Girl, Interrupted: The Book and the Film

Girl, Interrupted by Susanna Kaysen was first published in book form in 1993 (1), parts of it having appeared before that in three different magazines. The book was published in paperback in June 1994 (2) and then reissued in 1999 to coincide with the release of the Hollywood movie version. The renewed interest in Girl, Interrupted prompts a second review of this book, first discussed in this journal in 1993 (3), and a commentary on the book's translation into film.

Girl, Interrupted is a short book structured from three building blocks: a reconstruction of the author's hospitalization at McLean Hospital in Belmont, Massachusetts, beginning in April 1967 when she was 18 years old; sections reproduced from hospital medical records; and the perspective of a woman in her forties examining an earlier phase of her life about 25 years later. The first two components work well and construct an interesting historical record; the third can be problematic and sometimes confuses the account and detracts from its value.

On page 1 we learn from the reproduction of Ms. Kaysen's case record folder that she was voluntarily admitted to McLean, was a high school graduate, and was the daughter of parents living in Princeton, New Jersey, where her father was on the Princeton University faculty. She was characterized as a white, Jewish, single female with admitting diagnoses of "psychoneurotic depressive reaction" and "personality pattern disturbance, mixed type." There was also a rule-out diagnosis of "undifferentiated schizophrenia." Finally, we see that the diagnosis eventually established for her was "borderline personality."

On the last page of the book, also from Ms. Kaysen's case record folder, we see that she was discharged in January 1969, after 496 days in residence at the hospital and 121 days on authorized leave. The book's title, reflecting this interval, comes from the Vermeer painting Girl Interrupted at Her Music in the Frick Museum in New York City. In January 1969 Ms. Kaysen was living in her own apartment and was deemed recovered.

Between the first and last pages the reader is exposed to the retrospective presentation of an 18-year-old's life as an inpatient on an adolescent women's unit, with further information presented through reproduction of other hospital records. The author presents her text in very brief chapters—really vignettes, or verbal snapshots.

Ms. Kaysen's depiction of her life as a patient in that era rings true. She was on a ward whose population included young women with such psychiatric diagnoses or histories as acute psychosis, self-immolation, anorexia, depression, schizophrenia, character disorders, and substance abuse. She mentions, but does not describe in any detail, treatments including medications, cold packs, and electroconvulsive therapy. She describes patients whose main treatment was individual psychotherapy five times a week, group therapy about once a week, and little else that was directly tied to treatment objectives. Patients had scheduled leisure-time activities but also enormous amounts of downtime.

The use of hospital records in a narrative, although not a new technique, adds information and variety. For example, the reader learns that Ms. Kaysen was referred for admission, by a Boston psychiatrist known for evaluating patients he planned not to treat but to refer, because she was profoundly depressed, suicidal, "increasing patternless of life," and promiscuous, to the point that she might either kill herself or get pregnant. The evaluator thought that she was "desperate." By today's standards, it is highly unlikely that Ms. Kaysen would be hospitalized.

The author's description of her life at McLean poignantly portrays how her fellow patients—about 20 of them, referred to as "twenty-odd patients"—form bonds and are supportive of one another. Ms. Kaysen describes good and bad personnel and why the patients so characterized them. She paints an accurate but limited picture of life in the psychiatric hospital in the late 1960s.

While the book has these attributes, it carries with it aspects that are potentially detrimental to contemporary good-quality psychiatric care. First, unless one is reasonably well informed, it is not easy to separate out what is historical record, what is the author's contemporary evaluation of that historical record, and what is inappropriately described or criticized using contemporary standards to measure treatment 25 years earlier. The most glaring example of this last is Ms. Kaysen's application of DSM-III criteria to her diagnosis of borderline personality. When she entered the hospital, the operative diagnostic manual was DSM-I, and when she left, it was DSM-II, neither of which even mentioned "borderline personality." When Ms. Kaysen theorizes on or contemplates such things as the difference between mind and brain, she presents little that is new, and she jars the reader from the much more interesting first-person account.

Along the same lines, it is not always clear in which voice Ms. Kaysen speaks when she uses derogatory language to describe patients—such as "gone bananas" or "nuts" or "lunatics" or "retard" or "psychotics"—or when she calls people by their diagnosis. Is this the teenager talking in 1967, or, more damaging, the woman author speaking 25 years later?

What does Hollywood do with this book by Susanna Kaysen? The screenplay, written by the film's director, James Mangold, uses the book as its basis and dances off from there. Because Girl, Interrupted is written in a format that is not easily translatable to the screen—unlike The Snake Pit (4), for example—Mangold needed devices to communicate the themes. One device he does not use very successfully, in my opinion, is attempting to create parallels between Susanna's situation in the movie and Dorothy's in The Wizard of Oz. He employs both the book and the film version, with Judy Garland, which is seen on the ward television. Further, as Girl, Interrupted is a lean book, Mangold fleshes it out with events and relationships not in the book, and he dramatizes events by placing Susanna in them when in her written accounts she was not there.

The film was shot in and around Harrisburg, Pennsylvania, and uses Harrisburg State Hospital as the treatment setting. McLean in the book is transformed into Claymoore in the movie, but the book's references to Boston remain in the film. However, the resulting visual and continuity errors will probably bother few people who are not from eastern Massachusetts.

The director uses admirable and effective devices to place the film in the 1960s. Sixties music and visuals like cars and clothing are constant reminders of the era. An important but unanswerable question is whether viewers will remember after they leave the theater that the psychiatry depicted is the psychiatry of the 1960s, not of the year 2000.

But in fact, psychiatric practices are portrayed much less clearly than the 1960s are re-created. It is never explained why Susanna has two psychiatrists; what the nurses, who regularly check on all the patients, are doing when all the young women patients disappear off the ward for long periods at night; what medications are used for besides sedation and the relief of constipation; and what is and is not a boundary violation. And why do the women patients always wear makeup? Is this a psychiatric practice of the 1960s or a Hollywood convention?

As in the book, historical accuracy about borderline personality disorder is abandoned. At the time Ms. Kaysen was in the hospital, one could not simply take a book of diagnostic criteria off the shelf, as occurs in the film, and read about "borderline personality" (5). The film needs this distortion to make itself whole.

Finally, the film also finds it necessary to tie everything up at the end—it is, after all, a Hollywood product. The book is not so neat. And in the film, much to my puzzlement, Vermeer is nowhere to be found. Dorothy of The Wizard of Oz is no substitute for the girl, still interrupted, at the Frick.

Dr. Geller is professor of psychiatry and director of public-sector psychiatry at the University of Massachusetts Medical School in Worcester.