The venerable literary genre of madness memoirs has so proliferated in the decades since the 1970s and 80s that even those with a scholarly interest must read selectively among them, and any catalogues seem doomed to incompleteness. Now, sporting a new title as examples of patient narratives of illness or”pathography,” and cast as a form of therapeutic writing (“bibliotherapy” or “writing therapy”), such stories abound. And they have taught us much —  about inpatient and outpatient experiences of mental health care, of diagnosis and meds and side effects, of the ins and outs of CBT, and of discrimination and loneliness, for example, as well as about the sometimes exhilarating, often confusing and distressing experience of mental disorder itself, its horrors, and temporarily liberating certainties, its alienation and disorientingdifference from the humdrum, comforting everyday sameness most people take for granted. We have learned about not only the authors’ personal stories, but their social and medical histories more broadly understood, and about institutions and attitudes. And we’ve admired the skill, courage, honesty and grace with which such tales are told.

There are too many of these works for us to read them all. But Barbara Taylor’s is not to be missed. The Last Asylum is an extraordinarily measured, fascinating and honest account, that stands out from all but a handful within the genre.

Judged in the terms of assessment we apply to such books, Taylor’s succeeds well. It falls into none of the predictable traps: there are no elements of self–pity, no hints of manic insouciance, or grandiosity; and, while the writing never gives way to the confusing or turgid, there are no efforts to paper over or rationalize earlier incoherencies in light of later, revised perspectives. But this is only one way in which we can evaluate the virtues of this book. There is a better way to see it, not as a madness memoir only, but – as suggested by the first part of its title – also as a piece of social history, documenting the demise of asylum mental health care during the years of de–institutionalization; and in addition, as a rare, revealing glimpse into the intimate world of the psychoanalytic relationship. Rather than a simple madness memoir, Taylor interweaves these three elements throughout the entire book, granting each equal prominence. In this respect, her book can more readily be compared with another brilliant, tripartite recent work by a young woman written in the UK, Helen Macdonald’s H is for Hawk, which so effectively entwines a grief memoir with a primer on hawking, and an account of the troubled life of T.H.White, author of The Once and Future King. As in Macdonald’s masterpiece, Taylor’s complex juggling act works to perfection. None of the three ever lags, nor does any one overshadow or swamp the others. And together they form a coherent, compelling, and closely–woven unity.

Taylor’s personal story is briefly told. Brought up in Canada and now in the UK, she is today a professor of humanities at the University of London, and author of several scholarly books. She found her life falling apart only after she had won acclaim as an historian for a prize–winning work of feminist history. With anxiety, panic, bodily ills and a range of other symptoms, and spiraling distress accompanied by reckless alcohol use, she finally entered (or as she puts it, fell into) the Friern Mental Hospital, previously the Colney Hatch Lunatic Asylum. But this was during the 1980s, when the old asylum system was being dismantled. Today, Friern is physically replaced by luxury housing, Princess Park Manor. For its patients, back then, however, it was to be replaced by a much–vaunted, although underfunded, system of community care. During the decades of her disorder and treatment, Taylor thus experienced the demise of Friern, and the inadequacies of its substitutes, a day hospital and later a hostel, as she careened through episodes of more and less severe dysfunction and suffering. She writes as an historian here, and seems to have managed to keep journals and notes, even during the worst times. She retained her acute powers of observation and sense of history in the making, and the book documents these enormous policy shifts at every level, including as effects on the dwindling group of inpatients at Friern, and later outpatients at other facilities. Although the network of day centers and community care arrangements that were supposed to replace asylum care were rarely sufficient (some were little more than cynical politicians’ pipe dreams), some of her experiences of these substitutes were a success, providing her with the comfort and care she required. In an anomalous arrangement permitted by economic security  (made possible by her parents) and official flexibility, however, Taylor was luckier than any of the other patients. She was able to continue her in–depth, intensive psychoanalytic treatment throughout these years, with the persistent, uncompromising and unflappable analyst she refers to only as “V.”

That this psychoanalytic treatment provided the supportive consistency enabling the eventual return of her stability seems to be Taylor’s own considered conclusion. But she does her readers an enormous favor.  Threaded through the entire text are italicized transcriptions (or something approaching them), reports of these exchanges between herself and V. So we are able to decide for ourselves how much credit is due to psychoanalyst V, how much to her no–nonsense psychiatrist Dr D, how much her wry and resourceful fellow patients, about whom she writes with admirable decency and humanity, how much to her loyal and helpful London friends  — and how much to her own resilience and inner strength.

In an epilogue, Taylor offers her analysis of what ails mental health care today, quoting service workers whose emphasis is on sympathetic care relationships as instances of best practice. Required to achieve such practice, she insists, would be “reliable, open–ended care, sometimes in supportive institutional environments.” She scoffs at the CBT that, as the “modern face of Anglo–American psychotherapy,” has been carried to absurd extremes, she believes, in the National Health Service’s computerized CBT, which flies in the face of “a host of studies” showing that “it is the quality of the relationship with the therapist that determines the outcome of…all therapeutic encounters.” About what she needed at her most needy, she is clear: it was “asylum, a safe place to be.” And what helped most: a costly, intensive, long–term psychoanalysis. This is not a solution, she recognizes, for less advantaged patients. Yet her final recommendation still remains something as close to it as is possible. She rightly identifies the problems. They include “a fantasy of adult autonomy” at odds with human realities; reduced funding for psychotherapy of all stripes, and especially antipathy to psychoanalysis, an obsession with time and efficiency – and a rejection, finally, of personal history as relevant to healing. The story of the Asylum Age is not a happy one, she concludes. But “if the death of the asylum means the demise of effective and humane mental health care, then this will be more than a bad ending to the story; it will be a tragedy.” We may differ with her model of humane mental health care, with its exclusive focus on late–stage treatment responses to adult disorder. A more sweeping and preventive public health approach that would anticipate and attend to the societal ills responsible for those intractable adult experiences seems worth a try. (It is increasingly being recognized in response to the world–wide epidemic of depression symptoms, that cannot realistically be dealt with in any but society–wide measures of this kind.) But if we grant her premise, then we can hardly disagree.

As a work of social history, The Last Asylum is a valuable document. It reveals the cruel underside of deinstitutionalization policies that in the US, at least, have resulted in populations of the mentally ill homeless in city streets, and locked up in county jails and prisons. While she recognizes the larger meaning of these policies, Taylor also appreciates the importance of the way they affect individuals, and her depiction of the effects of asylum life and then deinstitutionalization on particular, closely–described patients in the context of one particular hospital (albeit a famous one), proves an effective way of bringing these vast historical transformations home to us. Then, in its careful and measured account of what can go wrong, and how difficult it can be to emerge from the defeating darkness of mental disorder,The Last Asylum helps us understand madness and its treatment in ways that are genuinely illuminating. Combining her report on the last asylum with her “memoir of madness in our times,” Barbara Taylor is to be applauded for an important and original contribution to our understanding of such disorder and its care — whether or not we grant her recommendations and solutions.  

© 2015 Jennifer Radden

Jennifer Radden, University of Massachusetts, Boston