On October 5, 2007, two days after being released from New Hampshire Hospital, in Concord, Linda Bishop discarded all her belongings except for mascara, tweezers, and a pen. For nearly a year, she had complained about the restrictions of the psychiatric unit, but her only plan for her release was to remain invisible. She spent two nights in a field she called Hoboville, where homeless people slept, and then began wandering around Concord, avoiding the main streets. Wary of spies, she cut through the underbrush behind buildings, walked through gullies beside the roads, and, when she needed to rest, huddled in the bushes. Her life was saved along the way, she later wrote, by two warblers and an owl.

A tall, athletic fifty-one-year-old with blue eyes and a bachelor’s degree in art history from the University of New Hampshire, Linda had been admitted to the hospital in late October, 2006, after having been found incompetent to stand trial for a series of offenses. She spent most of her eleven months there reading, writing, and crocheting. She refused all psychiatric medication, because she believed her diagnosis (bipolar disorder with psychosis) was a mistake. Each time she met a new psychiatrist, she declared her lack of respect for the profession. Only when conversations moved away from her mental illness, a term she generally placed in quotation marks, was she cheerful and engaged. Her medical records consistently note the same traits: “extremely bright,” “very pleasant,” “denies completely that she has an illness.” In the weeks leading up to her discharge, her doctors urged her to make arrangements for housing and follow-up care, but Linda refused, saying, “God will provide.”

During a rainstorm on her fourth day out of the hospital, Linda broke into a vacant farmhouse for sale on Mountain Road, a scenic residential street. The three-story home overlooked a brook and an apple orchard, and a few rooms were still sparsely furnished. Linda intended to stay only a few nights, but she began to worry that her dirty clothes would attract attention if she walked back to town. “I look terrible . . . like a vagrant,” she wrote in a black leather pocket notebook that the previous tenants had left behind. Linda had led a nomadic existence ever since she had abandoned her sleeping thirteen-year-old daughter, in 1999, leaving a note saying that she was going to meet the governor. She drifted between homeless shelters, hospitals, and jail. She wrote in the journal that she wasn’t ready to “make my presence known—and just start the whole mess again—to prove what—that I’m all right? Have done that too many times.” Two days after breaking into the house, she decided to make the place her temporary home. She would subsist on apples while “awaiting further instructions” from God.

Linda settled into a routine. In the morning, when the sun poured through the living-room window, warming the end of the couch, she read college textbooks she found in the attic. The former tenant appeared to have dropped out of school in 1969 (“but his creative writing is very good!” she noted), and she began embarking on the education he had abandoned. She began with Joseph Conrad and moved on to biology (“chloroplasts, lysosomes, mitochondria + cell division!”) and “Great Issues in Western Civilization.” When she had enough energy, she did her “chores.” She combed her graying brown hair—first with a small rake, and, when that proved too cumbersome, with a fork—and tidied the house, in case potential buyers came for a viewing. There was no electricity or water, but, after dusk, she rinsed her underwear in the brook, collected water with a vase, and picked apples.

After the first week, she estimated that she had lost ten pounds. When she looked in the mirror, she was startled by how drawn her face had become. Yet after enduring so many irritations in her hospital unit—patients who wouldn’t stop talking, or who touched her, or sat in her favorite chair, or made noise in the middle of the night—she didn’t mind having time alone. From her windows, she enjoyed watching purple finches, tufted titmice, chickadees, and “Mr. and Mrs. Cardinal.” She wished she had binoculars. A neighbor came over to mow the lawn and pull the weeds. “He has no idea I’m here!” Linda wrote, as she watched him from an upstairs window.

The threat that Linda was hiding from was a shifty one—she alluded to conspiracies involving her older sister, the government, and Satan’s workers—but she also wondered if anyone was even looking for her. She kept retracing the series of events that had led her to this house. She knew it didn’t “make sense to be barely existing”—she got light-headed just walking up the stairs—but she felt that the situation must have been willed by the Lord. By the end of October, she had a stash of three hundred apples. She worried about the coming winter as she watched trees lose their leaves, milkweed seeds blow in the wind “like it’s snowing,” and geese migrate south. Still, she could find “no signs or clues that I should be doing anything different.”

Throughout Linda’s stay at New Hampshire Hospital, her doctors routinely noted that she lacked “insight,” a term that has a troubled legacy in psychiatry. Studies have shown that nearly half of people given a diagnosis of psychotic illness, such as schizophrenia or bipolar disorder, say that they are not mentally ill—naturally, they also tend to resist treatment. The psychiatrist Aubrey Lewis defined insight in 1934 in the British Journal of Medical Psychology as the “correct attitude to a morbid change in oneself.” But the definition was so ambiguous that his paper was ignored for over fifty years. Psychiatrists were reluctant to move away from objective, observable phenomena and to examine the private ways that people make sense of the experience of losing their minds. Today, insight is assessed every time a patient enters a psychiatric hospital, through the Mental Status Examination, but this form of awareness is still poorly understood. Patients are considered insightful when they can reinterpret unusual occurrences—growing angel’s wings, feeling as if their organs have been removed, decoding political messages in street signs—as psychiatric symptoms. In the absence of any clear neurological marker of psychosis, the field revolves around a paradox: an early sign of sanity is the ability to recognize that you’ve been insane. (A “correct attitude,” for most Western psychiatrists, would exclude interpretations featuring spirits, demons, or karmic disharmony.)

Getting patients to acknowledge their own disorders also has become an ethical imperative. Implicit in the doctrine of informed consent is the notion that before agreeing to take medication patients should be aware of the nature and course of their own illnesses. In balancing rights against needs, though, psychiatry is stuck in a kind of moral impasse. It is the only field in which refusal of treatment is commonly viewed as a manifestation of illness rather than as an authentic wish. According to Linda’s treatment review, her most perplexing behavior was her “continuing denial of the legitimacy of her ‘patienthood.’ ”

When psychoanalytic theories were dominant, patients who claimed they were sane were thought to be protecting themselves from a truth too shattering to bear. In more recent years, the problem has been reframed as a cognitive deficit intrinsic to the disease. “It has nothing to do with willfulness—you just don’t have the capacity to know,” Xavier Amador, an adjunct professor of psychology at Columbia University’s Teachers College, said. Amador is the author of the most widely used test for measuring insight, the Scale to Assess Unawareness of Mental Disorder, which asks patients why they think their judgments or perceptions have changed. Although researchers haven’t uncovered distinct neurological anomalies linked to lack of insight, Amador and other scholars have adopted the term “anosognosia,” which more typically describes patients with brain damage who lose the use of limbs or senses yet cannot acknowledge the existence of their new disabilities. Those who go blind because of lesions in their visual cortex, for instance, insist that they can still see, and tell fanciful stories to explain why they are walking into furniture.