\documentstyle[11pt]{cmu-art}
\title{Breakdown}
\author{Phoebe Sengers}

\renewcommand{\baselinestretch}{2.0}

\begin{document}

\maketitle

Institutionalization - the very terminology already begs a question.
How does institutionalization operate?  How does someone become
{\it{institutionalized}}?  Deleuze and Guattari say any social machine
- of which the psychiatric institution with its streaming in/out flow
of people is certainly one - works in the places where it breaks down.
``The social machine's limit is not attrition, but rather its
misfirings; it can operate only by fits and starts, by grinding and
breaking down, in spasms of minor explosions.''{\footnote{Gilles
Deleuze and F{\'{e}}lix Guattari, {\it{Anti-Oedipus: Capitalism and
Schizophrenia}}, trans. Robert Hurley, Mark Seem, and Helen R. Lane,
(New York: Viking Press, 1977) 151.}}  The breakdown of its patients
is reflected onto the ward; in its case, however, breaking down is
productive and creates the institutional moment.  To break down this
breakdown we must resort to the psychologist's tools: discourse
analysis via the hermeneutics of suspicion.{\footnote{Reference to
Ricoeur, please - ask Mathew}}  We will read a story of a breakdown,
writing into it the narrative written under the surface of the story. 

\begin{quotation}
{\it{In the middle of September, I started to get depressed.  By the
middle of October, things had progressed to the point that I could no
longer function: I couldn't read or write and was having trouble
walking.  I went to see a counselor at school and told him, ``I think
I need to go to the hospital.'' He took me to Western Psychiatric
Institute and Clinic.}}{\footnote{This is my story in my words.  I
wrote them with this paper in mind, but before I wrote the paper.}}
\end{quotation}

The quickest way into and out of theorizing about insanity is to state,
``people are labeled insane if they fail to correspond to social
norms.''  Such a statement fails to take into account the experience
of many mental patients who have committed themselves or of people who
are seeking treatment outside the institutionalized stream.  For these
people the experience of being ``crazy'' - schizophrenic, depressed,
or anxious, to follow the clinical classification - is routed through
feelings of misery and, often, physical symptoms like an inability to
concentrate, insomnia, or involuntary movement.  This is not to deny
that these physical symptoms bear the mark of the social formation
(``[I]t is a founding fact - that the organs be hewn into the socius,
and that the flows run over its surface...''{\footnote{Deleuze and
Guattari, {\it{Anti-Oedipus}} 149.}}).  It is merely to state that
insanity and institutionalization are more complicated than a mere
labeling on the part of a social organization. Insanity is something
experienced both from the individual and from the social point of
view.  

I do not pretend to be able to (re)present the real
institutionalization, the real experiences of mental patients.
Instead, I want to consider the period of institutionalization as a 
moment where two flows come into contact with each other: that of the
institution, with its labels and categories, ready to take in new
input, and that of the individual, who leaves his or her everyday life
to become, for a while, a more-or-less functioning member of a
social community under the auspices of the ward.  Corresponding to
these two flows there are two points of view or modes of
representation of the conjunctural period to be considered, that of
the institution and that of the patient. 

For the institution, any particular institutionalization is just a
moment in its history, though each of these moments is in the
strictest sense {\em{essential}} -  the institution really only
consists of the sum of these institutionalizations.  For the
individual, ripped from his or her normal existence and deprived of
his or her accustomed social context, the commitment is a traumatic
event, but one that is not constitutive.  The meeting of the
institution and the patient is a point of conjunction of the paths of
two very different social machines.   In this paper, I would
like to consider the dis- and conjunctions between the ways in which
these two social machines deal with their shared moment.  By
considering their respective representations of that moment - 
particularly the gaps between those representations - I hope to gain
an understanding of how the processing of both machines comes to
constitute the process of treatment in the institution.  

\begin{quotation}
{\it{I had to wait a long time in the emergency room before I was
checked in. After a long wait someone took my temperature. After
another long wait I talked to a counselor. After yet another long wait
I talked to the psychiatrist. 

While I was waiting someone was brought in from the state
penitentiary.  They locked him in a little room.  He was screaming and
kicking the door.  The screaming went like this: ``Society has made me
this desperate!  I was only arrested because I'm black and living in a
white world.'' All the staff in the room, including the receptionist, put on latex
gloves.  They put a crying woman in a private room so she wouldn't
be bothered by this man.  They asked me to move, too, so I wouldn't be
so dangerously close to the room where they had him locked up.}}
\end{quotation}

As the soon-to-be-patients stand on the threshold of entering the
institution, they are immediately confronted with its first moment of
breaking down.  There is a conflict between two functions of the
mental hospital: its function as a site of medical care or
rehabilitation and its role as a custodian of certain more dangerous
elements of society.  As Erving Goffman discusses in ``The Medical
Model and Mental Hospitalization,''{\footnote{Erving Goffman, ``The
Medical Model and Mental Hospitalization,'' {\it{Radical Psychology}},
ed. Phil Brown (New York: Harper Colophon, 1973) 25-45.}}  the
stresses and gaps between these two models are felt keenly within the
institution, which currently prefers to underscore the service model.
``Each time the mental hospital functions as a holding station, within
a network of such stations, for dealing with public charges, the
service model is disaffirmed.  All of these facts of patient
recruitment are part of what staff must overlook, rationalize, gloss
over about their place of service.''{\footnote{Goffman, ``Medical
Model'' 30.}} Nevertheless, the institution continues to be able
to operate on both registers (``No one has ever died from
contradictions''{\footnote{Deleuze and Guattari, {\it{Anti-Oedipus}}
151.}}).   

This presents a quandary for the mental patient.  S/he is generally
all too aware of being incarcerated despite the staff's assurances
that s/he is only there ``for your own good.''  ``[O]ur conversation
[had] the character of an authoritarian interrogation, overseen and
controlled by a strict set of rules.  Of course neither of them was
the chief of police.  But because there were two of them, there were
three....''{\footnote{Maurice Blanchot, {\it{The Madness of the Day}},
trans. Lydia Davis (New York: Station Hill Press, 1981), 18.}} Though
the institution claims to work on the medical metaphor, it is apparent
that it differentiates patients according to how well they fit into
the service model. In the case of the man in the emergency room, the
patients (i.e., I and the other woman) that are more or less
``normal'' are treated courteously and are even physically separated
from the ``problem patient.''  He is considered dangerous and alien;
the staff dons gloves to avoid coming into contact with him.  The
patient occupies a troubled status; s/he is at the same time the 
``good patient,'' being  treated for an illness more or less external
to him or her, and the ``bad patient,'' fundamentally flawed and not
allowed to go outside; the latter status is all the more real for
being denied.  

\begin{quotation}
{\it{Then two big white men went into the room and gave the black man
a shot.  He was still kicking and screaming.  Later they went into the
room again.  I heard the receptionist talking on the phone.  She said,
``They've already given him twice the normal dosage and he's still not
calm.'' 

They brought me papers to sign myself in.  I joked with the nurse.
``This is so I can still run for president, right?''  She didn't think 
it was funny.}}
\end{quotation}

The moment of entrance into the institution is a symbolic one.  It is
accomplished through what Deleuze and Guattari call ``order
words''{\footnote{Deleuze and Guattari, {\it{A Thousand Plateaus:
Capitalism and Schizophrenia}}, trans. Brian Massumi (Minneapolis:
University of Minnesota Press, 1987) 80.}}\  - deeds that occur
entirely through an act of signification.  In the case of the
institution, the order word is the signature.  The papers I sign mean
that I no longer have a right to speak for myself before the law. Once
I have signed the paper, my signature is worthless. This gives the
signature on the commitment form an eerie status - a signature,
sealing its own inability to seal.  

The signature, despite or perhaps thanks to its paradoxical status, is
central to the institution.  It is what binds the patient to the
institution; it is what controls the flow of patients in to and out of
the institution. The patient arrives, bound by his or her own signature
or by that of a doctor. The patient may not leave, even if s/he came
voluntarily, without the signature of a proxy:{\footnote{If a patient
voluntary commits him or herself, s/he can sign him or herself out,
but must wait three days before s/he can leave.  In the meantime, s/he
can be, and often is, committed by the hospital against his or her
will.}} the psychiatrist, competent, as though by an act of
conservation of agency, to speak for two. 

The signature is itself a proxy for the law.  Maurice Blanchot writes,
\begin{quotation}
Behind [the doctors'] backs I saw the silhouette of the law. Not
the law everyone knows, which is severe and hardly very agreeable; this
law was different.  Far from falling prey to her menace, I was the one
who seemed to terrify her.... She would say to me, ``Now you are a
special case; no one can do anything to you.  You can talk, nothing
commits you; oaths are no longer binding to you; your acts remain 
without a consequence.''{\footnote{Blanchot 14-15.}}
\end{quotation}
In this respect, the patient stands beyond the grasp of the arm of the
the law.  But it would be more appropriate to say the patient is
jettisoned by the law. ``When she set me above the authorities, it meant,
you are not authorized to do anything.''{\footnote{Blanchot 15.}}  The law
deprives the mental patient, not only of his or her culpability, but
also of his or her ability to speak.  The category of the ``insane,''
then, is defined by its inability, socially speaking, to speak for
itself.  It is a category without legal status in the narrowest sense.

The breakdown of the institution at the moment of entrance, then, is
mirrored by a breakdown of the social machine of the patient.  It
would be better, perhaps, to speak of a breakout: the patient is no
longer seen as a functioning member of society.  This is a Catch-22
for the patient trying to affect reform or even just trying to voice
his or her experience; how can a group of people {\it{defined}} by an
inability to speak find a voice in society?  By definition this
should be impossible, except perhaps for the gap between ``insane''
(insane as a social label, from the point of view of the institution) and
insane (insane as an experiential label, from the point of view of the
labeled individual).  In the mental reform movement, one finds most
such voices stemming from ex-patients: ``We, of the Mental Patients'
Liberation Project, are former mental patients.''{\footnote{Mental
Patients' Liberation Project, ``Statement,'' {\it{Radical Psychology}}
521.}} ``Insanity'' in the first person is invoked as a category of
nostalgia. 

The Mental Patients' Liberation Project approaches this problem by a
loosening of the term ``we,'' which is used alternately to mean the
``former mental patients''{\footnote{Project 521.}} of the project and
patients currently in asylums.  ``We have drawn up a Bill of Rights
for Mental Patients.... Because these rights are not now legally ours
we are now going to fight to make them a
reality....''{\footnote{Project 522.}} By blurring the categories
patient/ex-patient the Project also blurs their respective legal
statuses, pulling the patient into the realm of  the law occupied by
the ex-patient.  The Project still speaks {\it{for}} the patient, but
with some sleight of hand its voice appears to come out of the
patient's mouth. 

The Liberation Project also plays the role of the law for the mental
patient. The Project presents the patient with a Bill of Rights,
rights, the Project grants, without true legal status but ``which 
we unquestioningly should have.''{\footnote{Project 522.}} A major concern
of this Bill is the legalization of the mental patient: ``You are an
American citizen and are entitled to every right established by the
Declaration of Independence and guaranteed by the Constitution of the
United States of America.''{\footnote{Project 523.}}  The project thus
solves its theoretical problem handily - it plays the parts of the
constituencies that cannot or do not want to appear on the
stage.{\footnote{Compare to Thomas Szasz: ``[M]ental health is the
ability to play whatever the game of social living might consist of
and to play it well.  Conversely, to refuse to play, or to play badly,
means that the person is mentally ill.''(T.S.Szasz, ``Politics and
Mental Health,'' {\it{American Journal of Psychiatry}}, CXV (1958):
509; cited in Erving Goffman, ``The Medical Model'' 43).}}  

\begin{quotation}
{\it{After I had waited for a total of seven hours they took me
upstairs. When we got to the 11th floor (the depression ward) I was
met by a disoriented-looking patient, who said, ``You'll like it here.
We all help each other get better.''  I thought to myself, ``Oh no!
I'm going to be locked on a floor with all these strange people.''}}
\end{quotation}

The moment of the signature has passed.  As far as the hospital is
concerned, the patient has already been classified into the type that
will determine how s/he will be processed for the rest of the stay.
For the patient, however, the order word is not enough to change his
or her entire system of functioning.  His or her point in the social
hierarchy has changed but this change has not yet manifested itself
in the realm of action.  The machine is still running, just as it did
before.  On entry into the social situation of the ward its old system
of functioning will choke; the machine will have to reprogram itself. 

\begin{quotation}
{\it{My clothes and all my belongings were searched and they took
everything they thought was ``dangerous'' out of it.  That includes my
suntan lotion{\marginpar{\em{contact lens solution?}}} and my tampons.
I said, ``What could I possibly do with my tampons?''  The staff
person checking me in couldn't think of anything.  But those were the
rules.}} 
\end{quotation}

Although the commitment took place at the moment of the signature, the
{\it{institutionalization}} really begins here.  This is the moment at
which the patient is made to realize the rights and privileges s/he
has lost by seeking help within the institution.  The incoming patient
is stripped, searched, given hospital clothing, and led onto the ward
identified only by a hospital bracelet.  No one on the ward knows the
patient, who is reluctant to circulate with the other patients, people
from whom until recently s/he was protected by the comforting arm of
the law.  Any attempts to identify with the staff, however, will soon
be rebuffed; the patient becomes forcibly alienated from the person
s/he thought s/he was and must assume a new role.

From the point of view of the institution, this is a dangerous moment.
A new element has been absorbed but at this point it still retains
marks of the outside world.  These now out-of-date attributes must be
removed as quickly as possible.  Erving Goffman points out, ``Many of
[the admission] procedures depend upon attributes such as weight or
fingerprints that the individual possesses merely because he is a
member of the largest and most abstract of social categories, that of
human being.  Action taken on the basis of such attributes necessarily
ignores most of his previous bases of
self-identification.''{\footnote{Goffman, ``On the Characteristics of
Total Institutions,'' {\it{Asylums}}, (New York: Anchor Books, 1961) 
16.}}  The institution must create a deterritorialized space onto
which to reterritorialize its input.

Once the incoming patient has been sanitized, s/he is more easily
adapted to the role the institution has planned for him or her.  
``Admission procedures might better be called `trimming' or
`programming' because in thus being squared away the new arrival
allows himself to be shaped and coded into an object that can be fed
into the administrative machinery of the establishment, to be worked
on smoothly by routine operations.''{\footnote{Goffman, ``Total
Institutions'' 16.}} Institutionalization becomes mechanization; the
humanity of the patient is stripped away and replaced by a robotic
faciality.   The issue is not whether the patient is comfortable in
the new role; from the point of view of the institution, the patient
can only be dealt with in so far as s/he is 
mechanized.{\footnote{Consider, for instance, that in many mental  
hospitals there is {\it{no}} individual psychotherapy; all treatment
is done in group mode.}}  The model for the psychology of the mental
patient is a robot psychology, working mechanically in the roles of
the automated patient, Parry,{\footnote{Parry is a program that
simulates a paranoid schizophrenic.  See Kenneth Mark Colby,
{\it{Artificial Paranoia: A Computer Simulation of Paranoid
Processes}} (New York: Pergamon Press, 1975).}} and his analyst,
Eliza.{\footnote{Eliza is a computer program intended as a study in
natural language communication.  It plays the part of a Rogerian
psychoanalyst.  It is described in J. Weizenbaum, ``ELIZA - A Computer
Program for the Study of Natural Language Communication Between Man
and Machine,'' {\it{Communications of the Association for Computing
Machinery}}, 1 (1965) 36-45.  To the shock of its programmer it was
received with enthusiasm by the psychiatric community and was
recommended for eventual therapeutic use in K.M. Colby, J.B. Watt, and
J.P. Gilbert, ``A Computer Method of Psychotherapy: Preliminary
Communication,'' {\it{The Journal of Nervous and Mental Disease}}, 2
(1966) 148-152.}}

\begin{quotation}
{\it{After a while, I had a headache.  I went to the nurses' station
and knocked.  After a couple of minutes of ignoring me, someone came.
I asked for a Tylenol.  ``Has your doctor approved it?'' she asked.
``I don't have a doctor.'' ``Well, then you can't have any.''  After a
couple more equally humiliating trips to the nurses' station I gave 
up, even though by then my new doctor had given me permission to take
two Tylenol every four hours.}}
\end{quotation}

Changing arbitrary people into cogs in a machine takes some filing
down of resistance.  In the institution, the most innocuous requests
are taken as an opportunity to regulate the life of the patient more
closely. ``[T]he inmate's life is penetrated by constant sanctioning
interaction from above, especially during the initial period of stay 
before the inmate accepts the regulations unthinkingly.... The autonomy
of the act itself is violated.''{\footnote{Goffman, ``Total
Institutions'' 38.}}  The patient is made to feel that any unusual
activity -  one that is not already structured by the institution -
requires too much effort.  S/he becomes more passive; the authority of
the institution is reinforced.   

The power of deciding over the patient's life does not disappear; it
is given to the psychiatrist.  ``Incarcerating institutions operate on
the basis of defining almost all the rights and duties the inmates
will have.  Someone will be in a position to pass fatefully on
everything that the inmate succeeds in obtaining and everything he is
deprived of, and this person is, officially, the
psychiatrist.''{\footnote{Goffman, ``Medical Model'' 35.}}  The
psychiatrist has an enormous amount of power over his charges.
Blanchot: ``[T]hese men are kings.''{\footnote{Blanchot 14.}} But it
is not the individual psychiatrist who has gained agency; s/he too
must play within the parameters of the game.  ``Almost any of the
living arrangements through which the patient is strapped into his
daily round can be modified at will by the psychiatrist, {\it{provided
a psychiatric explanation is given}}''{\footnote{Goffman, ``Medical
Model'' 36.  Compare to Ralph Ellison: ``[Y]ou don't have to worry
about the brothers' criticism. Just throw some ideology back at them
and they'll leave you alone - provided, of course, that you have the
right backing and produce the required results.''(Ralph Ellison,
{\it{Invisible Man}}, (New York: Vintage, 1972) 350.) }} (emphasis
mine).

Paradoxically, the institution's control over the patient is limited by
the very mechanisms it uses to gain control over him or her.  The
institution can only control the patient insofar as s/he is
mechanized.  There are aspects to the patient that the  institution
cannot even see, let alone do anything about.  For instance, some
(perhaps many) patients have gotten very good at playing the part of
the patient.  These patients may use their acting  abilities to
shorten their length of stay or to get a hospital bed as an
alternative to sleeping in prison or on the street.  I myself took
advantage of their ignorance to read what might be considered
subversive literature ({\it{Anti-Oedipus}} and {\it{The Birth of the
Clinic}}) without any problems.   {\it{One Flew Over the
Cuckoo's Nest}} is usually cited as an example of the power of the
institution over its charges: McMurphy places himself in the way of
smooth running and is crushed by the institutional machine.  But in
the same novel Chief Bromden has staked out a territory of agency: he
pretends to be deaf, stays away from the moving parts and hence finds
space to maneuver.{\footnote{Ken Kesey, {\it{One Flew Over the
Cuckoo's Nest}}, (New York: Signet, 1962).}}

\begin{quotation}
{\it{Soon I started meeting the other patients.  At first I thought that
would be a little scary.  But it turned out they were no weirder than
the average person you meet on a bus. One of them was even a
psychologist himself!  When I arrived, there was only one patient on
the ward who had lost grips with reality.  She talked a lot, very
enthusiastically. I've met a lot of people like that on the bus, too.  

There was only one scary person on the ward.  She showed up a couple
of days after I did. She wore latex gloves all the time, thought she
had all sorts of horrible diseases and tried to get everyone to take
care of her.  We were afraid of her and thought she should have been
on a different floor.}}
\end{quotation}

As far as the institution is concerned, all patients on a ward are the
same (except as differentiated by whatever deed-reward system has been
put into place).  The patients, however, continue to differentiate
among themselves as they always have.  Thus the patients will coalesce
into social groups on the basis of educational level, race,
intelligence and so forth.  The patients on the ward repeat (though
without institutional support) the same status differentiation of
sane/insane as on the outside; those patients perceived to be ``more
insane'' are treated with a similar kind (though not a similar level)
of distancing as the `saner' patients themselves receive at the hands
of social organization.  Thus, the patients think the strange woman
should have been on a different floor - just like the rest of society,
they want to be separated from her.

The paradox is that the strange woman (we dubbed her ``Latex Lady'')
actually comes to embody the institution.   Her preoccupation with
disease and desire for care reflect the ``medical model of
hospitalization'' Erving Goffman points towards, while her perpetual
donning of latex mirrors the less appetizing aspects of the
institution.  We considered it in bad taste; it reminded us of our
loss of agency, which we were all too willing to gloss over just as
the staff did. She brings forth the same kind of stratification within
the hospital that the hospital brings forth in society.  This
stratification is different in that it has no legal backing and this
is what brings about the fear in other patients.  They realize that
under the law they have no protection against her because they
belong to the same class of undesirables.   

\begin{quotation}
{\it{I started meeting the staff then, too.  That is when you realize what
your status is. The patients still treat you like a human.  The staff
treats you like you've lost the right to speak about yourself.
Everything you do is treated as a symptom.  You'd better not confide 
in any of them since they report to each other.  You run into your
psychologist and he says, ``I hear you had a hard group therapy
session.''  In that respect, there is no privacy.}}
\end{quotation}

The mental hospital treats the ``whole patient'' (as much of him or her
as the hospital can recognize):  for the institution there is no room
for excess.  ``All of the patient's actions, feelings, and thoughts - 
past, present, and predicted - are officially usable by the therapist
in diagnosis and prescription.... None of a patient's business, then,
is none of the psychiatrist's business; nothing ought to be held back
from the psychiatrist as irrelevant to his
job.''{\footnote{Goffman,``Medical Model'' 34-35.}}  All information
about the patient is funneled to his or her psychiatrist. For all
intents and purposes s/he becomes the patient's institutional  alter
ego. ``Throwing open my rooms, they would say, `Everything here
belongs to us.'  They would fall upon my scraps of thought: `This is
ours.' ''{\footnote{Blanchot 14.}} The psychiatrist takes over the
legal role of the patient: s/he alone can make decisions about what kind
of medication (including over-the-counter) the patient can take, what
kinds of `privileges' the patient can have and whether the patient
will be allowed to go home. 

Now that the psychiatrist has taken over the agency of the patient,
everything the patient does is treated as symptomatic.  The patient
can no longer act, only signify.  ``Right before their eyes, though
they were not at all startled, I became a drop of water, a spot of
ink.''{\footnote{Blanchot 14.}}  The patient's actions only function
insofar as  they are informational - they only {\em{act}} as ciphers,
which it is then the responsibility and right of the doctor to decode.
The institution makes a double movement - it ciphers the patient in
order to {\em{de}}cipher him or her.  Though the patient cannot speak,
the patient is always - already - signifying, against his or her will. 

We already noted that the patient has lost the right to speak.  Now we
see how his or her language is re-routed, being cited to the patient as
the rationale of his or her loss of control - ``my story would put itself
at their service.''{\footnote{Blanchot 14.}}  In turn, the staff often no
longer considers the patient as a worthy addressee.  Goffman notes,
\begin{quotation}
Often he is considered to be of insufficient ritual status to be given
even minor greetings, let alone listened to.  Or the inmate may find
that a kind of rhetorical use of language occurs: questions such as,
``Have you washed yet?'' or ``Have you got both socks on?'' may be
accompanied by simultaneous searching by the staff which physically
discloses the facts, making these verbal questions
superfluous.{\footnote{Goffman, ``Total Institutions'' 44. }}
\end{quotation}
By this point, the patient {\em{qua}} human agent has been written out
of the institutional picture.  The patient has no social choice but to
turn to his or her fellows. 

\begin{quotation}
{\it{The main kind of therapy is talking to the other patients.  Once you
realize your status in the hospital you'd much rather talk to them
than the staff anyway.  There is no hope of fruitful discussion with
the psychologist at all.  He or she is just someone you see 
for five minutes a day and who asks if you've been feeling suicidal.

We patients talked about a couple of different things.  We were all
depressed so we spent a lot of time talking about how pathetic we were
and about our miserable problems.  Another popular topic of
conversation was medication.  Almost everyone was medicated, so we
spent a long time discussing our medication and rumors about what
different drugs (or treatments, such as shock therapy) would do to
you.  Finally we spent a lot of time complaining about being in the
hospital and being treated like a mental patient.  This was usually 
done when there was no staff around. One common comment was, ``The people on the outside are just as crazy
as we are.  We just had the sense to get treatment.''}}
\end{quotation}

Modern psychiatry has had a hard time determining at whose door to lay
the blame for the genesis of insanity.  It has developed the notion of
``schizophrenogenic'' and other dysfunctional families to describe a
situation in which someone becomes insane because of the madness of
his or her world.  ``Madness, that is to say, is not `in' a person but
in a system of relationships in which the labeled `patient'
participates.''{\footnote{David Cooper, ``Violence and Psychiatry,''
{\it{Radical Psychology}} 149.}}  Indeed, it seems that if one's world
lacks logical coherence the only {\em{sane}} response is to go mad.
All this calls into question the utility of labeling the individual
patient as insane in contrast to the rest of society. ``[The law]
exalted me, but only to raise herself up in her turn. `You are famine,
discord, murder, destruction.'  `Why all that?' `Because I am the
angel of discord, murder, and the end.'  `Well,' I said to her,
`that's more than enough to get us both locked up.' ''{\footnote{Blanchot 16.}}

\begin{quotation} 
{\it{The end result was that many patients felt a strong bond with the
other patients but were a lot less enthusiastic about the staff and
doctors. 

After a couple of days in the hospital I was starting to get
claustrophobic (in its usual metaphoric sense). None of the windows
open - since patients might be tempted to jump out - so the ward never
got fresh air.  I started to feel like I was living in a fishbowl,
constantly observed. }}
\end{quotation}

That is the one real difference between patients and non-patients: the
very experience of being in the hospital itself.  This is particularly
true of people with schizophrenia, whose terms of hospitalization are
generally longer than those of anxious or depressed people.
Some psychiatrists claim they ``[need not] fear that it is [their]
diagnosis which separates a schizophrenic person from his family and
peers,''{\footnote{Daniel X. Freedman, M.D., foreword, {\it{The
Meaning of Madness: Symptomatology, Sociology, Biology and Therapy of
the Schizophrenias}}, by C. Peter Rosenbaum, M.D. (New  York: Science
House, 1970) {\it{xviii}}.}}.  But in a very real sense it does.

In fact, the notion that the institution itself participates in the
construction of its patients' insanity has developed currency in the
psychiatric community, who label it ``institutional
neurosis.''{\footnote{Cooper 129.}}  The effect of the institution is
not limited to the changes we have already seen a person must
make to adapt to the hospital situation. David Cooper sees the
structure of the hospital ward as reproducing the conditions of the
schizophrenogenic family, thereby creating, not a curative climate,
but one that fosters the development and maintenance of insanity.
Documented effects of the asylum on its inmates lead some people to
believe that  ``[w]hat [psychiatry] attempts to cure us of is the cure
itself''{\footnote{Mark Seem, introduction, {\it{Anti-Oedipus}}
{\it{xvii}}.}} and to speak of ``the artificial schizophrenic found in
mental institutions.''{\footnote{Deleuze and Guattari,
{\it{Anti-Oedipus}} 5.}}
``One is left with the sorry reflection that the sane ones are perhaps
those who fail to gain admission to the mental observation ward.  That
is to say, they define themselves by a certain absence of
experience.''{\footnote{Cooper 129.}}

\begin{quotation}
{\it{I wanted out.  But that wasn't so simple.  

If I checked myself out (since I was a voluntary) I would have to wait
three days before they let me go.  If they let me go.  A number of my
fellow voluntary patients were committed by the hospital (or
threatened with commitment) when they tried to leave.  This was
rumored to be because the hospital was afraid of being sued. And even
if they did let me go, it would be `AMA,' against medical advice, and I 
would forfeit my right to come back if I should take a turn for the
worse.  The only option was to fool the doctors into thinking I was
better.}}
\end{quotation}

The antipsychiatric community is well aware of that many patients
manipulate the doctors into letting them out prior to any basic change
in them that can be correlated with cure.  ``I am quite sure that a
good number of `cures' of psychotics consist in the fact that the
patient has decided, for one reason or other, once more to {\it{play
at being sane}}.''{\footnote{R.D. Laing, {\it{The Divided Self}},
(Baltimore: Penguin, 1959) 148.}}  But consider what a patient needs
to be able to do in order to ``play at being sane.'' Among other
things, the patient must have enough control of him or herself to be
able to play a role, s/he must be able to monitor him or herself well
enough to understand what his or her social role is expected to be,
and s/he must be suspicious of the doctors and/or the psychiatric
institution.  In short, s/he must be able to function in his or her
role to the satisfaction of the institution.  Fooling the doctors is
therefore equivalent to being healthy for the institution. The nature
of the institution means {\em{there can be no question}} of whether
the patient is ``really'' better, or only pretending; the two states
are identical. 

Again, this is a question of the gap between the institution's
mechanized view of the patient as symbol and the patient's view of him
or herself.  The patient as agent always exists in a space beyond the
totalizing view of the institution and is hence after a certain point
invisible to it. ``The whole of me passed in full view before them,
and when at last nothing was present but my perfect nothingness and
there was nothing more to see, they ceased to see me too.  Very
irritated, they stood up and cried out, `All right, where are you?
Where are you hiding? Hiding is forbidden, it is an offense,'
etc.''{\footnote{Blanchot 14.}}  On the one hand, this gap between
agent and role means there can be no question of a ``real'' or
``objective'' cure; on the other,  it provides some play in the system
where the denied agency of the patient can work.  

\begin{quotation}
{\it{I actually was feeling somewhat better.  The pressure of constant
observation was returning me to a normal level of repression and I got
some tips from some of the more seasoned patients on what the doctors
looked for.  After three more days I was allowed to go home. 

Now when I think back to my time in the hospital the main impression I
have is one of being trapped.  I also got pretty good at ping-pong.  
A few weeks after I got out of the hospital, I received a final
reminder - the bill,  \$11,000. }}
\end{quotation}

Money is a theme running discreetly under the surface of the
institutional situation.  Many of the deprivations of freedom the 
patients suffer (not being able to go for a walk, for example)
can be traced to worries on the hospital's part of being sued.  The
fact that the patient is paying to be in the hospital runs in strange
counterpart to this loss of agency.  After all, the patient is being
held accountable for the bill, even though s/he has no control over
the length of the stay (witness recent allegations of hospitals
unnecessarily committing people for their insurance money). 
%reference please! 
This brings a new twist to Henry Miller's comment: ``The analyst has
endless time and patience; every minute you detain him means money in
his pocket;''{\footnote{Henry Miller, {\it{Sexus}} (New York: Grove
Press, 1965) 429; cited in Seem {\it{xv}}.}} in this case, it is
every minute he detains you.

In the end, then, the legal status of the patient is restored to him
or her in the form of the bill.  The hospital says, in effect, ``You
are now a legally responsible person - we entrust you with the ability
to pay us.''\footnote{It might be interesting to speculate on the
status of health insurance...} But the patient is not merely returned
to his or her former existence.  As we have noted, the hospital stay
leaves marks, both intended and unintended, on the functioning of the
now ex-patient, while the hospital churns on, processing new patients.

The stated function of hospitalization is to take in those who are
labeled ``insane'' and return them to some level of normality.  We see 
that the institutional machine does not function at this ideal level
in its performance of its task.  The institutional nature of the
ward, with its emphasis on a cookie-cutter mold of patient, demands a
total abandonment of agency on the part of the patient, who is reduced
to a cipher.  At the same time it leaves an unmonitored gap between
the ideal and the actual patient, a space where the real patient can
maneuver. 
The institutional moment works both through and despite the
point where the institution breaks down: the  point at which the
mechanical is not identical to the real.    

\newpage
\section*{Works Cited}

\begin{tabbing}
bbbbb\= \kill
Blanchot, Maurice. {\it{The Madness of the Day}}.  Trans. Lydia Davis.
New York: Station Hill Press,\\
\> 1981. \\
\\
Colby, Kenneth Mark. {\it{Artificial Paranoia: A Computer Simulation
of Paranoid Processes}}. New \\
\> York: Pergamon Press, 1975. \\
\\
Colby, K.M., J.B. Watt, and J.P. Gilbert, ``A Computer Method of
Psychotherapy: Preliminary \\
\> Communication.'' {\it{The Journal of Nervous and Mental Disease}} 2
(1966): 148-152. \\ 
\\
David Cooper. ``Violence and Psychiatry.''  {\it{Radical Psychology}}.
Ed. Phil Brown. New York:\\
\> Harper Colophon, 1973. 128-155.\\
\\
Deleuze, Gilles and Felix Guattari. {\it{Anti-Oedipus: Capitalism 
and Schizophrenia}}. Trans. Robert\\
\> Hurley, Mark Seem, and Helen R. Lane. New York: Viking
Press, 1977. \\ 
\\
---, {\it{A Thousand Plateaus: Capitalism and Schizophrenia}}.  Trans.
Brian Massumi.  Minneapolis: \\
\> University of Minnesota Press, 1987. \\
\\
Ellison, Ralph. {\it{Invisible Man}}. New York: Vintage, 1972. \\
\\
Freedman, Daniel X.  Foreword. {\it{The Meaning of Madness:
Symptomatology, Sociology, Biology}} \\
\> {\it{and Therapy of the Schizophrenias}}. By C. Peter Rosenbaum.
New  York: Science House,\\
\> 1970.  {\it{xvii}} - {\it{xix}}. \\
\\
Goffman, Erving. ``On the Characteristics of Total Institutions.''
{\it{Asylums}}. New York: Anchor, \\
\> 1961. 1-124.\\
\\
---, ``The Medical Model and Mental Hospitalization.''
{\it{Radical Psychology}}.  Ed. Phil Brown. New\\
\> York: Harper Colophon, 1973. 25-45. \\
\\
Kesey, Ken. {\it{One Flew Over the Cuckoo's Nest}}. New York: Signet,
1962. \\
\\
Laing, R.D. {\it{The Divided Self}}. Baltimore: Penguin, 1959. \\
\\
Mental Patients' Liberation Project. ``Statement.''  {\it{Radical
Psychology}}.  Ed. Phil Brown. New \\
\> York: Harper Colophon, 1973. 521-525. \\
\\
Seem, Mark.  Introduction.  {\it{Anti-Oedipus: Capitalism and
Schizophrenia}}. By Gilles Deleuze and \\
\> Felix Guattari.  Trans. Robert Hurley, Mark Seem, and Helen R.
Lane. New York:\\
\> Viking Press, 1977. {\it{xv}}-{\it{xxiv}}. \\
\\
Weizenbaum, J. ``ELIZA - A Computer Program for the Study of Natural
Language \\
\> Communication Between Man and Machine.'' {\it{Communications of the
Association for}} \\
\> {\it{Computing Machinery}} 1 (1965): 36-45. \\ 
\end{tabbing}

\end{document}