This reading group guide for Behind the Gates of Gomorrah includes an introduction, discussion questions, ideas for enhancing your book club, and a Q&A with author Stephen Seager. The suggested questions are intended to help your reading group find new and interesting angles and topics for your discussion. We hope that these ideas will enrich your conversation and increase your enjoyment of the book. 

 

Introduction

Behind the Gates of Gomorrah is psychiatrist Stephen Seager’s account of his first year working at California’s Napa State Hospital, one of the largest forensic mental hospitals in the United States. While Dr. Seager is no stranger to locked pysch wards, nothing can prepare him for the dangerous reality of his post in Unit C, reserved for the “bad actors”: the mass shooters, the child rapists and murderers, and the serial killers. Surrounded by a volatile population of criminals in a hospital environment, Dr. Seager and his colleagues risk their lives on a daily basis.

Over the course of his rookie year at Napa State, Dr. Seager climbs a precipitously steep learning curve, navigating the often bizarre world of Napa State, learning to cope with fear and violence, and finding humor and grace where he least expects it. His memoir is an intimate, behind-the-scenes portrait of the nation’s justice and mental health systems, told with honesty and empathy.

 

Questions for Discussion

1. Seager’s financial and practical motivations for taking the job at Napa Sate are clear. But over time, his attachment to the job becomes more complex. On p. 70, his wife Ingrid tells him, “I don’t know what it’s about, but it’s not money. Nobody puts up with that for money.” Discuss how Seager’s interest in working at Napa State evolves over time. Can you relate to his feelings about the job?

2. Throughout the book Seager recounts how staff safety and patients’ rights are often at odds. How is this contentious relationship most pointedly illustrated? Do you think Napa State should handle the issue differently?

3. Regarding the staff’s attitude toward Mathews in the wake of Dr. Tom’s death, Seager writes, “I realized as well that the patients faced this same dilemma. They had to live with Mathews, too. But it got complicated after that. Hadn’t many of them murdered also? Maybe it wasn’t that Mathews had murdered per se, but that he’d murdered so recently. And he killed someone we all knew, in our home” (p.97). What do you make of this distinction? Do you agree with the author?

4. Seager often keeps the details of his job from his wife and son. Do you agree with his decision to hide the worst from them, or do you think he should have been more honest?

5. On p. 107, Seager asks himself, “What do you say to a murderer who tells you a dreadful Halloween story from his childhood? How are you supposed to feel?” How would answer this question?

6. Seager’s history with Caruthers makes their relationship particularly complex. What was your opinion of Caruthers? Were you able to reconcile Seager’s memory of him as a scared, abused child with the facts of his crime he committed?

7. Cohen is a capable and reliable presence at the hospital, but at times Seager feels suspicious of him. How did your impression of Cohen change over the course of the book, and why?

8. What is your take on Seager’s testimony at McCoy’s hearing? Do you think he made the right decision in telling the judge that McCoy is insane?

9. Seager peppers his narrative with surprising moments of levity. Discuss your favorite funny or heartwarming scenes. Did these moments change or modify your opinion about the hospital, the staff, or the patients?

10. Why do you think the author decided to include epigraphs at the beginning of every chapter? Did any one in particular stick out to you? Why?

11. Did reading Behind the Gates of Gomorrah challenge any preconceived notions you had about the mental and criminal justice systems in the United States? Why or why not?

12. In the Afterword, Seager takes a strong stance on the root cause of mass shootings. Do you agree with him? Why or why not?

 

Enhance Your Book Club

1. Read the Biblical story of Sodom and Gomorrah and discuss how it relates to the book.

2. Read a fictional account of a mental hospital, such as One Flew Over the Cuckoo’s Nest. Compare and contrast the novel with Behind the Gates of Gomorrah.

3. Inspired by Seager’s message? Write letters to your governor to protest the unsafe conditions in state mental hospitals.

 

A Conversation with Stephen Seager

1. What inspired you to write a book about your first year at Napa State Hospital?

When I took the job, I had no idea what really goes on at a state forensic mental hospital. Few people do and, surprisingly, most psychiatrists don't either. My first day is recounted in the book. And that level of violence and mayhem pretty much just continued on. There are, I learned, 3,000 assault a year at Napa State Hospital and similar numbers at other state hospitals around the country. Patients were taking most of the beatings, although the staff - mainly female nurses - were being struck with regularity as well. I quickly realized what a tragic and bizarre place Napa State was.

As I looked further, I realized that no media had ever been inside the hosptial - the BBC, 60 Minutes, NY Times, NPR, every magazine and newspaper all tried - but hospital administration had successfully stonewalled everyone. The carnage in the hospital occured under a conspiracy of silence. I realized my patients had no voice. Nor did the staff. And since the media couldn't get in to tell this awful story, I decided to take the information out. So I wrote "Behind the Gates of Gomorrah" to give my patients and the staff a voice, to have their story heard and maybe help stop this violent nightmare.

2. What was the most difficult part about writing Behind the Gates of Gomorrah?

Writing the book was actually quite therapeutic. It helped me sort through my feelings about my job and made me answer questions about why I continued to work in such a dangerous, crazy place. It allowed to sort through issues about the violence we inflict on the mentally ill. And the neglect. And why no one seems to care much about this. It made me face issues of personal safety. It made me to see more clearly how difficult my job had been on my wife and son. 

3. How has your attitude toward your job evolved since your first day?

 A nurse in the book says that working at Napa State is a "Jesus Job." She explains that if you knew Jesus was coming back for one day and you wanted to meet him, where would you go? Her answer: I'd go to work. I'm from Utah. I grew up in a religious environment. I get this. There are no more down-trodden people in America than those who suffer from severe mental illness. They are abused, neglected,  and allowed to suffer and die without public attention or care. And Napa State is a distilled version of this. Even when we hospitalize these poor souls, they are beaten.

That being said, I never lose sight of the fact that my job is crazy dangerous. I walk the halls with mass murderers and rapists. I watch every step I take every day. As you might guess, I'm still conflicted about my job and probably always will be. Which, if you take a look at Napa State, is probably the correct response.

4. What do you think is the most important lesson that you’ve learned while working at Napa State?

I've re-learned that people don't care much about persons with mental illness. That mentally sick people get regularly beaten, doesn't strike much a cord with anyone. The federal and  California state Occupation Safety and Health Administrations are aware of the problems at Napa and other forensic state hospitals, yet do nothing. Cal OSHA signed off on the place two years ago. The governor is aware of the problems at Napa but says nothing. Nor does anyone else.

I suppose the most important lesson I've learned is to fight becoming cynical. I realize people dont care much about other Americans with severe mental illness. But this may not always be the case. I see my book as a small step in a larger process of perhaps re-engaging the national debate on a shameful aspect of our current society.

5. The unsafe conditions at forensic mental hospitals are rarely in the news. Why do you think so few doctors and staff have spoken out about this issue?

I don't know for sure but I have some ideas. I do know at Napa there is a carefully cultivated culture of silence at the hospital. I have never been told explicitly to keep quiet, but others have. "Don't make waves." "If you don't like it here then quit." It's really like an abusive relationship. Why don't abused spouses speak out more? I think the answers are all the classic answers you hear from abused persons. And I've heard them all from the hospital staff about why they stay and why they keep quiet. "I need the money."(I'm financially dependent on the abuser.) "I don't want to make anyone angry." (It's really not that bad.) "If I speak out I'll get fired then I lose my house and what will the kids do then?" (If you say anything, we'll hurt your family.)

A lot of the physicians at Napa, come from a geographically diverse background. They fear making waves and maybe getting deported or something. It's a classic culture of fear and silence, which is the abusive relationship in a nutshell.

6. Do you feel optimistic about the treatment being offered at mental hospitals? What would you most like to change?

I was an internist and an ER physician before becoming a psychiatrist. My psychiatric patients get well at an equal or higher rate than all my other patients. The treatment of psychiatric illness is frequently very successful. The problem is, due to a 50 year history of the court system involvement in mental health issues, this treatment is frequently unable to be given. We have persons remanded to our hospital for treatment of a mental illness - for which they have avoided prosecution often for an awful or multiple awful crimes -  and they can often refuse that treatment. This makes no sense to me. It's the same problem in the outpatient mental health world. It's why we have so many homeless mentally ill and so many violent mentally ill persons assaulting other people. Treatment is available but it can be refused. The problem is most acute for the parents of mentally ill children. Many of them watch a child deteriorate and die from a treatable disease.

7. Why do you continue to work at Napa State, despite the obvious risks?

I realized early on that my book would afford a voice to the 50,000 people confined in American state mental hospitals. If I quit, my book and it's message could be easily refuted. "None of that's true. He was just a disgruntled employee." But I still work there. My editor put it nicely, "If you're still there, what can they say, this place is safe?" And she's right.

8. Has your family’s perception of your job changed over time?

They still hate it.

9. What do you hope your readers will take away from this book?

I hope people take away some awareness of the message it contains, namely that patients in state mental hospitals endure an extraordinarily level of violence and no one knows this. And if they do, they don't seem to care.

I hope that the book carries a larger message as well: that almost all persons who suffer from a severe mental illness are treated very badly in our country. They are ignored, beaten up, lit on fire, shot, raped, tortured and, basically, left to rot in the streets. I'm hoping the book will become part of something that creates a dialogue on how the mentally ill are treated in America. What "treatment" really means. That we have allowed the courts to dictate the treatment of a medical disease. And that this has created the worst mental health care system imaginable.

I'm hopeful that things can be made a lot better. But the first step towards changing things is information.  I hope "Behind the Gates of Gomorrah" puts a human face on the mentally ill, even the criminally insane mentally ill. That's what I'm hoping my book does: inform, humanize and raise awareness.

10. What are you working on next?

I'm involved in two film projects. One is a documentary about the book and the issues it raises. I will co-write and co-produce this with Nikki Forston, a film maker from Philadelphia. The other project is more mainstream and still in the talking stages. I have a sequel nearly finished called, "The Gods of Gomorrah." I'm preparing to do an episodic audio blog for NPR. And I'm doing some international publicity mainly now in Australia and New Zealand where the book was recently released.

I'm also working on my badminton game.