Anosognosia Exlained by a Schizohrenia Sufferer

INFLUENCE

Practical Tips for Overcoming Resistance

by Mark Goulston

Although many managers and leaders are under pressure to get things done quickly, pressuring subordinates frequently leads to resistance. This is not due to stubbornness as much as it is due those subordinates simply feeling overwhelmed by the volume of work they have. Emotions also come into play; for instance, if you’re trying to get through to an irate customer or shareholder, it can be tough to break through the resistance their anger creates.

To get some tips on how to overcome resistance I reached out to Xavier Amador, originator of the LEAP Method (LEAP stands for Listen-Empathize-Agree-Partner) and Founder of the LEAP Institute and author of I’m Right, You’re Wrong, Now What? Break the Impasse and Get What You Need.

MG: Dr. Amador, or shall I call you, Xavier, how did you come up with the idea that we needed a more effective way of overcoming resistance than the usual pushy/persuasive approach?

XA: Mark please call me Xavier. Okay if I call you Mark?

MG: Of course!

XA: Before answering your question, I want to point out something that just happened. By asking me what name I prefer you call me by, you took a step toward connecting with me and not creating resistance — You did this before we were even out of the gate! I practice the same simple habit with almost everyone. Without asking, you didn’t know if I would find “Dr. Amador” too formal and distancing, or “Xavier” too presumptuous and disrespectful. Either reaction would have raised a little resistance. And the fact that you pronounced my name correctly — “Javier” instead of “Zavier” — helped too. You obviously took the trouble to find out, or saw me speaking, and remembered the pronunciation. So without hearing one word from me you were already listening. And that’s the cornerstone to lowering resistances.

Now to your question: I would love to say the idea was mine, but it’s actually ancient wisdom and the result of paying attention to what actually works. The lesson learned is: You don’t win on the strength of your argument. You win on the strength of your relationship. And you can strengthen relationships in seconds and easily by putting down your rusty overused communication tools and picking up some new ones. Feedback from thousands of

LEAP followers who are company owners, CEO’s, managers and sales reps reinforced the universality of this vital lesson I learned years ago working with psychotic patients who were literally living in an alternate universe: it feels [like] “What planet is he on?” when someone gives us a reflexive no and resists what is obviously common sense.

You never win on the strength of your argument — or your negatively perceived directive if you are the one holding power in the relationship. Even if your subordinate does what you wanted, the initial resistance will fester and spread as they implement the details. If it was pushed down their throats, instead of something they felt some ownership of, they will resist…[and] it will come back to bite you later. What we hear over and over again is this:

“When I stopped trying to convince her and instead focused on listening to his point of view and respecting it, the resistance just disappeared. It happened so fast it felt like magic!”

MG: Why do so many people especially managers and leaders approach resistance in such an ineffective manner?

XA: Because its natural to punch back. It’s a lifelong habit most people have. We repeat ourselves, often more loudly and over and over again, when someone hasn’t heard or doesn’t agree. When I have a good idea, a solution to a problem, or a product/service I know will increase market penetration, I am eager to communicate it to the other person or group. And when I get resistance, it feels like I’ve been pushed back or hit. And so the reflex is to push or hit back — to counter punch in an effort to show the other side why they were wrong. The reflex is to stand my ground.

This type of interaction looks just like a boxing match. Using LEAP we’ve learned you can stand your ground without verbally hitting back. Here’s the first and most important tool:

When you get resistance, [say to yourself], “Shut up, listen and win!”

That’s what I say to myself to remember to use the tools I know work. “Shut up” may sound rude and counter productive, but for me it’s a splash of cold water. It gets my attention so I can stop dismantling and start using my authority to build stronger relationships. That’s the prize, a strong relationship. Strong relationships are the key to meaningful and effective partners and work relationships. Nothing else comes close to being as important. Noproductive business can exist without strong relationships — think about it. And yet, too often, we ignore the “state of the union” while resistance, defensiveness and even tempers are on the rise.

Now that you’ve stopped talking, to show you listened, repeat back what you’ve heard “So you don’t think this will work and it’s a bad idea because…. Did I get that right?” Just listen and make sure you’ve heard it the way the other person meant it. Then explore just a little bit more. Go for the emotion behind the push back. Empathize.

[Say something like,] “Now that I understand your position, I can see why you would be uneasy buying in.” Take the resistance that is negative energy and use it, by absorbing it, so the person feels respected and safe, lowers their defenses, and as a result opens up to you.

In this exchange, instead of boxing, the verbal interaction looks more like Jujitsu. You meet the resistance, not with a push or punch but instead with open hands. As the person comes at you with their resistance, with open hands you step aside and embrace the negative movement, use its energy, to move the person where you want them.

MG: What would you say to those who may feel that “lowering their guards” and leading

with “open hands” will undermine their authority?

XA: Well first I would listen to their resistance and lower it by communicating my genuine

understanding and empathy for it. With authority comes strength. You can use that strength to strengthen the relationship or to strong-arm the other person and create a resistance movement in your own backyard.

You have the luxury of being able to speak softly knowing that you are the one carrying much bigger stick.

Here’s a life and death example of this principle. LEAP-trained hostage negotiators have far superior firepower when they’ve cornered the person they’re trying to persuade, but they approach their subject with an open ear and open hands “Talk to me, tell me what you want?” is what works to engage someone who has taken hostages, and to convince them to release their hostages and come with you peacefully. “Come out with your hands up we have you surrounded and out-gunned,” leads to a fire fight. Don’t help others hold your ideas, proposals and directives hostage with their resistance by opening fire.

MG: I don’t know if this is an example of Partnering with you, or just showing good manners, but Xavier I’d like to give you the final word. Do you have a quote or statement that will help remind our readers of the importance of LEAPing into better communication rather than jumping down people’s throats when they are resistant?

XA: I will repeat myself because the following two things are that important. First, if you are getting push-back, shut up, listen and win. And second, remember when you are faced with resistance you never win on the strength of your argument, you win on the strength of your relationship. One final word, I hope your readers will let me know if our conversation helped them by contacting me at XavierAmador@LEAPinstitute.org or visit LEAPinstitute.org. Thanks Mark for the opportunity to have this conversation.

Mark Goulston, M.D., F.A.P.A. is a business psychiatrist, executive advisor, keynote speaker, and CEO and Founder of the Goulston Group. He is the author of Just Listen (Amaxom, 2015) and co-author of Real Influence: Persuade Without Pushing and Gain Without Giving In (Amacom, 2013).

Anosognosia Keeps Patients From Realizing They’re Ill

About half of the people with schizophrenia and bipolar disorder may not be getting the treatment they need because of a brain deficit that renders them unable to perceive that they are ill, according to one expert.

Anosognosia, meaning “unawareness of illness,” is a syndrome commonly seen in people with serious mental illness and some neurological disorders, according to Xavier Amador, Ph.D., who spoke at the 2001 convention of the National Alliance for the Mentally Ill in Washington, D.C., in July.

People with this syndrome do not believe they are ill despite evidence to the contrary, said Amador, who is director of psychology at the New York State Psychiatric Institute and professor of psychology in the department of psychiatry at Columbia University College of Physicians and Surgeons.

“People will come up with illogical and even bizarre explanations for symptoms and life circumstances stemming from their illness,” he said, “along with a compulsion to prove to others that they are not ill, despite negative consequences associated with doing so.”

Take Theodore Kaczynski, for example. Kaczynski, otherwise known as the unabomber, rejected claims that he was mentally ill even though it could have cost him his life.

At one point during his 1997 trial, Amador explained, Kaczynski, who stood accused of killing three people and injuring 23 with his homemade bombs, refused to be examined by state psychiatric experts. Although a mental illness defense was his only hope of escaping a first-degree murder conviction and a possible death sentence, he blocked his attorneys from using the insanity defense.

Amador, who served as an independent expert for the court, reviewed Kaczyinski’s extensive psychiatric records, neuropsychological test results, and the infamous unabomber diaries. Amador then supplied the court with mounting evidence that Kaczynski’s refusal to be evaluated related to anosognosia, a manifestation of Kaczynski’s schizophrenia.

Amador’s quest to understand the basis of this syndrome lies a little closer to home.

It was his experience as a clinician and as a brother of someone with schizophrenia, Amador said, that led him to do research on anosognosia, “which is not to be confused with denial,” he emphasized, although in the beginning, he did not make that distinction.

“That’s what I called it when my brother refused to take his medications, and that is what I called it when after his third hospitalization, I found his Haldol in the trashcan,” said Amador.

“This is someone who taught me to throw a baseball and ride a bicycle. I really looked up to him and was appalled by what I thought was his immaturity, stubbornness, and defensiveness.”

But research points to a much more complex problem.

Intrigued by a 1986 study by William H. Wilson, M.D., and colleagues that found that 89 percent of patients with schizophrenia denied having an illness, Amador conducted his own investigation of the issue.

Amador and his colleagues found in a 1994 study that nearly 60 percent of a sample of 221 patients with schizophrenia did not believe they were ill.

A Frustrating Existence

Amador also described what it is like to work with someone who has anosognosia. One patient encountered by Amador had a lesion on the frontal lobe of his brain. He was unaware that he was paralyzed on his left side or that he had problems writing. When asked to draw a clock, the patient thought he did fine, Amador recalled.

However, when Amador pointed out to the patient that the numbers were outside of the circle, the patient became upset. “The more I talked to him [about the drawing], the more flustered he got. . . . Then he got angry and pushed the paper away, saying ‘it’s not mine—it’s not my drawing.’ ”

Amador finds the same reaction appears when he talks to people with severe mental illness, which sometimes involves similar frontal lobe deficits. “Instead of being an ally, I end up being an adversary,” he said.

Building Trust

Amador urged family members and mental health professionals at the NAMI meeting to understand that collaboration with treatment by someone who has a severe mental illness and anosognosia is a goal, not a given.

“Don’t expect them to comply with any treatment plan, because they don’t believe they are ill,” noted Amador.

It is important instead to develop a partnership with the patient around those things that can be agreed upon.

Amador said that family members and clinicians should first listen to the patient’s fears, such as being placed in the hospital against his or her will.

Empathy with the patient’s frustrations and even delusional beliefs is also important, remarked Amador, who said that the phrase “I understand how you feel” can make a world of difference.

The most difficult thing for family members to do in building a trusting relationship, he said, is to restrict discussion to the problems that the person with mental illness perceives as problems. “You might see the hallucinations or delusions as the big problem,” said Amador. “Your loved one, however, may be complaining about not getting to sleep at night. That is the problem you should be discussing.”

Perhaps a patient will only take his or her medications to get family members and clinicians to quit bothering them, and this is sometimes enough, Amador said. “You have to find out what motivates them to take their medications, then reflect that reason back and highlight the perceived benefits.”

Read article on Anosognosia Keeps Patients From Realizing They’re Ill (APA Psychiatric News) site...

On October 5, 2007, two days after being released from New Hampshire Hospital, in Concord, Linda Bishop discarded all her belongings except for mascara, tweezers, and a pen. For nearly a year, she had complained about the restrictions of the psychiatric unit, but her only plan for her release was to remain invisible. She spent two nights in a field she called Hoboville, where homeless people slept, and then began wandering around Concord, avoiding the main streets. Wary of spies, she cut through the underbrush behind buildings, walked through gullies beside the roads, and, when she needed to rest, huddled in the bushes. Her life was saved along the way, she later wrote, by two warblers and an owl.

A tall, athletic fifty-one-year-old with blue eyes and a bachelor’s degree in art history from the University of New Hampshire, Linda had been admitted to the hospital in late October, 2006, after having been found incompetent to stand trial for a series of offenses. She spent most of her eleven months there reading, writing, and crocheting. She refused all psychiatric medication, because she believed her diagnosis (bipolar disorder with psychosis) was a mistake. Each time she met a new psychiatrist, she declared her lack of respect for the profession. Only when conversations moved away from her mental illness, a term she generally placed in quotation marks, was she cheerful and engaged. Her medical records consistently note the same traits: “extremely bright,” “very pleasant,” “denies completely that she has an illness.” In the weeks leading up to her discharge, her doctors urged her to make arrangements for housing and follow-up care, but Linda refused, saying, “God will provide.”

During a rainstorm on her fourth day out of the hospital, Linda broke into a vacant farmhouse for sale on Mountain Road, a scenic residential street. The three-story home overlooked a brook and an apple orchard, and a few rooms were still sparsely furnished. Linda intended to stay only a few nights, but she began to worry that her dirty clothes would attract attention if she walked back to town. “I look terrible . . . like a vagrant,” she wrote in a black leather pocket notebook that the previous tenants had left behind. Linda had led a nomadic existence ever since she had abandoned her sleeping thirteen-year-old daughter, in 1999, leaving a note saying that she was going to meet the governor. She drifted between homeless shelters, hospitals, and jail. She wrote in the journal that she wasn’t ready to “make my presence known—and just start the whole mess again—to prove what—that I’m all right? Have done that too many times.” Two days after breaking into the house, she decided to make the place her temporary home. She would subsist on apples while “awaiting further instructions” from God.

Linda settled into a routine. In the morning, when the sun poured through the living-room window, warming the end of the couch, she read college textbooks she found in the attic. The former tenant appeared to have dropped out of school in 1969 (“but his creative writing is very good!” she noted), and she began embarking on the education he had abandoned. She began with Joseph Conrad and moved on to biology (“chloroplasts, lysosomes, mitochondria + cell division!”) and “Great Issues in Western Civilization.” When she had enough energy, she did her “chores.” She combed her graying brown hair—first with a small rake, and, when that proved too cumbersome, with a fork—and tidied the house, in case potential buyers came for a viewing. There was no electricity or water, but, after dusk, she rinsed her underwear in the brook, collected water with a vase, and picked apples.

After the first week, she estimated that she had lost ten pounds. When she looked in the mirror, she was startled by how drawn her face had become. Yet after enduring so many irritations in her hospital unit—patients who wouldn’t stop talking, or who touched her, or sat in her favorite chair, or made noise in the middle of the night—she didn’t mind having time alone. From her windows, she enjoyed watching purple finches, tufted titmice, chickadees, and “Mr. and Mrs. Cardinal.” She wished she had binoculars. A neighbor came over to mow the lawn and pull the weeds. “He has no idea I’m here!” Linda wrote, as she watched him from an upstairs window.

The threat that Linda was hiding from was a shifty one—she alluded to conspiracies involving her older sister, the government, and Satan’s workers—but she also wondered if anyone was even looking for her. She kept retracing the series of events that had led her to this house. She knew it didn’t “make sense to be barely existing”—she got light-headed just walking up the stairs—but she felt that the situation must have been willed by the Lord. By the end of October, she had a stash of three hundred apples. She worried about the coming winter as she watched trees lose their leaves, milkweed seeds blow in the wind “like it’s snowing,” and geese migrate south. Still, she could find “no signs or clues that I should be doing anything different.”

Throughout Linda’s stay at New Hampshire Hospital, her doctors routinely noted that she lacked “insight,” a term that has a troubled legacy in psychiatry. Studies have shown that nearly half of people given a diagnosis of psychotic illness, such as schizophrenia or bipolar disorder, say that they are not mentally ill—naturally, they also tend to resist treatment. The psychiatrist Aubrey Lewis defined insight in 1934 in the British Journal of Medical Psychology as the “correct attitude to a morbid change in oneself.” But the definition was so ambiguous that his paper was ignored for over fifty years. Psychiatrists were reluctant to move away from objective, observable phenomena and to examine the private ways that people make sense of the experience of losing their minds. Today, insight is assessed every time a patient enters a psychiatric hospital, through the Mental Status Examination, but this form of awareness is still poorly understood. Patients are considered insightful when they can reinterpret unusual occurrences—growing angel’s wings, feeling as if their organs have been removed, decoding political messages in street signs—as psychiatric symptoms. In the absence of any clear neurological marker of psychosis, the field revolves around a paradox: an early sign of sanity is the ability to recognize that you’ve been insane. (A “correct attitude,” for most Western psychiatrists, would exclude interpretations featuring spirits, demons, or karmic disharmony.)

Getting patients to acknowledge their own disorders also has become an ethical imperative. Implicit in the doctrine of informed consent is the notion that before agreeing to take medication patients should be aware of the nature and course of their own illnesses. In balancing rights against needs, though, psychiatry is stuck in a kind of moral impasse. It is the only field in which refusal of treatment is commonly viewed as a manifestation of illness rather than as an authentic wish. According to Linda’s treatment review, her most perplexing behavior was her “continuing denial of the legitimacy of her ‘patienthood.’ ”

When psychoanalytic theories were dominant, patients who claimed they were sane were thought to be protecting themselves from a truth too shattering to bear. In more recent years, the problem has been reframed as a cognitive deficit intrinsic to the disease. “It has nothing to do with willfulness—you just don’t have the capacity to know,” Xavier Amador, an adjunct professor of psychology at Columbia University’s Teachers College, said. Amador is the author of the most widely used test for measuring insight, the Scale to Assess Unawareness of Mental Disorder, which asks patients why they think their judgments or perceptions have changed. Although researchers haven’t uncovered distinct neurological anomalies linked to lack of insight, Amador and other scholars have adopted the term “anosognosia,” which more typically describes patients with brain damage who lose the use of limbs or senses yet cannot acknowledge the existence of their new disabilities. Those who go blind because of lesions in their visual cortex, for instance, insist that they can still see, and tell fanciful stories to explain why they are walking into furniture.

Anosognosia was introduced as a synonym for “poor insight” in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, but the concept remains slippery, since the phenomenon it describes is essentially social: the extent to which a patient agrees with her doctor’s interpretation. For Linda, the validity of her diagnosis was the subtext of nearly all her encounters with her psychiatrists, whose attempts to teach her that parts of her personality could be “construed as a mental illness,” as she described it, only alienated her. She wrote to a friend that she was using her hospital stay as an opportunity “merely to prove that I don’t have a mental illness (and never did).”

“See? It never hurts to ask.”

Linda had always been fond of farmhouses. She grew up on Long Island and took pride in her family’s sprawling vegetable garden. “My childhood was a good one, with loving and supportive parents who believed in doing things as a family,” she wrote in an application to an assisted-housing program. She had a large circle of friends and excelled in school with little effort. “She was bubbly and exuded competence,” an old friend, Holliday Kane Rayfield, who is now a psychiatrist, said. Linda’s family thought she would become a professor, but she never settled on a professional career. Kathleen White, her closest friend from college, said that her “dream was to find a guy with a sense of humor, have kids, and live on a farm.”

Linda got married in 1985, and gave birth to her daughter, Caitlin, five months later. But she complained about her husband’s temper, and after her brief marriage ended she struggled to support Caitlin on her own. She worked long hours at a Chinese restaurant in Rochester, New Hampshire, and on her days off she and Caitlin visited museums in Boston or went on camping trips or took aimless drives through the state. Caitlin, now a twenty-five-year-old photo technician at Walmart, told me, “We were each other’s world.” It wasn’t until her mother quit her waitressing job in order to evade the “Chinese Mafia” that Caitlin, who was in seventh grade, began to doubt her mother’s judgment. In 1999, in a purple Dodge Dart, the two fled the state, heading toward Canada. Caitlin, too, was terrified of being captured. “I figured I was collateral damage,” she said. Linda called friends on the way but lied about her location, because she suspected that she was talking to spies. While her mother used pay phones at gas stations, Caitlin waited in the car. “At some point, I just thought to myself, I know better than this,” she said.

When they returned, a little more than a week later, after Linda’s fears had subsided, Linda’s sister, Joan Bishop, and their parents tried unsuccessfully to persuade Linda to see a doctor. Soon, she disappeared again. She went to Concord, the state capital, to inform authorities that the government was behind John F. Kennedy, Jr.,’s plane crash, and then wandered alone through the state for several days, feeling as if she had “ingested some sort of poison or drug without knowing it.” Caitlin moved in with her paternal grandmother and stayed there even when Linda came home. Linda finally checked into a hospital in Dover, New Hampshire, where she was given a diagnosis of schizoaffective disorder, and began taking Zyprexa, an antipsychotic, and lithium, a mood stabilizer. (Her diagnosis shifted between bipolar and schizoaffective—a mixture of schizophrenia and a mood disorder—depending on the doctor.) Psychotic disorders typically begin in early adulthood, but it is not uncommon for them to develop later in life, particularly after periods of stress or isolation. Linda sobbed for the first few days, and talked about how betrayed she felt by those who were scheming against her. By the fourth day, though, her psychiatrist wrote, “She now has insight into the fact that these are paranoid delusions, and a part of her is able to say that maybe some of these things didn’t happen, perhaps some of the people she felt were plotting against her really weren’t.” Ten days later, she was released.

It was the beginning of a persistent and common cycle. With each hospitalization, Linda was educated about her illness and the need for medication. This is the standard approach for increasing insight, but it does not account for the fact that people’s beliefs, even those which are wildly false, shape their identities. If a person goes from being a political martyr to a mental patient in just a few days—the sign of a successful hospital stay, by most standards—her life may begin to feel banal and useless. Insight is correlated with fewer hospital readmissions, better performance at work, and more social contacts, but it is also linked with lower self-esteem and depression. People recovering from psychotic episodes rarely receive extensive talk therapy, because insurance companies place strict limits on the number of sessions allowed and because for years psychiatrists have assumed that psychotic patients are unable to reflect meaningfully on their lives. (Eugen Bleuler, the psychiatrist who coined the term “schizophrenia,” said that after years of talking to his patients he found them stranger than the birds in his garden.)

With medication as her only form of treatment, Linda was unable to modify her self-image to accommodate the facts of her illness. When psychotic, she saw herself as the heroine in a tale of terrible injustice, a role that gave her confidence and purpose. After the World Trade Center attacks, in 2001, she moved to New York City, because she felt she had been called to offer her help. A December, 2001, article in the New York Post, “Homeless ‘Angel’ a Blessing at Ground Zero,” described how Linda patrolled the perimeter of the site, waving an American flag, greeting visitors, and giving impromptu tours. “Angels come to earth in disguises—some come as paupers,” a construction worker was quoted as saying. A man identified as a 9/11 victim said that “God rested on her shoulder.” Linda thanked workers at the site for their efforts and talked to tourists about what they were witnessing. “I try to help people understand the enormity,” she told the reporter. She dubbed herself the head of Hell’s Chamber of Commerce.

For the next few years, Linda wandered: she lived on the streets, in homeless shelters, and in her sister’s house, on the condition that she take medication. Joan, who works as the director of education for the New Hampshire Supreme Court, has the same warm, jovial manner as her sister, and the two spent much of their free time together, though Linda’s goal was to find her own home. In 2003, she entered a supported-housing program in Manchester, New Hampshire, and told her caseworker that she wanted to “live like an adult again.” She was upset that her illness had alienated her daughter and friends. Joan told me that “Linda would talk analytically about how it had felt to be delusional. It wasn’t a matter of imagining. It wasn’t as if she felt she was being chased by government agents. In her mind, they were as real as I am right now.”

In the summer of 2004, Caitlin, by then a senior in high school, decided to move back in with her mother for the first time in five years. Their new apartment, in Rochester, New Hampshire, became the preferred hangout spot for her friends. “She was the cool mom,” Jessica Jamriska, a close friend of Caitlin’s, said. “She had stopped talking about the government, except maybe if there was an election. And the only reason she quoted the Bible is if we were having intellectual debates about, you know, whether it’s a book of morals or not.”

Linda enjoyed cooking large meals for Caitlin’s friends, but over time the stories she told at the dinner table became harder to follow. “At first, we just thought, O.K., it’s normal to have some fantasies and dreams,” Jessica said. “She would talk a lot about some dude she loved who was going to make everything all right, and we weren’t even sure he existed.”

Caitlin and Joan urged Linda to take her medication, but she said that she felt perfectly fine and complained that the drugs made her lethargic and caused her to gain weight. (Linda’s parents, who had encouraged her to follow her doctors’ advice, had died, both of them from cancer, in 2003 and 2004.) Caitlin and two of her friends finally decided to make an audiotape of Linda ranting. “We wanted to have proof, to say, look, this is objectively crazy, and someone needs to help her,” Caitlin said. They recorded her talking about how children should be armed with AK-47s, and called the police, but Caitlin said that their complaint was never taken seriously. In February, 2005, Linda’s car flipped on its side on Rochester’s main street. When the police arrived, they smelled alcohol on her breath. She said that she had purposely caused the accident, to prove “that police officers are ‘illegal.’ ”

Although it was a relatively minor offense (her alcohol level was below the legal threshold), Linda refused to pay the five-hundred-dollar bail, so she was sent to the Strafford County House of Corrections, in March. (Nationally, a quarter of jail inmates meet the criteria for a psychotic disorder.) After her first arrest, Linda threw a cup of urine at a corrections officer and struck a man with a broomstick. Joan wrote to the police department’s prosecuting attorney, explaining that before her illness Linda had never been “violent or aggressive towards anyone or anything.” She said that the family hadn’t been able to get Linda into psychiatric treatment, and asked the attorney to help.

Joan’s request led to competency evaluations, and, as Linda waited in jail for the results, she moved even farther away from the life she had led before her illness. She considered herself a “people person”—she made Christmas cards for other inmates out of lunch bags and magazine ads, sealed with grape jelly—but she found herself isolated from all the people with whom she had once been close. She wrote Caitlin long letters with tips about what cosmetics to wear, how to get a job, shop for bargains, lose weight, make apple pie, and avoid the presence of people who belong in Hell, but Caitlin stopped responding.

“We’ve agreed to count it as both a wave and a particle for tax purposes.”

After a year and a half in jail, Linda was deemed incompetent to stand trial and was transferred to New Hampshire Hospital for a commitment term of up to three years. She was humiliated by the idea of anyone evaluating her competence and wrote to Caitlin, “My constitutional rights have been ignored, trampled on and violated due to your Aunt Joan.”

New Hampshire Hospital was established, in 1842, as a kind of utopian community, a reprieve from the disorder of the outside world. The hospital’s early leaders tried to help patients regain their common sense—in the first year, more than a quarter of admitted patients suffered from an “overindulgence in religious thoughts,” with several claiming to be prophets—by immersing them in a model society. The hospital was situated on a hundred and seventeen acres, and patients lived in a stately, red-brick Colonial building with a steeple and a tiered white porch, surrounded by trees. They farmed, gardened, and cooked together; there was a golf course, an orchestra, a monthly newspaper, dances, and boating on the hospital’s pond. In 1866, the hospital’s superintendent described psychosis as a “waking dream, which, if not broken in upon, works mischief to the brain,” and wrote that the goal of treatment was to “interfere with this world of self—scatter its creations and fancies and people it with objects and thoughts foreign to its own.”

As the patient population expanded, though, the hospital couldn’t maintain its early idealism. Psychiatrists no longer had time for the benevolent form of care known as “moral treatment.” As of 1936, the hospital had sterilized a hundred and fifty-five patients, and later it began experimenting with newfangled remedies, like electroconvulsive therapy and insulin-induced comas; the shock of such procedures, it was thought, might clear patients’ minds. By the nineteen-fifties, the hospital’s population had swelled to twenty-seven hundred patients, and doctors were less concerned with creating a sense of community than with maintaining security. Patients spent so many years in the hospital that they no longer knew how to leave it. (The institution has two graveyards for people who died in its care.) The hospital’s crowded wards resembled those studied in Erving Goffman’s 1961 book, “Asylums,” which showed how, through years of institutional life, people lost their identities and learned to be perfect mental patients—dull, unmotivated, and helpless.

The idea that mental illnesses were exacerbated, even caused, by the measures designed to treat them was elaborated by many scholars throughout the sixties. Thomas Szasz, a psychiatrist and prolific author, described mental illness as a “myth,” a “metaphor.” The psychiatrist R. D. Laing called it a “perfectly rational adjustment to an insane world.” In 1963, President Kennedy (whose sister Rosemary had received a lobotomy which left her barely able to speak) passed the Community Mental Health Centers Act, which called for psychiatric asylums to be replaced by a more humane network of behavioral-health centers and halfway homes. His “bold new approach,” as he called it, was plausible because of the recent development of antipsychotic drugs, which seemed to promise a quick cure. In the years that followed, civil-rights lawyers and activists won a series of court cases that made it increasingly difficult for patients to be treated without their consent. In 1975, the Supreme Court ruled that the state may not “fence in the harmless mentally ill.” Four years later, in Rogers v. Okin, a federal district court decided that involuntary medication was unconstitutional, a form of “mind control.” The court maintained that “the right to produce a thought—or refuse to do so—is as important as the right protected in Roe v. Wade to give birth or abort.”

Deinstitutionalization was a nationwide social experiment that did not go as planned. Overgrown hospitals were shut down or emptied, but many fewer community centers were opened than had been proposed. Resources steadily declined; in just the past three years, $2.2 billion has been cut from state mental-health budgets. “Wishing that mental illness would not exist has led our policymakers to shape a health-care system as if it did not exist,” Paul Appelbaum said in his 2002 inaugural address as president of the American Psychiatric Association. Today, there are three times as many mentally ill people in jails as in hospitals. Others end up on the streets. A paper in the American Journal of Psychiatry, which examined the records of patients in San Diego’s public mental-health system, found that one in five individuals with a diagnosis of schizophrenia is homeless in a given year.

New Hampshire Hospital, which now has only a hundred and fifty-eight beds, admits people who have been sent from jail or who pose a danger to themselves or others. Often, people arrive at the emergency room, with concerned relatives and friends, but they are turned away, because they are not an imminent threat. “Clinically, it’s a shame,” Alexander de Nesnera, the hospital’s associate medical director, told me. “These are people who may be making choices they would never have made when they were healthy. But then there’s the civil-libertarian argument: Who are we to say that they don’t have the right to change their opinions?”

Freedom often ends up looking a lot like abandonment. Tanya Marie Luhrmann, a Stanford anthropologist, told me that “there is something deeply American about the force of our insistence that you should be able to ride it out on your own.” Luhrmann has followed mentally ill women in Chicago through what is known as the “institutional circuit”—the shelters, halfway homes, emergency rooms, and jails that have taken the place of mental asylums. Many of the women refused assisted housing, because to gain eligibility they had to identify themselves as mentally ill. They would not “formulate the sentence that psychiatrists call ‘insight,’ ” Luhrmann said. “ ‘I have a mental illness, these are my symptoms, and I know they are not real’—the whole biomedical model. To ask for this kind of help is to be aware that you cannot trust what you know.”

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