things, on complex systems of technology and social organization that almost nobody understands in full. And yet the abiding anxiety of American culture in the twenty-first century is of being scammed, of falling victim to manipulators, misinformation, and liars. The form these predators take depends on one’s politics, but the lesson is the same: In any situation where you may need to rely on another, whether for emotional intimacy or reliable public policy prescriptions or even medical care, there is nothing worse than to discover that you have been tricked or abused. The shame is almost worse than the injury.

Georges Gusdorf, the chauvinist father of the study of autobiography, took this delusion to be a precondition of the genre itself: “The concern, which seems so natural to us, to turn back on one’s own past, to recollect one’s life in order to narrate it, is not at all universal,” he wrote. “This conscious awareness of the singularity of each individual life is the late product of a specific civilization. Throughout most of human history, the individual does not oppose himself to all others; he does not feel himself to exist outside of others, and still less against others, but very much with others in an interdependent existence that asserts its rhythms everywhere in the community.” Gusdorf, writing in 1956, believed the individual really could exist outside of others. He believed the West, unique among civilizations, had escaped the vampire’s castle for good and invented memoir as a result.

In Roland Barthes by Roland Barthes, the great deconstructionist set out to show that Gusdorf was mistaken. There was no integrated subject, no real “I” in life, much less on the page, capable of cohering across moments or years, independent of the dizzying communal nexus of language and culture. Roland Barthes is a startling book, a memoir premised on disintegration, but it reads at times like the product of the rare, brilliant schizophrenic of the romantic imagination: an endless series of digressions punctuated by moments of striking clarity. Barthes lived much of his adult life with his mother. When she died, his whole work turned over to mourning the sanctuary of which he’d never been ashamed, and now had lost forever.

Any delusion, a psychiatrist will tell you, is volatile. It must be met with a kind of neutrality, neither explicitly affirmed nor denied. Otherwise, the results will be explosive. I suppose this must be true of ordinary delusions as much as it is of psychotic ones. During my first few years in New York, I suffered from the occasional belief that my apartment and my neighborhood and perhaps New York itself were all built upon the deck of an immense hospital ship anchored somewhere in the ocean. I believed my wife and my friends and the old men who looked up as I passed them smoking cigars outside their shops on my street were all orderlies working to keep me on the narrow path. This delusion was never detected by a professional because it never struck me as worth mentioning. Everybody knew, and it was all designed for my benefit, so what was there to point out or protest? It is not uncommon for a delusion to incorporate awareness of its impossibility into itself, to swallow up its contrary visions, to see the irreconcilable conditions that give rise to the mistake, and, unable to be silent, simply absorb them into the content of the mistake itself.

X.

In Asylum Piece, Anna Kavan tells the story of Marcel, her disgruntled tennis partner in their Swiss clinic, who ditches a doubles match they’re set to play and wanders off across the grounds. He reaches the edge of the lake that separates them from the interior coast of France. Noticing that the staff is distracted by other patients, he commandeers a rowboat and begins rowing frantically away. “Soon he is far out from the land, alone in his boat in the midst of the practically colourless expanse of smooth water. . . . It is further than he expected across the lake, but before very long the French coast is appreciably nearer.”

Until now, Marcel has been “occupied solely with the physical effort and with the elation he feels at his own enterprise,” but as the shore approaches, he must plan. He rows parallel to the shore for a while, looking for a secluded place to disembark. He must not be caught. He must find those who have wronged him—his wife, his business partner, everyone else who conspired to have him put away—and take back his life from them. But then he stops. “He brings the boat close to the shore but makes no attempt to disembark. He sits still, with the oars trailing in the water and the sweat slowly drying on his face which now begins to acquire a look of uncertainty.” He waits awhile longer. Then, suddenly so tired, and feeling so much older, “his eyes empty and downcast,” Marcel begins the long journey back toward the other shore.