On the morning of August 8, 1894, a long line of horse-drawn carriages raised the summer dust on Broadway, turned right at the porter’s lodge at 115th Street, and entered the spacious grounds of the Bloomingdale Insane Asylum. In front of West Hall, a large brownstone building that was home to the female patients, thirty women of varying ages stood waiting, dressed in traveling clothes. With them stood Dr. Samuel Lyon, the superintendent of the asylum, along with the physician in charge of women and several attendants.
Some of these patients had lived in the Bloomingdale Asylum for many years (one had been there for nearly half a century), others for only a few months. The asylum’s property, thirty-eight acres of prime real estate, had been sold. After seventy-three years on Manhattan’s West Side, the asylum was moving twenty miles north to the village of White Plains in Westchester County. Dr. Lyons had chosen the most “tractable” and cooperative patients for this first trial day of the exodus. In all, some three hundred patients suffering from a variety of illnesses including mania, melancholia, dementia, and alcoholism, had to be moved.
Under the watchful eyes of the two doctors, the attendants helped their charges into the carriages. The drivers set out to the northeast, crossed the Harlem River into the Bronx, and pulled up next to the stone railway station at Mott Haven. There, private cars had been added to the train especially for the asylum’s use, and when all the women were seated the attendants locked the doors. In less than an hour they arrived at the White Plains station, the patients entered closed horse-drawn carriages once again, and were driven to the new asylum buildings where the staff waited to settle them into their assigned rooms. For those patients likely to be troubled by unfamiliar surroundings, the furniture from their old rooms had been moved into place.
Dr. Lyons returned to the city to prepare for the following morning, when the next group of patients would be moved. The process continued through August and September. More elaborate plans had been made for special cases: ambulances would transport bedridden patients; those who were agitated, violent, or unpredictable had to be taken separately, accompanied by strong guards. Wealthy patients, whose families paid for special treatment, could travel with their private attendants apart from the group. The very last patients to go, because their new residence was still incomplete, were the dozen or so men who lived with their servants in a handsome brick house at the Bloomingdale Asylum called Macy Villa. The villa, only recently finished, was built to accommodate patients who wished to live in the style they had known before coming to the asylum. These patients would be moving into a new building much like it, which would be connected by an underground passage to the residence of Dr. Lyons.
The transfer of a major urban institution to a new location was a task of serious magnitude. Planning had taken five years, construction had taken two more. By October the move was complete, and the new asylum held an open house. Journalists arrived, along with the curious public, the families of patients, and the board members of the Society of the New York Hospital, whose funding had been necessary to the whole process. The next day, under the headline “New Home for the Insane,” The New York Times reported that “Everything was found in the best of order, and the buildings and their admirable arrangement were praised by everyone.” The thirteen redbrick buildings were designed with secure access to one another as well as to sunlight and fresh air: “This new Bloomingdale is of the class called pavilion hospitals . . . which afford convenient and protected access to all parts of the wards from every other ward.” The connecting corridors looked out onto the grounds so that patients, “in being transferred from one section to another, will get as much change of view as possible to break the monotony of their daily routine.” A ward for suicidal cases was designed so that the staff could see all patients at all times.
A great deal of thought had gone into creating a pleasing social atmosphere for both patients and staff, who would spend time together in the dining rooms and in the living areas located in the central part of each hall. The asylum’s therapeutic effect depended in part upon the patient feeling comfortable in the community. Each patient’s day would be structured with activities and exercise, and the facilities, which included a theater, a library, and a social amusement hall, would provide many choices. The buildings would amply accommodate over four hundred patients, as well as the doctors and staff who would live there. Like the asylum it replaced, the new Bloomingdale had a fine view. It stood on the ground occupied formerly by a three-hundred-acre hilltop farm, and this generous acreage, now reduced by a third, provides a buffer for its proximity to the busy Cross-Westchester Expressway. The firm of Frederick Law Olmsted created a landscape design that included gardens, a golf course, and tennis courts.
Almost ninety years on from the August morning when the patients first set out for White Plains, I was allowed access to that inviting outdoor space after eight weeks of confinement indoors, once shock treatment had returned me to something like my former self. It was early May, and the grounds were vivid with bright green lawns and flowering trees. The formerly rural asylum stood at the edge of the busy White Plains business district, and traffic zipped along the tall fence at the property’s limit. While the surrounding countryside had disappeared, other aspects of the 1894 asylum were unchanged. My long walks with one of the staff to and from the shock treatment room in another building had taken me along those connecting ground floor corridors mentioned by the Times reporter, giving a view to the outdoors along the way. I remember the calm of those corridors, strangely quiet and empty, and their gleaming, immaculate floors. At the time, I vaguely knew that this was supposed to be a very good hospital, but I didn’t know of its importance as one of the first institutions in America to provide care for the mentally ill.
Everywhere, the hospital’s grounds revealed traces of its long history, although modern buildings had been added and old spaces adapted to new therapeutic uses when their original uses proved outdated. The tiled surroundings I noticed in the shock treatment room suggest that the room was designed for hydrotherapy, where agitated patients were wrapped in wet sheets or restrained for hours in supposedly calming baths. Psychotropic drugs, ECT, and psychotherapy now took the place of hydrotherapy, insulin coma treatment, and other superseded treatments of the asylum’s earlier decades. Some of the illnesses had new names: bipolar disorder, major depression, obsessive-compulsive disorder. Gone were the terminal patients with general paresis; with the advent of penicillin, syphilis was no longer a cause of insanity and death. And the asylum had been renamed: in becoming the Bloomingdale Hospital for Diseases of the Mind in 1910 and then New York Hospital—Westchester Division in 1936, the former Bloomingdale Asylum for the Insane had, nominally at least, sloughed off the stigma of insanity.
We who were patients there in the mid-1980s felt that stigma nonetheless. Cultural attitudes are pervasive, and we tend to be unconscious of having absorbed them. Without knowing anyone who had been in a psychiatric hospital, I had resisted my psychiatrist’s urging that I sign myself in, for fear of what the words “mental patient” would do to my sense of self and my future prospects. When I was a child we would occasionally drive past the notorious Byberry state hospital in Philadelphia, and a shiver of morbid curiosity ran through us each time because our mother had told us that the best man at her parent’s wedding—a man we knew from the photograph, dressed in 1920s finery—had been confined there. I was much luckier than he, with a private room in a private hospital. Looking back on the impact of having lived for three months in a former asylum I can see that the worst time of my life had some redeeming aspects because of where I spent that time.
Historically, for both good reasons and bad, the mentally ill were kept apart from society. The belief that the insane required not a space for imprisonment but one of sanctuary, a protected place for recovery in which nature would play a healing role, only emerged in the nineteenth century. My experience of a fairly extended stay has more in common with nineteenth than twenty-first century treatment in this respect. Today patients are treated more briskly, often on an outpatient basis. It’s expensive to stay in a hospital for any length of time, and insurance companies want to limit costs as much as possible.
By 1894, the Bloomingdale Asylum was subject to a different kind of economic pressure from that faced by psychiatric hospitals today—not from health insurance companies but from real estate investors. The fear of a stigmatized institution’s effect on local property values was what forced the move. The day after the asylum’s opening in White Plains, The New York Herald published a detailed description, like that in the Times, full of praise for the new arrangements. But as the voice of business interests who wanted access to the asylum’s valuable land, the Herald had campaigned tirelessly to force it out. As the neighborhood grew more urban, the Herald’s crusade appealed to many who wanted the insane to be not only out of sight, as they had been in this quiet location for many years, but out of the way.
In 1821, when the asylum opened as the psychiatric branch of the New York Hospital, the plateau between the Hudson River and the Harlem valley was rural countryside, seven miles north of the city. There were open views to the Palisades across the Hudson, and across Long Island Sound to the east. The asylum was named Bloomingdale after the locale, which Dutch settlers had called Bloemendaal, a flowery dale. In an early print, the wide Federal-style building stands on an open knoll. A sailboat can be glimpsed on the Hudson immediately to the west, two figures stand on the sloping lawn, and several deer browse amid wildflowers in the foreground. In 1846, the writer of a guidebook to New York City described the “lunatic hospital” as a surprisingly beautiful place, praising it as a model of landscape gardening that would help to “relieve the melancholy mind from its sad musings.” Because fresh air and quiet surroundings were believed to be curative, early asylums placed a strong emphasis on their gardens and enclosed as much outdoor space as possible. By the time of the move to White Plains, several more buildings had been added to accommodate the growing number of patients, but the property held on to traces of its rural beginnings. A pasture, vegetable gardens, and some barns were features to the north and south of the cluster of buildings.
By the 1880s, the rapidly expanding metropolis pressed right up against the property. A row of brownstones stood at the southern edge of the asylum’s land, along with some ramshackle wooden houses. The country homes of wealthy merchants dotted the high ground above the river’s edge. With the city’s street grid filling in as construction pushed north, real estate developers and investors wanted to get their hands on the asylum’s very fine views and extensive acreage. The Herald began to draw negative attention to the asylum in 1886. Under the headline “Remove Bloomingdale!” the paper declared that the presence of “the famous madhouse” was causing people seeking to walk from Morningside Park to Riverside Park to make a considerable detour because streets ended at the asylum’s fenced enclosure. Real estate brokers complained that people wouldn’t risk having the asylum as a neighbor, and politicians urged that there could be “no neighborhood, no development . . . so long as lunatics are stored in that madhouse.” Why not move what was essentially a human storage facility out of the way of progress and profit-taking? The New York Times, too, voiced that obsession with real estate that continues to excite the minds of New Yorkers: the Times agreed that the asylum was standing in the way of the creation of “the most magnificent park and residence district in the known world.” In response, the hospital’s board of governors was implacable. “We will go, but we will not be driven,” said one of the governors to a Herald reporter. Capitalist aggression was not in line with the ethics of the hospital, whose mission had always included providing care for the insane, and whose governors came from old money families and looked down upon the upstarts flooding their city.
Among the possible new locations that the governors explored was the White Plains farm they had bought in 1868 in the knowledge that rapid urbanization might eventually force their relocation. The farm supplied fresh meat and vegetables to the asylum, and patients and staff stayed in cottages there on visits to the countryside. When the governors decided to move the institution to that property, they chose someone they trusted to oversee the project. Charles Nichols had spent a few years as superintendent of the Bloomingdale Asylum in the 1840s before being hired away to take on the creation of a national asylum in Washington, D.C., known today as St. Elizabeth’s. Returning to New York as superintendent during the transition, he would lead the task of planning the new asylum. In 1889 the hospital board sent him to visit the best European institutions, seeking models for what the Bloomingdale should provide its patients. He returned from Europe and made his report before dying of cancer within months of his return, and it fell to Dr. Lyons to implement Nichols’s suggestions for creating a fully up-to-date asylum.
This project reached its completion with the transfer of patients in the autumn of 1894. Shortly before the move, the agitators of the Morningside Park Association learned that the New York Hospital had sold the asylum’s property to Columbia University for two million dollars. The university, which would move north from Madison Avenue and Forty-Ninth Street, would increase the value of surrounding property, but no one would be able to buy and sell the many building lots the asylum’s land would have yielded. The sole architectural vestige of the original asylum, the brick residence for wealthy men called Macy Villa, is now Buell Hall on Columbia University’s campus—a five-minute walk from where I live.
BY THE TIME I WAS admitted to the former Bloomingdale asylum, the New York Hospital had been caring for psychiatric patients for nearly two hundred years. The approaches to treatment in this single institution reflect the faltering, trial-and-error path of psychiatry itself. If mental illness, varied as it was, still lacked surefire cures in my time there, treatment methods were far more humane than they had been at the time of the Hospital’s founding in 1771, when New York was still a British colony. Right from the start, the building plans included “wards or cells for the reception of Lunatics” in the basement of the hospital. Fire, a yellow fever epidemic, and the Revolutionary War interrupted construction, but in 1791 the hospital opened at Pearl Street and Broadway, then the northern edge of the city. By 1792 it was taking in mentally disturbed patients along with those in need of medical and surgical treatment. Those cells set aside in the general hospital quickly grew overcrowded, and a new three-story building, called the Lunatic Asylum, opened in 1808 to accommodate mentally ill patients separately from medical ones, so that “the sick are not incommoded by the lunatics.”
Among the early documents from the New York Hospital are receipts for the purchase of chains, leg irons, and iron staples for attaching chains to the walls, and there is at least one reference to these chains being used for lunatics. We have an idea what confinement was like for Colonial-era insane patients from a description of Philadelphia’s hospital. According to a visitor, the cells were “partly underground,” and “made as strong as a prison. . . . In each door is a hole, large enough to give them food, which is closed with a little door secured with strong bolts.” In warmer weather, the patients in Philadelphia could take the air in an outdoor barred enclosure, much like a cage in a zoo. Going to gaze at the lunatics became such a popular entertainment that in 1762 the hospital decided, supposedly in an effort to discourage such visits, to charge admission. Nonetheless, visits by the public continued until the 1830s.
In the Colonies, as in old Europe, there was no question that the social order trumped the good of the disordered individual. Philadelphia’s Pennsylvania Hospital set aside space for the insane in 1751 in the hope that “the wretched maniac, sequestered from society, might be made subject to such regiment and regulations, which if not always the means of recovery, would at least insure safety, decency and order.” The New York Hospital followed suit, providing “a place of safekeeping” where the mad would be “disabled from injuring themselves and others.” Until the early nineteenth century (and beyond, in less progressive institutions), binding in chains was standard treatment for the so-called raving maniac, the person who was agitated, violent, or uncontrollable.
Two strands of philosophical and religious thought emerged in the late eighteenth century to bring about more humane practices. One was a belief in the rights of man, exemplified in post-revolutionary France by Philippe Pinel. The other, promoted by the Quakers, was a belief that all human beings share the divine inner light, and that the loss of reason does not alter a person’s essential humanity or spiritual being. Enlightened doctors of the time came to believe that insanity could be cured or diminished through a shift in the mode of treatment: to house the insane in home-like settings designed to be calm and healing, and to replace beatings and chains with a doctor who would listen to them and treat them well. This idea that madness could be alleviated through kinder treatment, and in a special sort of institution, was the impetus for a wave of asylum building.
Philippe Pinel usually gets the credit for beginning this revolution. When Pinel was appointed to be physician in charge of the men’s hospice at Bicêtre outside of Paris, criminals and the insane were imprisoned together, chained in stone cells on beds of filthy straw. This was in 1792, during the Reign of Terror. In that revolutionary moment, the story goes, Pinel had his assistant Jean-Baptiste Pussin remove the chains from all but the most violent patients. Many had been immobilized for so long that they could not walk. According to Pinel’s son Scipion, an official of the Commune visited and asked Pinel, “Look here, citizen, art thou mad thyself, that thou wilt unchain such animals?” Pinel reportedly replied, “These lunatics are so unmanageable only because they are robbed of air and liberty; and I dare to hope much from the opposite means of treatment.”
Unfortunately, there is no evidence that this dramatic meeting ever occurred, but Pinel expressed much the same belief in his writings. He called this opposite means le traitement moral—the French phrase conveys something like “treatment of the mind” or “psychological treatment.” Pinel was certain that bleeding, purging, and other bodily remedies of the time were useless. English and American asylum doctors soon followed Pinel’s lead and adopted his term, “moral treatment.” What was most important about Pinel’s approach was his belief that the insane should be treated in a way that did not deprive them of their human rights.
In 1790, two years before Pinel arrived at Bicêtre and just before the New York Hospital opened its doors in lower Manhattan, Hannah Mills entered the York Asylum in England. She was a young Quaker, poor, recently widowed, and suffering from melancholia. After a few weeks had passed, her family, who lived at some distance from York, asked some acquaintances to go and see how Hannah was faring. The doorkeeper refused to let them in, saying that she was not in a condition to be seen. Within six weeks of her admission, and before anyone could see her, Hannah died. The cause of death is unrecorded: it’s likely that she committed suicide or contracted a contagious illness in the asylum.
The death of Hannah Mills awakened the Quaker community in the north of England to a grim realization: any one of their members could fall ill and be lost to them, to die alone without the solace of their faith. The case also led many to believe that the practices of the York Asylum were corrupt. Founded in 1777 as a charitable institution that would take in patients in “low and narrow circumstances” whose families would have difficulty looking after them, the York Asylum was meant to be a humane alternative to confinement in the poorhouse or the jail. But an investigation found that the physician in charge was skimming money from the public funds meant for the pauper patients, whom he neglected, while taking in paying patients to whom he gave the best food, rooms, and care. The investigators found that abuse of poor patients included “fatal neglect,” rape, and whippings.
Soon after Hannah Mills’s death, William Tuke, a Quaker tea and coffee merchant already active in support of abolition and prison reform, sought donations to build an asylum that would protect others from a fate like hers. The name of the new Quaker asylum, “The Retreat,” was meant to convey the idea of “a quiet haven in which the shattered bark might find the means of reparation or safety.” The Retreat opened its doors in 1796 just a mile from the York Asylum, and stood as a public rebuke to that institution during the years it was under investigation.
Like Pinel, Tuke called his method “moral treatment.” Also like Pinel, he did not believe medical treatment effective in cases of insanity. Instead, he believed that if patients were treated with kindness they would come to like and admire their keepers and wish to be esteemed in turn, which would encourage them to exercise more self-restraint. Moral treatment assumed a childlike quality in the insane and emphasized the paternal role of the caretaker, who might wield the power of fear, shame, or kindness as needed to bring a patient under control. The atmosphere was domestic, and at the outset about ten attendants lived with and cared for thirty patients. The superintendent and his wife lived in the house as well and acted in a parental role. A medical doctor visited, but did not live on the premises.
The results at The Retreat were remarkable, and English and foreign visitors were soon convinced of the value of the Quakers’ innovation. (It has been noted that the Quaker culture had, from birth, instilled in these patients a willingness to cooperate and to exercise self-control; in the larger, secular, and diversely populated asylums modeled on the Retreat, positive results were not so reliable.) News of the Retreat’s success spread quickly to Quakers across the Atlantic. William Tuke’s grandson Samuel wrote a small book on the experiment that would have an enormous impact in the history of psychiatry, providing a conceptual foundation for the ensuing era of asylum-building.
THE HOSPITAL IN WHICH I was treated was indebted to these emerging ideas of moral treatment and originated in the efforts of Thomas Eddy, another Quaker merchant, who was on the governing board of the Society of New York Hospital. He had corresponded with Samuel Tuke and had read his book. Because the freestanding Lunatic Asylum adjacent to the general hospital in lower Manhattan was overcrowded after only five years, Eddy urged his fellow board members to create a new rural asylum that would offer “a course of moral treatment for the lunatic patients.” His recommendations came almost directly from Tuke’s book: “the patient should be always treated as much like a rational being as the state of his mind will possibly allow”; no patient would be confined in chains, although in violent mania a straitjacket might be used; kindness would prevail, but if necessary the power of fear might be used; and the asylum must accommodate poor patients.
In architecture and landscape design, this New York asylum would be closely modeled on Tuke’s York Retreat. Moral treatment called for a peaceful environment with opportunities for fresh air, exercise, and useful work, and to that end Eddy urged the board to purchase a site in upper Manhattan with extensive grounds that avoided, “as far as possible, the aspect of a prison.” For patients who had experienced more prison-like arrangements, or who had been confined in their family’s homes, it must have been a pleasing change. The Bloomingdale Asylum, begun with such humanity and optimism, seemed certain to set a new standard in the care of the mentally ill.
For its first thirty years the New York Hospital received money from the state legislature, and in return the asylum agreed to take patients from the city almshouse. As time went on, the asylum grew crowded and new buildings were added to handle the overflow. Despite the annual contribution from the state, the asylum always operated at a loss. Crowded conditions eased when, in 1839, the city opened a municipal public asylum, the nation’s first, on Blackwell’s Island in the East River. Here the city consolidated its prison and welfare institutions, both swelling with inmates as the city received wave after wave of immigrants.
Once the city’s yearly contribution ended, the Bloomingdale superintendent emphasized that it would serve “the wealthy,” as well as “indigent persons of superior respectability and personal refinement,” including “families of clergymen and other professional persons . . . teachers and businessmen who have experienced reverses . . . [and] dependent unmarried females.” The asylum did not, however, refuse to accept patients who could not pay the full cost of their care: a sliding scale applied, and the gap was filled by charitable contributions. But laborers and the desperately poor had to make the best of Blackwell’s Island. When Charles Dickens visited during an 1842 tour of New York, he found that “Everything had a lounging, listless, madhouse air, which was very painful. . .. The terrible crowd with which these halls and galleries were filled, so shocked me, that I abridged my stay within the shortest limits, and declined to see that portion of the building in which the refractory and violent were under closer restraint.”
Although less crowded than the so-called pauper asylum on Blackwell’s Island, Bloomingdale also had trouble maintaining a hopeful atmosphere. At midcentury the medical superintendent was Pliny Earle, who was keenly interested in figuring out why his profession did not have better success. He found that the asylum’s cure rate was inflated because it did not account for patients who had been admitted again and again. Instead, each time a patient was discharged as “improved” and returned some time later after a relapse, that person was counted as a new patient, and upon improvement and release, counted as another successful case. Earle noted too that as time went on, the incurable and chronic cases comprised a greater percentage of the patients, so that unless the asylum were to take in more and more curable cases, the atmosphere of hopelessness could only intensify with the years. Earle was clearsighted about treatment’s limited effects. He wrote, “If insanity is to be diminished it must be by prevention and not by cure.” As to diagnosis, the classification of illnesses was so muddled that “there are scarcely two physicians who would classify a series of cases, such as are admitted into any institution, in precisely the same manner.”
The Bloomingdale Asylum’s reputation suffered a setback in 1872, when the muckraking journalist Julius Chambers, pretending to be insane, was admitted to a padded room on one of its back wards. He reported that violent, raving patients howled all night. On admission, he wrote, the physician took his pulse but didn’t speak with him before locking him in. The attendants were brutish, and the famous amenities of the Bloomingdale Asylum were only available to the most well-behaved patients. He described in detail (and included a drawing) how one patient was subjected to the “cold-water douche,” a punitive treatment that looks much like a form of waterboarding. Abuses in asylums were a popular news item, for there had been several habeus corpus cases brought on behalf of patients who argued that they were not insane, whose families had had them committed. “The Bloomingdale,” Chambers wrote, “had always been considered a place for ‘genteel’ lunatics,” where family and friends of the inmates need not worry about anything like the conditions at the pauper asylum on Blackwell’s Island: “Here was an aristocratic insane asylum, with pleasant grounds, bowling-alleys, and other means of making a patient’s time pass agreeably. Here were supposed to be books and papers and easy chairs, skilled physicians and kind nurses—the very paradise of Bedlams.” But he had infiltrated the place and exposed its abuses, “for nothing that the public deserves to know can be effectually barred against the press any more. . . . And then the paradise of Bedlams was a paradise no longer.” If the most disturbed patients were being cruelly treated, the asylum had moved far from its roots in Quaker kindliness.
When Charles Nichols arrived to manage the relocation, he introduced a high internal standard once again. In his report of 1887, Nichols noted that of 202 patients admitted, he classed the prognosis of 80 as favorable, 61 as unfavorable, and 61 as incurable, of whom 35 had the insanity of late-stage syphilis. It must have been a frustrating career, given the unpromising prognosis for so many. And yet, judging from the intelligence and dedication of such figures as Nichols, Pliny Earle, and Samuel Lyon, Bloomingdale attracted some of the profession’s best doctors.
The move to White Plains presented an opportunity for the institution to reinvent and modernize itself, while staying true to the original mission set out by Thomas Eddy in 1818, to diminish the suffering of the mentally ill and “to restore many of them to the bosom of society, to their former usefulness and to the affections of their families and friends, redeemed from a calamity the most awful and severe which can befall humanity.” In the design of its landscape and living areas, the new Bloomingdale asylum was faithful to the tradition of moral treatment even while implementing each innovation in psychiatric care as the decades passed. Talk therapy developed the directives of Pinel and Tuke that patients need conversation with empathic doctors. The greatest breakthrough in treating mental illness did not arrive until the 1950s, with the introduction of antipsychotic and antidepressant drugs.
LOOKING BACK AT my own stay in the former Bloomingdale Asylum, I have decidedly mixed feelings about the care I received. I retain a sense of lasting harm, but I was also helped. Because I expected that the hospital would protect me from the danger of being suicidal, the word “asylum” takes on a certain degree of irony in this regard. It’s taken all this time for me to realize that the shame I’ve so long felt about the scar is unwarranted, and that what happened was not my fault. But I still needed to be there. I needed ECT, and I needed the time and space to recover. To be fair, most of the people who worked on the unit did seem to embrace the spirit of Thomas Eddy’s vision of moral treatment. My three-plus months there felt like ages, but because the period immediately after discharge is the most dangerous time for patients who have been suicidal, my caretakers needed to be relatively confident that I would be safe if discharged.
In the United States in 2016 there were nearly 45,000 suicides, a number that has surged more than 28 percent in the past two decades. While very few of these deaths—perhaps 6 percent—occur in hospitals, one small study estimated that a psychiatric nurse will be confronted with a suicide every two years or so. Most inpatient suicides are the result of inaccurate clinical assessment of the patient. Malpractice suits often cite “inadequate monitoring and protection of new patients with moderate or high suicide risk.” Even when a patient is correctly assessed as very suicidal, surveillance isn’t foolproof. One way to ensure that no patients attempt suicide, short of immobilizing them with drugs, would be to return to the use of physical restraints like the straitjacket. It can be very hard to save the life of someone who is determined to die.
Taking care of suicidal patients was a perennial challenge for the Bloomingdale Asylum. In 1880, while in a storeroom with the attendant who was guarding her, a suicidal woman found a piece of glass from a broken window, quietly hid it in her clothing, and later made a fatal gash in her throat when the attendant allowed her to go into a bathroom alone. In 1914, a thirty-nine-year-old patient escaped from attendants and was found the next day, drowned in the pond on the hospital grounds. In 1916, a wealthy woman suffering from “melancholia with suicidal tendencies” went missing after living in the asylum for four years. Police speculated that she had been hiding in the woods or in barns for a week when she lay down on the railroad tracks near the White Plains station and was killed by the train. This grim catalogue includes many entries over the years, though the numbers decrease as time passes. These patients were suicidal despite their time in the asylum because there was no effective treatment for the illnesses fueling their desire to die. Especially in the years before ECT, antidepressants, and other drugs that could diminish the power of self-destructive impulses, the asylum’s role was to guard patients and to provide long-term care if they were unable to live at home.
Shock treatment had brought my own suicidal crisis under control. The nurses observed me closely, and each day their notes in my record include their asking about, and my denial of, suicidal thoughts. In early May my demeanor was returning to normal, and the nurses recorded my “good spirits” and social interactions with patients and staff. On the day of my final ECT treatment, I had improved so much that Dr. Young wrote, “Patient is felt to be fully treated for her Major Depression and course during next week will shape what the nature of further treatment and transition out of hospital should consist of.”
I no longer needed to be checked on every fifteen minutes, and I began to attend therapeutic activities like art classes, games in the gym, and the required group therapy. I was allowed to enjoy the grounds, though not unaccompanied, and I was able to engage in the communal life of the unit and pay more attention to my fellow patients. My short-term memory wasn’t working well because of the ECT and the “at least moderately severe organic brain syndrome.” One nurse noted that sometimes I asked the same question several times. By the time evening came I had trouble remembering what had happened in the morning, and even in the afternoon. Writing things down helped me feel more clear-headed, and when Jake visited after work I could remember enough to tell him about my day.
In the spiral notebook that was my hospital journal, the people I knew and our days together emerge from the fog of time with surprising clarity. The notes I wrote on a single day, “a crazy day on the unit,” bring back the feeling of living there, and the shifting array of people with various presentations of mania, depression, obsessive compulsions, and psychosis.
A young woman named Rita, her nails bitten to the quick, believed there was something wrong with her body, something she called “a cosmetic problem.” She talked about it constantly, and desperately needed to have it fixed. Instead, her father had forced her to come to this hospital. She was worried that they’d make her take all kinds of major tranquilizers and that she would become crazy. Rita was talking to me all the time, so I asked Dr. Young about her. He said that her beliefs about her body were delusional.
An older woman called Mrs. Cole was confined to her room, but at fifteen-minute intervals she was allowed to take a walk in the hall. On every tour of the corridor, she talked in loud and anxious tones about a laundry bag. Within a day, Mrs. Cole was transferred to another unit. I never understood why some people stayed while others passed briefly through our midst. Presumably this had to do with the doctors’ assessment of what kind of treatment they required, and perhaps it had to do with what sort of insurance coverage they had.
Another woman, tall, very thin, and dark-haired, called herself the Queen of Israel. She clattered up and down the hallway in a bathrobe and high-heeled mules, stopping occasionally to aim her pronouncements at other patients. This time she fixed on a Cuban man named Luis and shared her predictions about the doomed state of Israel and of the world itself, which she said would end tomorrow. Luis was playing cards, as he often did, with a woman from Puerto Rico, and they always spoke Spanish together. Like Rita, the Queen of Israel talked incessantly to whomever would listen. Luis nodded a few times, and she moved on to where I sat talking with two new friends, Meg and Paul, on the sofas in the hall. In her bathrobe and high-heels, she walked with a provocative wiggle. She sat down next to me and said, “Have you been to these nudist camps where they have the parties? They started them in America, back in 1956, when Sputnik went up.” We shook our heads—no, we hadn’t ever been. She told us how great the nudist camps were, and then walked on, her heels clacking away down the hall. We smiled to each other, murmuring about how that woman was “really nuts.” But we knew that we were nuts too—why else would we be here in the nuthouse with her?
By then I felt better off than many of the people on the unit. I wasn’t obsessed anymore with my own evil, and I wasn’t obsessed with the end of the world, or nudist camps, or a laundry bag. Those of us who were more or less able to think rationally and to speak in the mode of normal social conversation considered ourselves not as “crazy” as those who couldn’t. People were passing through, so we didn’t often see the full development of one person’s case from crisis to remission. Those who were there on the day of my suicide attempt would have been aware of the time when I was perhaps the most crazy, or at least the most troublemaking, person on the unit. But for those who arrived later, the only evidence of my craziness was the still raw wound on my neck. Now it was others’ turn to make trouble—by not calming down, by making a lot of noise. In doing so they gave the rest of us something to talk about.
Meg was one of the quiet ones, and we became close. Like me, she was in her twenties, and she was scheduled for shock treatment. Like me, she came from a Catholic family, and she seemed to be going through a similar kind of crisis. She had lost one sister to cancer and another to an accident. She was her parents’ sole remaining child, and she had been depressed for most of a decade. She was engaged, and she worried that she couldn’t go through with getting married if she was only ever going to be hopelessly depressed. Dr. Young and the staff asked me to talk with her about ECT and to calm her fears about it. I spent time with her and with her parents, telling them it would be okay, emphasizing the fact that suddenly one day, I had gotten better.
I always enjoyed sitting with Paul, a painter who had bipolar disorder. I don’t know whether mania or depression brought him to the hospital, but by the time I met him he was extremely calm and companionable. He smoked a lot, and once I was allowed outside, we would sit together on a bench by the tennis courts. Sometimes we played tennis in a desultory way, because neither of us had much energy. Paul was an old hand at being hospitalized and seemed resigned to his life with illness. What I found comforting about him was that, unlike me, he wasn’t panicking about his future, and he wasn’t terrified. It was a relief to be around him. He was stoic, enduring yet another stint in the hospital, waiting it out.
The difference between the Queen of Israel, in her chatty psychosis, and Paul, in his subdued and patient depressive state, was the difference between drama and stillness. The more voluble people seemed to be having more fun, if that is the word, while the quiet ones seemed to be waiting for a prison term to come to an end. For both groups, the illness that had brought us to the hospital was what we needed to be released from. We just didn’t know how long it might take, and whether it would all just keep happening over and over.
Jacob, perhaps twenty, was one of the liveliest presences during his stay on the unit. He was bipolar as well. His kippa and the fringes of his prayer shawl hanging beneath his shirt marked his identity as an Orthodox Jew. He played the guitar, which he had brought with him to the hospital, and he wrote poems and songs. He loved to talk about the many books he had read. He came by while Meg and I sat talking to tell us he had lost the capo for his guitar, and complained about how manic and upset he became when he lost things. He told us about visiting Auschwitz and Treblinka with his father, a Holocaust survivor, and about his sister, who had killed herself in Israel. I was struck by the fact that Meg and Jacob were both traumatized by what their families had been through: in their illnesses they seemed at once to suffer and carry on their families’ pain.
Shortly before he was discharged, Jacob handed me a poem. It was written in pencil, in English, with Hebrew letters at the top and at the bottom. When I recently found the poem tucked inside the hospital notebook, I looked into the meaning of the Hebrew. The four letters at the top indicate the Jewish year 5744, which was 1984. In Hebrew, numbers can spell out words, and the four Hebrew letters for 5744 read as tashmad, or destruction. In Israel in the years leading up to 1984, visionaries and astrologers had been predicting destruction, disaster, even the end of the world. Jacob had written this word, tashmad, above the poem that begins, “In ebon-topped waves / you glide by,” as he, “post / deep sea dive,” imagines rising “immaculate” from the depths, with “her as my beacon.” At the bottom was his name, in Hebrew. Was I the beacon of the poem, despite the shift from “you” to “her”? Maybe handing out poems was one of Howard’s ways of being crazy. It was a way of expressing his creativity, and perhaps also a way of expressing his longing for escape from illness, from the pressures of his family’s worry that he might not be able to get married and have lots of children. But disaster, tashmad, was his family’s history and, so far, his own.
We were all feeling the pressure of our families; they were worried, and in some cases distraught. When they visited, they brought with them their understandable desire that we get better right away. I think all of us had experienced the sense of slipping under the waves that Jacob expressed. We were desperate to be saved, even as some of our loved ones failed to recognize that we were going under. While some of my new friends had plunged more dramatically into madness than I had, my own less noticeable descent was something like what Stevie Smith captures in her poem “Not Waving but Drowning.” Swimming far out, a man has been waving as those on shore mistake his desperate call for help as no more than a casual, playful gesture. He is “the dead man” who says, “I was much further out than you thought / And not waving but drowning.” I had drifted into those waters, much too far out, sometime after Anna died.
Smith’s poem is powerful in registering the way that many people, some of them with undiagnosed depressive illness, move through life. If they are practiced, as I was, at the cheerful demeanor necessary to social life (the “poor chap” in the poem “always loved larking”), they may not reveal, as I didn’t, just how much danger they’re in until it’s too late. Being in the hospital—the asylum, the madhouse—meant that the deception was over. Our families and friends might not have been keenly perceptive, but they were used to the selves we presented to them. Now the game was up. We had failed to keep the secret of just how far out we felt. The hospital took us in when we could no longer function in the world.
THE INITIAL EXCITEMENT about my recovery was short-lived. Although I was much better, I wasn’t at all well. A week after ECT was over, I was writing about the extreme physical anxiety I was feeling: “I’m so nervous and anxious sometimes throughout the day, my muscles clench and unclench and I can’t relax. My life is unreal. There’s no visiting today, and I don’t know how I’ll get through it. Sometimes when I’m reading or writing the backgrounds reverse themselves and the white background looks dark. I can’t imagine myself ever having a life, being at ease in it, having a home that I feel comfortable in. That’s what I’m so afraid of.” Thoughts like these circled endlessly when I was alone. I worried I would become suicidal again, and that I would need to stay in the hospital indefinitely. And as I sometimes did when I was full of fear, I tried to pray.
I looked through the Psalms just as I had done on my last day at work, trying to tether my agnostic, spiritually alienated mind to these ancient pleas for help. Thinking it might calm me, I wrote down some verses:
Be not far from me, for trouble is near, for there is none to help. . . .
I am poured out like water, and all my bones are out of joint:
my heart is like wax; it is melted in the midst of my bowels. . . .
In my distress I called upon the Lord, and cried unto my God.
He heard my voice out of his temple, and my cry came before him, even into his ears.
For thou wilt light my candle, the Lord my God will enlighten my darkness.
If I was slipping back into illness as I feared, the language of the Psalms promised more effective help than shock and seizures, or talking to a young psychiatrist. But if there was no God, and prayers were only a heightened form of pleading, I was sending these words from my anguished self out into the emptiness. I was relieved that several people were praying for me who were better at it than I was. If prayers are most effective when the person praying is most sincere, my mother’s mother, Bridie, would certainly be heard. Her prayers, coming from a place of absolute humility and faith, might have real power.
My mother had given me a book called Beginning to Pray by a monk named Anthony Bloom, and I was reading it in my room on that anxious evening of no visitors. To my surprise, the author immediately addressed the feeling of sending prayer into the void. He wrote, “Obviously I am not speaking of a real absence—God is never really absent—but of the sense of absence which we have. We stand before God and we shout into an empty sky, out of which there is no reply. We turn in all directions and He is not to be found. What ought we to think of this situation?” People expect God to be there only when they need Him, he wrote, but prayer should arise from a relationship in which we seek the presence of God regularly. I was ruminating on all of this—my lack of belief, my despair, my suspicion that my marriage was part of my problem with the future—when one of the mental health workers came in doing room checks. Teddy, a Jamaican man who was the kindest of all the staff, asked me why I was crying. When I told him that I was feeling hopeless and scared, he suggested I try to use my experience to feel stronger rather than weaker—something Jake was always telling me as well. I didn’t understand why that was so difficult, but it seemed that the whole foundation of my life had disintegrated. Love, marriage, work, self, all were in ruins. Doubt and fear were all I knew.
Teddy mentioned that he would have to note my fragile condition in my chart. This was three weeks after shock treatment ended. I had not been on any medication since then, and Dr. Young now tried to halt my downward slide by putting me on an antidepressant. I had been telling him about my fear of relapse, my feeling of being “other than human,” and of being “in a black box.” I was having trouble getting to sleep, and was waking very early. Reading the record, it’s clear to me that the symptoms of melancholia had returned. Because I was a patient who had no prior contact with psychiatry and no history of depressive illness, I think Dr. Young and the attending psychiatrist assumed that postpartum bereavement had caused the crisis—that it was situational, and not the eruption of an unrecognized disorder that had been quietly present for years. The pessimism and self-deprecation that I had long believed to be aspects of my character I now see as the familiar indicators of a syndrome that emerged when I was in high school, if not earlier. Anna’s death had caused it to leap into visibility: unavoidable, urgent, and deadly.
Depression has been viewed as a complex “biopsychosocial” illness; it can have biological determinants, but psychological and social stressors contribute as well. It was the biological component, very powerful in melancholia, that I assume Dr. Young felt that ECT had resolved when he wrote “Patient is felt to be fully treated for her Major Depression.” We had been addressing the psychological issues in talk therapy and family meetings. My fragile emotional state was what concerned him now, and the way my marriage and career situation continued to cause stress and anxiety. He thought I would need another three weeks in the hospital for my mood to stabilize before I went home.
When Jake visited, we talked about things I could do to help myself feel better when I got home. We made plans for the garden. We talked about trying to have another child. We made lists. A list in Jake’s handwriting includes items to address my sense of uselessness and my fear of suburban isolation, like “make new friends” and “get new job” and schooling for potential new careers: landscape architecture programs, the Botanical Garden’s horticulture program, graduate school in literature, the nurse-midwife program. The occupational therapist at the hospital gave me an aptitude test and found, not much to my surprise, that I wasn’t suited for a career in nursing. Part of the appeal of midwifery was the potential for being employable when we moved to Vermont, where otherwise my only plan was to teach high school English. In the years that followed I would continue to believe that feeling miserable about myself and my future—core symptoms of depression—could only be fixed by finding the profession in which I would finally feel comfortable, useful, and hopeful.
My hospital notebook contains drawings too. I made a sketch of Ellie, who was one of my minders when I had to be within arm’s distance of a staff member at all times. Sitting on the bed, I drew her in colored pencils as she sat on a chair beside me, as if we were roommates: her close-cropped Afro, her calm and benevolent face, the details of her sweater pattern. There is an unfinished profile of Lisa, the nurse who after my suicide attempt continued to dislike me, writing in my chart that I was “passive aggressive” and “acted condescending to staff.” There is a drawing of our house and its outer hedge, where the privet made an archway over the entry path. There are diagrams of garden areas to be created. There’s a self-portrait by Jake, to amuse me. He’s drawn his curly dark hair and glasses, given himself a beard, a goofy face, and an arrow through his head, like the arrows you see through hearts on valentines. In its way, that drawing carries its own sense of tashmad. In the journal’s drawings and written observations of goings on, its plans and lists, I can feel the slow time of the hospital, the pressure and desire to get well.
While the hospital provided a space away from the world, most of what happened there was intended to return patients to it, better able to cope with their lives. Each patient on the unit had a treatment plan focused on getting the illness under control so that he or she could return home. Recovering patients were sent on day and weekend passes to their homes, to practice getting ready for discharge. Our social workers and the psychiatrists talked with our families, gauging the support that they could provide. They arranged for residence in halfway houses for patients whose families were likely to exacerbate the illness.
Family meetings took place once a week, and in those meetings we patients felt the sharp pressure of our families’ concern, along with their impatience and even their incomprehension. I was usually pretty shaken after these meetings, since until I was much, much better I couldn’t help but disappoint Jake and my parents. My social worker made a note about my parents’ “denial,” in the context of their requests that I be released as soon as possible. Our status as patients points to our trouble in the presence of our impatient families. The word, as both adjective and noun, comes from Latin patientia—“patience, endurance, humility, submission.” We had no choice but to submit to our circumstances, our suffering, and our possibly long-term or recurring illnesses.
Living in the hospital, compounded with the harrowing experience of having been suicidal and psychotic, seemed to mean that I was now fundamentally different from people outside. Erving Goffman, in his book Asylums, writes about the shift in identity that first-time mental patients undergo, passing from a “normal” to a “discredited” social status. While Goffman’s work focused on patients in state institutions and I was lucky to be in a much better kind of place, his observation describes the way I now thought of myself, and the way I feared others would see me. I worried that if it were known that I’d been hospitalized for a psychiatric problem, I might have difficulty being hired in the future. Worse, if the illness were to recur unpredictably, I might have to leave any job that I had. It was to suppress this damaged identity that I avoided talking about my illness or my hospitalization afterwards, except to close friends who already knew about it. But the fact that I had made a mark on myself, a scar on my neck, during my time there, meant that the stigma—literally, a mark or brand of pain, punishment, or difference—would be for me a permanent reminder of that identity.
Given that when I was alone I just swam round and round my worry tank, it was better to go and sit with other people who were in similarly bad shape. That way we could distract and amuse each other. In our free time on the unit and in our group therapy sessions, we patients provided each other some relief from family pressure and a sense of being understood. We chatted and gossiped in the hours we were sitting around, but being together in group therapy was different, and the tone was more serious and respectful. I was in a women’s group that met three times a week, and there I began to talk about Anna’s death and the feelings that had brought me to the hospital. One day a new patient who was a psychiatric social worker spoke. Several years earlier, she had been diagnosed with a rapid-cycling form of manic-depressive illness and spent eight months in another hospital. Now she was hospitalized again, and her husband had left her amidst all the upheaval. I was moved by the stories of people like this woman, who gave me a glimpse of what it was like to move in and of mental disorder, in and out of normal adult life. I admired people who had learned how to accept the disruptive nature of their illness, and still carried themselves with dignity.
In our therapy sessions, Dr. Young was honing in on painful matters. Doubts about my marriage were coming out into the open, and the scrutiny by a third party only made things worse for Jake. I felt like a traitor, but I knew that marrying too young had weakened me. I was in mourning for my unfulfilled potential, and I was having to talk about it with someone roughly my age who was already a doctor. Leaving college, I had lacked the confidence to think I could become a professor and had not pursued graduate work in literature. Our move to the suburbs, where I was miserable and disoriented, made me realize that I needed to claim some independence. I had to pursue what would make me feel happier, even if I could no longer fit into the life Jake and I had made together.
I had written about my dissatisfaction in the journal that I destroyed the day I came to the hospital, but I hadn’t talked about it much with Jake until it became a huge issue in my post-ECT psychotherapy. Given the crushing event of Anna’s death, I had been hoping to salvage the life I had chosen and the marriage I had promised to be faithful to. But I had trouble summoning any optimism about it. It was hard to know what I could trust about these feelings and what was the pervasive negativity of depression. When I went home a couple of times on passes I was devastated to have to acknowledge how disconnected I felt. I told Dr. Young I felt “like a stone,” and was afraid I would always feel this way. Feeling like a stone was symptomatic, though. It was how depression felt. He focused on my marriage as a major source of stress, writing in my record that when we talked about it, “it appeared on many occasions that the affective symptomatology was recurring.”
The medication Dr. Young put me on to address the return of symptoms was nortriptyline, another of the tricyclics, but one that didn’t give me hives. It helped me sleep, and I began to sleep a lot. The sleep was wonderful. I gained five pounds in a week and I didn’t care, because it quieted the runaway anxiety so much that my life began to feel bearable. “Today for the first time I don’t feel completely hopeless,” I wrote in my notebook, “and I think the drug is beginning to work. I hardly trust these hopeful feelings.” Twelve days later, the positive response continued: “I’m alive. I can talk to people.” Instead of being a sleepless, hollow-eyed, suicidal wraith, on nortriptyline I was becoming a cheerful, sociable, chubby person.
With this improvement, I was restored to the highest level of privilege, meaning I could again spend time on the grounds with other patients and with my visitors. One visit I remember clearly: I went out to the hospital’s nine-hole golf course with Jake’s parents, and we played on the putting green. I realized that despite the stress of the visit and my guilt about the pain I was causing their son, we were kind of having fun. They were golfers and I was not, but I was pretty good at putting that day. I imagined that I would be safe if I just stayed in the hospital forever, and my friends and relatives would visit me here. I would entertain them on the putting green; we would take walks and play tennis; we would avoid talking about whether I was getting better. This was how I could protect the people who loved me from my inevitable suicide.
Early in June, my peers on the unit elected me their representative. My social worker had told me (in an effort, no doubt, to counter my negative self-perception) that I was one of the most well-liked patients. If the other patients thought I was functioning well enough to represent them and communicate their concerns at the weekly meeting of staff, doctors, and patients, then perhaps I was more together than I felt. I was honored that they chose me. We had created a community of support for one another. I was getting stronger, going on more frequent visits home, getting in touch with friends, and my time of asylum was winding down. Soon I would be leaving them.
Dr. Young recommended a psychiatrist who would see me through the transition to life after the hospital. Dr. Waters had a private practice in Manhattan, and I went to meet her on one of the days she was working at the hospital. I immediately felt comfortable with her, and in telling her about my situation I had to explain Anna’s death. I noticed with surprise that as I talked about it, her eyes filled with tears. She told me that she had also had a baby recently. This was a quality of empathy I hadn’t experienced before, and I felt more hopeful in her presence. We agreed that when I was released I would see her twice a week.
On the discharge summary, Dr. Young wrote his diagnosis of my marriage: “While on admission and for many weeks thereafter the marital relationship was presented as ideal, and both patient and husband seemed genuinely to believe their marriage was an excellent one, very major problems in the relationship surfaced in the course of this hospitalization. . . . In reality she was highly controlled by him and unconsciously greatly resented him although she submitted to the domination. Consciously her knowledge of the relationship in which she was deeply involved was extremely shallow and she conducted herself within the relationship as if true harmony prevailed.” Reading this for the first time over thirty years later I was struck by its accuracy, although I wasn’t as unaware of this dynamic as he says. In my years with Jake I had come to feel more and more insignificant, and I had never learned how to insist on what I needed as a separate person. To be in therapy was to begin to make space for myself, and to find my own way forward.
This was the beginning of a years-long process of coming to understand how undiagnosed depression had, for a decade at least, affected my perception and decisions, paralyzed my desire and ambition. I’d begun to speak truthfully about the most difficult aspects of my life, and to see more clearly. But I was far from well, according to the discharge form. On a 100-point scale called the Global Assessment of Functioning, Dr. Young recorded a grade of 45, which indicated “serious impairment” of functioning. He noted my prognosis as “good” and my condition “improved,” choosing neither “much improved” nor “recovered.” In a final family session, Dr. Young recommended that I continue long-term intensive treatment with the outpatient psychiatrist, and my social worker suggested that Jake and I join a bereaved parents group and see a couples’ therapist. I received my medication, with dosage instructions. On my last day on the unit, I said goodbye to everyone during the hall meeting, which felt strangely like a graduation. Being in the hospital had been an education, and graduation is not so odd an analogy.
Asylum, as I experienced it, was ultimately about the camaraderie and support of my fellow patients. Thrown together as strangers in terrible circumstances, we had no choice but to share our suffering, but we shared our humor and resilience too. In doing so we began to bring ourselves back into the human community. While ECT was vital to my recovery and antidepressant medication was even more so in the long term, these medical interventions were not sufficient in themselves. The acceptance and affection offered me by the other people there, both patients and staff, helped me to recognize my own value and begin to find an alternative to despair. In this commitment to helping patients reconnect with others, the Bloomingdale hospital in my time carried on the humane principles of its early Quaker lineage.