Welcome to the Madhouse: Q&A with Psychiatrist Stephen Seager

Dr. Stephen Seager
Dr. Stephen Seager

"You want to hear something amazing? We're thirty miles from San Quentin, and we've had people here who've worked in both places. Napa is considered a much more dangerous job. We lose doctors and staff to San Quentin because it's safer by a multiple of ten to work at a state prison than at the state mental hospital."

This a direct quote from Dr. Stephen Seager, author of the astounding book Behind the Gates of Gomorrah: A Year with the Criminally Insane. Seager, sixty-four, began writing the book, his sixth, as a way to tell the story of what goes on inside. As it evolved, he realized it was much more. It's an advocacy project for the staff and patients of Napa State Hospital, as brutal and violent a place as there is in the United States.

I've covered my share of disturbing books for Signature, but they've tended to be mostly personal stories that are redemptive. Due to the ongoing horror shows that are America's state mental hospitals, Behind the Gates of Gomorrah is far more harrowing. The realities are horrific, seemingly permanent, and wide in scope.

If you've always imagined mental hospitals to be dark, isolated, Dickensian torture chambers along the lines of Scorsese's "Shutter Island," get ready to revise those notions. They're open, free, and so much worse. As Dr. Seager explains, it can be a hospital or a prison, but it can't be both.

Signature: Prior to becoming a psychiatrist, you worked as an ER doctor. Why did you change careers?

STEPHEN SEAGER: I worked for ten years as an ER physician at the only level one trauma center in Phoenix, and I just got burned out. We'd have three, four, five codes going at once, and it got be too much. I decided to do something different, got retrained, did a second residency, and became a psychiatrist. I landed in the psychiatric emergency room, which was right next door. I did four years of training to move one foot. I must be drawn to this kind of thing, because I eventually ended up at Napa.

SIG: Did you have any inkling of what the job would be like when you took it?

SS: No. In fact, I went to Napa State Hospital thinking it would be different, a nice quiet change of pace. It isn't. In the orientation, they didn't say much of anything, and then my first day on the unit, there was a huge brawl where a patient fractured another patient's skull with a chair, and I ended up with stitches in my head. It's basically been the same thing every day since. We have over 3,000 assaults a year. We had five alarms yesterday.

SIG: It was so hard to wrap my head around what goes on in state mental hospitals. Violent people, some of the worst of the worst, have no restrictions on them whatsoever. Is this common knowledge? I had no idea.

SS: It's not even common knowledge within the psychiatric community. Nobody knows what goes on in state mental hospitals. I'd sent patients to Napa but still had no idea what I was getting into, what goes on behind the twenty-foot wall with a razor-wire top. No outsiders can get in. They stonewall the media, which is why the conditions go so underreported. I tried to find a book about life inside a mental hospital, but there weren't any. That was the impetus for writing Behind the Gates of Gomorrah. We've had staff and patients murdered, and it gets a bit of press, but there's a real code of silence. And it's not just Napa; it's all 200 of them across the country. In every single one, the staff and patients, including mentally ill folks who committed no crimes, are getting the hell beat out of them, and nobody is doing anything to help.

SIG: And it's been going on for quite a while, right?

SS: For decades. A few years ago, a staff member was murdered about ten feet outside my office. I researched and found out there was someone murdered in the exact same spot fifteen years ago. It goes on and on. It's not about me: I'm well paid and can leave whenever I want. It's about the staff and even more, the patients, who just have to put up with the constant abuse. They can't leave, and they can't get better if they're being beaten up all the time.

SIG: Why haven't any doctors spoken out about this before?

SS: Every doctor I've worked with has been assaulted at some point, had bones broken, or whatever. They usually leave Napa to recover, and we never hear from them again. Everyone inside is kind of isolated and segregated. I hope the book can establish some common ground between patients, their families, and staff, so everyone understands they're not alone. As it is now, it's the most unsafe place in America, and it has to stop.

SIG: I imagine most people, like myself, assumed mental hospitals were isolated dungeons where prisoners have no freedom, but it's the exact opposite.

SS: You think it's like "Silence of the Lambs," right? Hannibal Lecter in a cage? It's not like that at all. It's a hospital, and the patients are not prisoners. They're as free as anyone at any hospital. They have rooms, roommates, eat in the cafeteria, et cetera. They aren't allowed to leave the building without an escort, but inside, all of the criminally insane of Northern California are free to roam the halls. It breeds violence. For everyone's benefit, we need Napa to be more restrictive. Half our staff consists of female nurses, and half of them are out on disability for being punched, raped, or victims of attempted rape. It's unbelievable. People may not want to hear it, but it just can't be.

SIG: Even as we're talking, I'm thinking of the Thanksgiving dinner depicted in your book. Patients' families were allowed in for dinner, but they weren't separated from the child rapists and murderers.

SS: That is a dead true story. I watched kids going into the visitor center, a condensed area right along with the child molesters. Family visits are great, but kids should not be eating turkey with some of California's most notorious killers. It's madness. We have patients who will murder or maim a roommate, get sent away for a couple of weeks, return, and get put right back in the same room. There's no such thing as common sense at Napa. It doesn't apply.

SIG: I should add that there are some nice moments in the book as well, even if they're fleeting.

SS: Some of my best friends are mass murderers. As a physician, you can't hate your patients. I play softball with people whose crimes were too hideous for me to get through their files, but they aren't punching people 24/7. You can't face grim things without a sense of humor. Relationships form with patients, and some have to be let go for getting too personal. People are human. Life is funny, even in Napa. Especially in Napa.

SIG: How does a criminal end up there?

SS: Well, there are two classifications: not guilty by reason of insanity, where you didn't know what you were doing, period. The other is incompetent to stand trial, in which the defendant will face charges, but not at present time. In both cases, the person is sent for treatment. We've had patients who dodged the electric chair. Here's the crazy thing, though, and not just in left-wing California: If you're a patient, even one convicted of murder, you can refuse treatment. By law, patients don't have to take medication.

SIG: There's also the caveat that criminals can game the system. The most sadistic man in Napa is a meth head, but not insane.

SS: We have plenty of murderers who faked their way inside. They're conmen, and they're really good at it. They read up on the symptoms and know how to act in court in front of a judge so it appears they are mentally insane. They dodge the hangman and end up in our gym playing basketball. It drives us crazy because they're the most difficult to treat.

SIG: Can you give us a brief explanation of how we got to this point?

SS: In the 1960s, the big problem was that we were warehousing people. They were incarcerated in the hospital without getting any treatment. The theory arose that it was the institution itself that caused chronic mental illness. Through a series of laws, a lot of state hospitals were emptied and closed. Many of these mentally ill people are now homeless. The theory that being confined is what made them sick was wrong, and now, patients come to us from jail, which is the new warehouse. L.A. County Jail's psychiatric ward is the largest in the country.

The other thing that came out of the sixties was something called the "anti-psychiatry movement." It's basically people who think all psychiatry, medication, treatment, et cetera is bad. A lot of people in government today came out of it. They have the mindset that not everyone needs to be hospitalized, which is true, but the ones that do – especially the ones that have committed major crimes – need treatment. Patients' rights attorneys argue on behalf of patient safety, but the reality is, they're advocating for completely unsafe conditions. The whole system needs a shock. It's gone down the rabbit hole and been taken to an illogical extreme.

SIG: If you could change one thing today, what would it be?

SS: Mandatory medication orders with guard presence. Patients who need drugs would not be allowed to refuse them.

SIG: Can treatment work for the patients when they're constantly living in fear?

SS: Imagine if you went to get your appendix out, and while you were sleeping, your roommate knocks the shit out of you. This happens all the time. Most of our patients do want to get better and will when treated properly. We have a sixty percent success rate, but it's delayed or halted when you're beaten silly. Regardless of their crime, they are still patients in a hospital trying to heal. This book is my attempt to be an advocate for them. They bear the brunt of all this awful stuff.

SIG: What it's like among the staff, witnessing the constant brutality?

SS: Everyone is traumatized. People are constantly going out on disability due to stress. I tell people all the time, "Imagine if two people in your office were assaulted every week. Would you want to work there?"

SIG: No, and it's clear in the book that your wife and son who still lives at home aren't crazy about your working there.

SS: Begrudging acceptance is what I would call it. My wife is also a physician, so she gets it to some degree, but they both know it's bad, as do my other four children. I've never been a military person, but I think it's a bit like combat, in that when your life is in danger every day, it's impossible to explain, but there is something inside that doesn't want to leave your fellow soldiers. However, you can't live at the front all the time. I don't talk about work at home.

SIG: Let's end on an upbeat note. What do you do for fun?

SS: Thankfully, I've never had a problem separating work and home. I don't carry it with me. My wife and I are runners. We did four half-marathons last year, and we are tournament badminton players. Most people think of it as a backyard barbecue game. It's not. It's super-competitive.

SIG:  Sorry, but I can't help asking: Why do you continue to work there?

SS: One reason I'm continuing to work at Napa is because I sincerely hope Behind the Gates of Gomorrah will help people understand what goes on inside and lead to change. If I quit now, it's easier to deny what's in the book – to discredit me and call me a liar. I think my employment there lends the book more gravitas. I'm committed to this because I think it's important. If I can have one patient not get beat up, it will be worth it. Someone has to stand and say things have to change. It's bad for the staff, but it's worse for the patients. They're sent to Napa to get treatment, and they're getting pummeled. The answer can't just be to quit.