Mad, Bad and Sad: A History of Women and the Mind Doctors from 1800 to the Present 
by Lisa Appignanesi.
Virago, 592 pp., £12.99, January 2009, 978 1 84408 234 6
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I managed to grow up and leave home before I found out that my mother had once spent time in a mental ward. She was, at the time of her hospitalisation, a very new mother – of me – and consequently exhausted. What sent her to the mental ward was delirium. That, at least, was what the emergency room doctors thought when she arrived at the hospital extremely ill with encephalitis (which they never even suspected, despite her complaints about an unbearable headache and neck pain and nausea). She was admitted as a mental patient, and treated, over the course of the week, with ping-pong. My mother, no lover of the game even when not in shattering pain, played. It was clear to her that a show of friendly interest in her fellow lunatics and placid obliviousness to her frightening circumstances was the way to signal that she might safely be released. To have shown distress, much less anger, would have been crazy. The infection in her brain was diagnosed on the morning of her discharge, the masquerade having been a success, when one of the doctors nevertheless thought to order a spinal tap.

Why did it take her so long to tell me? The necessity of unresenting compliance with the extremes of unreasonableness hadn’t seemed – and still didn’t seem – extraordinary to her. Then again, who knew whether her daughters might not learn from the episode a different lesson from the one she had learned? When my sister in her turn fell ill with encephalitis (the occasion of my mother’s telling), she screamed at the doctors who informed her that when a young lady gets a bad headache the reason is that she’s been thinking too hard, and they ejected her (despite her screaming) from the emergency room into a thunderstorm.

I like to think that if I am in line for a brain fever I shall be better prepared than my mother or my sister. But if there is anything to be learned from Lisa Appignanesi’s survey of the past two centuries of Western mental illness and treatment, it is that knowing the stories just makes things worse. Not that we have any choice. Jean-Martin Charcot, Pierre Janet, Josef Breuer, Sigmund Freud, Mary Lamb, Alice James, Anna O., Zelda Fitzgerald, Marilyn Monroe and Sylvia Plath are household names. Not everyone may be able instantly to identify Henriette Cornier (who in 1825 chopped off her 19-month-old charge’s head), or Augustine (Charcot’s ‘model patient’, whose much publicised poses taught a generation of mental patients and filmmakers what hysteria should look like), or the Papin sisters (two maids who in 1933 ‘murdered and sexually maimed their mistress and her daughter, pulling out the eyes of the first’, because of apparent unhappiness about ironing), but the outlines of their stories are as familiar to us as Mother Goose. Then there are the gothic tales – true ones – of normal women, victims of family plots to seize their property, helpless to establish their sanity against the unfalsifiability of their diagnoses and broken by their treatment. When Hersilie Rouy protests late in the 19th century at having been kidnapped on the orders of her half-brother and incarcerated for 14 years in a succession of mental hospitals, ‘she is told: “Your delusion is total, and all the more dangerous and incurable in that you speak just like a person who is fully in possession of her reason.”’ The situation is no less Kafkaesque a century later. ‘On Being Sane in Insane Places’, published in a 1973 issue of the journal Science, describes an experiment the American psychology professor David Rosenhan conducted with seven friends (three of them psychologists and one a psychiatrist), who

presented themselves at the psychiatric emergency rooms of a range of state and poshly private hospitals and asylums. They had prepared themselves minimally. They were hairy, unshaven and unwashed, their teeth unbrushed. They probably emitted a pong. Apart from their appearance, their only spoken symptom was that they had heard a voice say ‘thud’.

This was enough to get them admitted – seven as paranoid schizophrenics, the eighth, for variety, as a manic depressive – and given drugs. They avoided swallowing the drugs, answered the doctors’ questions about their histories and feelings truthfully, and proceeded to behave normally. But, having been (mis)diagnosed, the pseudopatients found themselves unable to persuade the staff that they were sane. Appignanesi writes that ‘their “therapy” records showed that, although each had merely recounted his or her life, their histories were given meanings conforming to the diagnosis of schizophrenia.’ The asylum doctors would not allow them to leave. It took 52 days for the doctors to discharge the last of them, and even then only as ‘in remission’.

More than most other ailments, mental illnesses raise questions about the premises and motives of those who pronounce on them. So if, as Jean-Etienne-Dominique Esquirol had it, delirium is a condition in which someone’s ‘sensations are not at all in agreement with external objects, when his ideas are not at all in agreement with his sensations, when his judgments and his resolutions are not at all in agreement with his ideas, when his ideas, judgments and resolutions are independent of his volition’, it is impossible not to ask who is to determine the reality of those external objects, the nature of those sensations, the truth of that volition and by what standard he is to judge their concordance or lack of it. The mind doctors (as Appignanesi calls them) have often enough shown themselves to be not merely mistaken but delusional, in the grip of a fantasy no less nonsensical and destructive than those of their unhappy subjects: the story, long attributed to Hippocrates, of the hysteric’s wandering womb, seeking semen and turning all about it to chaos and confusion, maintained its hold (and its adherents their authority) for centuries. Under the influence of more recent theories, mind doctors have pierced their patients with needles, shocked them and induced seizures, cut away pieces of their bodies, created artificial memories and artificial selves. Whether by these means they have healed more than they have harmed is questionable. Whether the suffering their patients endure can entirely be distinguished from the effects of such treatments and from the social contexts from which such treatments derive is questionable too. But in Appignanesi’s view mental therapy has for the most part acted in parallel with or as a special medium for the pressures from which, through their illness, the mad, the bad and the sad have sought to escape.

What of mental illness in itself? Is there such a thing? If so, it is as unstable as the wandering womb, its strange mutability of aspect a puzzle and an epistemologically dizzying provocation to interpretation, only some of it medical. ‘Other illnesses . . . reveal themselves to us by constant signs, as invariable as their causes,’ G.-F. Etoc-Demazy writes in 1837; ‘Only madness [la folie], a kind of morbid Proteus, is the transitory and changing image of the interests that govern men.’ Not only doctors and medical historians but patients too suffer – often in mirror-fashion – from what Appignanesi calls ‘that continual redescription of illness which seems to be part not only of the history of mental medicine but of the patient’s own experience and interpretation of symptoms’.

Many of Appignanesi’s concerns converge on the linked topics of sexuality, hysteria, imitation and iatrogeny. Following Elaine Showalter, Roy Porter and other scholars, Appignanesi presents hysteria as the pathology that, more startlingly than any other, reveals the paradoxes of imitation and selfhood, expression and collusion and control, as they play out between (usually female) patient and (usually male) doctor, illness and society. Mental illnesses often involve some degree of copycatting: homicidal mania inspires homicidal mania, and recovered memories of satanic abuse come not singly but in epidemics. But hysteria became known as the illness that, more than any other, mimics illness, mimics even itself, and so entirely that to many observers it looks like nothing more than malingering. ‘Few of the maladies of miserable mortality are not imitated by it,’ the 17th-century physician Thomas Sydenham remarked, for ‘hysteria imitates culture.’

Hysteria surged and waned era by era but came into its own late in the 19th century. Appignanesi remarks that ‘often enough’ (but how often was enough?)

a nervous woman was also a ‘New Woman’. The contradictions of a time which demanded compliance and quiescence of the idealised feminine while championing dynamism in the culture as a whole might drive a woman to action or to the couch. The escape into illness was the mirror image of rebellion. Emancipation, feminism and neurasthenia, or its sometime twin sister, hysteria, took shape in the same nervous soil.

The Victorian hysteric’s mimicry of her own feminine helplessness – fainting, palpitating, panting, delirious, convulsing – exempted her, Appignanesi notes, from the domestic, social and sexual requirements she would otherwise have faced, and thereby won her a parody of independence. This parody must sometimes have seemed almost enough; but sometimes it made the impossibility of the real thing even harder to bear. The shifting, unnameable illnesses of Alice James, for instance, gave her, as Appignanesi suggests,

the wild outburst of occasional delirium, a kind of hysterical rebellion against the imposed constraints of her situation . . . it was illness that gave Alice the permission to explode. Illness also allowed the opposite – a parody of a very proper feminine passivity in that enforced resting which is depression or neurasthenia. Indeed, nervous illness was an altogether useful way out.

It gave James access too, Appignanesi suggests, to the male (medical) touch. But it is possible to make too much of hysteria as a tactic of feminist rebellion, or even as a tactic (or imitation) of seduction. The hysteric occupies too many psychic positions for the fantasy of resistance or seduction to continue without awkwardness or shame. Alice James once complained that the only difference between herself and a lunatic was that ‘I had not only all the horrors and suffering of insanity but the duties of doctor, nurse and straitjacket imposed upon me, too.’ She had all the humiliation of it as well: James would have known with what loathing hysterics were regarded by those (their doctors particularly) who suspected they took pleasure in the care they required.

The question of who was controlling whom, and to what end, became explicit at the peak of the hysteria craze, which developed under the eye and, especially, the camera of Freud’s early master, the Parisian neurologist Charcot of the Salpêtrière. Charcot began a series of lectures for his medical students – and the fascinated fashionable public, who attended in their hundreds – in which his hypnotised patients performed what had never been demonstrated before, the ‘stages’ of hysteria. In this arena certain young women, coached (so it was charged) before mirrors by his subordinates and grown into masters of what Appignanesi tells us evolved as ‘the hysterical style’, achieved something very like stardom. Discussing Charcot’s ‘supermodels’ in The Female Malady and Hystories, Elaine Showalter notes that one of them, Blanche Wittman, was ‘known as the Queen of the Hysterics’, and that Augustine, whose ‘poses suggest the exaggerated gestures of the French classical acting style’, would become ‘the Surrealists’ pin-up girl’. The documentary photographs Charcot took looked like stills from silent films. The actors of silent films studied and mimicked them in turn. And as the style made its way into the general culture, the patients who presented themselves at the Salpêtrière were increasingly proficient in what they took to be the natural behaviour of the hysteric. Years after Charcot had left, some of his aged and thoroughly acculturated hysterics remained; they were ‘excellent comedians’, one young doctor noted, who ‘when they were offered a slight pecuniary remuneration, imitated perfectly the major hysteric crises of former times’. But what had been the origin of those dramatic ‘stages’ that Charcot had long ago demonstrated and the crowds had flocked to see? It seems they were increasingly stylised representations of behaviour his hysterics had learned from the epileptics with whom in the early days of Charcot’s reign they had shared quarters. Wittingly collusive or not, the hysterics performed – without their doctor being aware of it – what they knew their doctor was interested in seeing. Eliot Slater puts it best: hysteria was ‘a disorder of the doctor-patient relationship’.

‘Our model of the human mind needs to be capacious,’ Appignanesi writes. Unsurprisingly, her book’s organisation runs towards inclusiveness rather than towards discrimination. It is an ethical choice with literary consequences. Mad, Bad and Sad contains more than it can reasonably account for or attend to. Convulsions, trances, paralyses, aphonias, anaesthesias, lesions of the will, anxieties, obsessions, manias (homicidal and otherwise), depressions, hypochondrias, neuralgias, hereditary taints, epilepsies, neurasthenias, hysterias (involving ‘spinal neurosis, nervous hyperaesthesia, rheumatic gout’, plus ‘fainting, tooth decay, irascibility, paralysis’, ‘fish-flaps’), the rise of the New Woman, sleeping sickness, shell-shock, erotomania, frigidity, schizophrenia, electro-convulsive therapy, insulin therapy, anorexia, bulimia, post-traumatic stress disorder, borderline personality disorder, multiple personality disorder, recovered memory, bad mothers, incestuous fathers, spiritualism, surrealism, jealous writers, co-dependency, poverty, misogyny, celebrity culture, Calista Flockhart, I Never Promised You a Rose Garden – all make an appearance here. Appignanesi tells or retells the stories of patients (most but not all of them female, some but not all of them creative figures), their caretakers (most but not all of them male), their disorders (some of bodily, some of psychic, many of indeterminate origin; many, especially those to do with hysteria, under constantly mutating names; some real, whatever that means, and some unreal, whatever that means; and just about all of them apparently contagious), together with the trends they formed, followed or exemplified. Her structure is approximately historical and only very approximately thematic; she raises questions as the stories she tells prompt them but stops short of committing herself to actual arguments or analyses. Despite her title, she is not apparently interested in the boundaries between madness, badness and sadness, or the relations among them. It is the energy of her concerns with women, outsiders, storytelling and freedom that contains (if only barely) her unruly material.

Reading Mad, Bad and Sad evokes much the same confusion of fascination, doubt and weariness that the members of Charcot’s audience must have felt at one of his later spectacles: we have been through much of this material in one form or another before, in better light; and while the patients certainly do behave oddly, the exhibition nevertheless seems almost to suggest a most puzzling presumption of the sanity of their aims. In the absence of analytical urgency or freshness, the book feels embarrassingly like an amusement of a kind we ought, surely, to be too civilised to enjoy yet are embarrassed (because it is, after all, an amusement, isn’t it?) to refuse.

Appignanesi gives the impression of a similar confusion. As her book proceeds it loses its appearance of focus. The apparently ‘random assortment of materials, from philosophy or textbook to hospital notes, memoir, letters, biography and popular magazines’ – for which she bravely refuses to make apology – accumulates. When she tells us about the origins of electro-convulsive therapy and the theory of its utility, it is illuminating; when she tells us ‘lithium is the salt that, because it was found in the 19th century to dissolve urate stones, was used to treat gout and was drunk as waters in spas and at first in the soft drink 7-UP’, the sheer weirdness of the fact redeems its irrelevance. But when she declares that anorexics’ ‘refusal of appetite and consumption marks them out as the perfect anti-capitalists’ (they ‘become the suicide bombers inside the bourgeois family’), or tells the unhappy stories of Josetta, Roxy and Dawn (‘an attractive 35-year-old Hispanic woman, separated from her husband, mother of a 12-year-old girl and a nine-year-old boy’, ‘a slim, pixie-like 23-year-old’, and a quiet woman, with a ‘polite, girlish and whispering quality to her speech which drew people near’) and then, in the distinctive tones of the self-help book, reveals Josetta and Roxy to be ‘my own inventions based on a cross-section of cases’, it is hard to resist the suspicion that she no longer entirely believes in the reality of what she is writing about.

She no longer seems even to register that the problems she has spent so many hundreds of pages on are in fact problems:

Lives span across time. They contain moments that are better and worse, and sometimes so bad, it looks as if you won’t get through. People have. Women have. They have got through the danger points: adolescence with its dramatic ups and downs, its crises about identity and image, its inner chaos and uncertainties. They have got through childbirth with its hormonal spurts and depletions and motherhood upon which so much is blamed. They have even got through mourning. They have got through with the kindness of relations, friends, doctors, therapists and strangers.

Or else they haven’t. Kindness is a fine thing, of course, certainly better than its contrary; and it would be convenient, given the dangers the mind doctors have so often posed to their patients, if nothing more than kindness were needed. Still, not everybody gets through, kindly treated or not, and it is an odd thing to forget. Appignanesi calls herself ‘something of an unattached outsider in the history of psychiatry and psychoanalysis’. This is not entirely accurate, as the history of her publications makes clear. But it does describe the sensation of being on the outside, a spectator safe from both the delights and the hazards of serious engagement, that reading her book produces.

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Vol. 31 No. 18 · 24 September 2009

The list of stories of unjust incarceration for insanity is long, as Susan Eilenberg suggests (LRB, 23 July). Does it still happen? Or have things gone in a completely different direction?

I have been in and out of NHS mental hospitals for more than forty years. The first, following a suicide attempt, was Bethlem Royal, the old Bedlam, by then moved to a huge semi-rural site near Beckenham. On arrival my first feeling was of immense relief; I was in a safe place and didn’t have to worry any more. One almost never saw a psychiatrist; ‘treatment’ consisted of tranquillisers that kept one calm and anti-depressants that did nothing at all; this was in the days before Prozac. But the nurses were friendly and spent all day with the patients, chatting, playing games (Scrabble with schizophrenics can be very entertaining), going for walks in the grounds, even cooking meals with us. The male wing had a full-size snooker table and the female a grand piano, though the eccentricities of women playing snooker and men the piano were tolerated. After the first week or two I could even go for unaccompanied walks in the grounds. It would have been a very nice place to stay if one weren’t mad.

The fact that discharge was never mentioned merely increased my feeling of safety; when after six months I felt ready to face the world again I had no idea how to arrange to be discharged and was a touch afraid that if I asked they might try to keep me in – ‘section’ me, as it’s called. So one day I just walked out. No one came after me.

Three or four years later I was in hospital again: this time at Broadgate, near Beverley in Yorkshire, a huge Victorian place with its own farm. Things were much the same as at Bethlem. Uniquely, I was privileged to see the chief consultant psychiatrist once a week, but that was because I played trumpet to his trombone at the Saturday dances. The nurses spent all day with the patients here too, the only difference – in retrospect an ominous one – being that they had to write brief daily reports on the patients. This duty was taken lightly; one report I saw said: ‘Patient rose at ten thirty and spent the rest of the day in a horizontal position.’ I came across a lot of people shuffling about the corridors who had been in the place many years: however they had come to be there, their only ‘madness’ now was that they were quite unfitted for life outside. Again, after six months I simply walked out.

Looking back, those two places did me a lot of good, in spite of the absence of real treatment. Merely being in a sheltered environment, protected from self-destruction for as long as I needed, was therapy enough. For many years I managed to avoid going into hospital, except for a year at the excellent, intensive, highly successful and soon closed down Paddington Day Hospital.

But about nine years ago I was close to suicide again and found myself being taken into another hospital. Things had changed. Now we had the policy of ‘care in the community’. All notion of protection, of asylum, had gone: a patient (or was it ‘client’?) information leaflet explained that one’s stay would be as brief as possible. Nurses no longer spent much time with patients: they were closeted together in an office filling in ‘care plans’, and could get quite cross if one knocked on the door to point out that a patient was smashing up the furniture or another patient. Usually, in fact, knocks on the door were ignored. True, we saw psychiatrists as often as once a week, but their concern was to see whether we were ready to be discharged. We lived in dread of being called before the psychiatrist: many, including myself, tried to seem madder than we were in the hope of delaying discharge. I managed to stay a month – twice as long as the ‘target’ period – before being ejected despite my vigorous protests.

I was soon back. Returning to the same hospital I expected the nurses to be surprised and disappointed to see me again; they batted not an eyelid. Soon I noticed familiar faces among the other patients; people who had been discharged during my earlier stay and who were back again. Nine years later I have lost count of how many times the NHS has ‘cured’ me of severe depression. Clearly the new policy is statistically – and that’s what counts – very successful. It must have cost them far more than one long stay, but they’ve had half a dozen cures instead of one.

At present, two kinds of people are admitted to NHS mental hospitals: those bonkers enough to be a social inconvenience and those depressed enough to be ready to do away with themselves. If one’s desperate enough to want to get in, the magic word ‘suicide’ whispered in a suitably shamefaced sepulchral tone will do the trick. But mad or sad, one will be out again in two weeks. And back again in another two.

Simon Darragh
Walmer, Kent

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