Kaysen writes that the McLean hospital was positioned on a hill just outside of town, “the way hospitals are in movies about the insane.” McLean was “famous,” and ex-patients included Ray Charles, Robert Lowell, and Sylvia Plath. The hospital grounds were large, pristine, and beautifully landscaped. Every once in a while, Kaysen writes, she and her fellow patients were taken through those grounds on the way to go on outings. “Darting, nervous” nurses would surround the “nucleus” of patients in a kind of “atomic structure” during these outings, protecting the patients from the world around them and vice versa.
The storied institution of McLean Hospital is built upon a tradition of displaying to the outside world a measure of perfect control. This is reflected in the pride the hospital takes in its roster of famous patients, the pristinely-kept grounds, and the ways in which, on group outings, the nurses bend over backwards to maintain the illusion that their patients are docile and easily controlled.
Kaysen explains that a complex system of privileges dictated how many nurses were required to accompany each patient. Being restricted to the ward was the baseline of “privilege,” and frequent runaways such as Lisa often lingered at this level. The next step was “two-to-one,” which meant that two nurses were needed to accompany one patient. One-to-one is the next highest level. There were many shades within this hierarchy of privileges, including “destination privileges,” which rewarded good behavior with being allowed to traverse small sections of the hospital alone, as long as the head nurse was called upon a patient’s arrival at her destination, and upon her departure from it to return to the ward. “Mutual escort”—two patients being allowed to travel places together—and “grounds,” or being able to travel the grounds alone, were the two highest privileges on the scale.
Nothing at McLean is simple, and maintaining the illusion of control and civility requires several complex systems to keep things in check. The privileges—if they can be called privileges—doled out to the patients reflect their behavior directly, and privileges which take months to accumulate can be stripped away in an instant. A tense balance of control and manipulation exists between staff and patients, and an atmosphere of distrust permeates every single interaction and happening on the ward.
On trips into the outside world, however, the scale reset. Kaysen notes that “someone who had mutual escort or grounds would probably still be on group outside.” On one ice cream outing, as the patients make their way toward the nearby Waverley Square, Susanna notes the complex arrangement of patients and nurses which must seem odd to those out and about on the street.
Privileges on the ward do not equate to privileges for travel outside the hospital or off of the grounds, and is just one more way in which life on the ward is kept completely isolated from life in the “real” world, and is not beholden to its rules. When the girls must move through the real world, then, the nurses create a complicated charade to keep their patients under control.