Mad, Bad, and Sad: A History of Women and the Mind Doctors

by Lisa Appignanesi

  PART FOUR

  INTO THE PRESENT

  12

  REBELS

  I think I’m so absolutely centred on the one thing–it’s, well, to get her well…since she’s ill, she’s never accepted anything any more. She’s had to reason it out for herself, and if she couldn’t reason it out for herself, then she didn’t seem to take my word for it.

  Mrs Abbott, mother of the ‘schizophrenic’ patient, Maya

  By the end of the fifties it was becoming increasingly evident to some that the triumphalist mind doctors, whatever their status in the media and as paid personal helpmates, couldn’t tell a troubled and rebellious growing girl, let alone a non-conforming all-American male, from a raving madperson. Defiance, unruliness, disobedience were characteristics they translated all too readily into the language of illness. Meanwhile, many asylums were little better than prisons where drugs, experiment and punishment were legitimated as treatment. Their classifications, though increasingly dressed in the powerful jargon of solid science and physical medicine, were as vaporous as smoke rings–and more dangerous. Even the most cultivated of analysts couldn’t avert a patient’s suicide.

  A part of the more general sixties political attack on the bastions of power and science, the anti-psychiatry movement was launched from a variety of sites. Primary amongst these were not the patients’ groups that were to evolve later, but the ranks of the psychiatric profession itself.

  Thomas Szasz’s ground-breaking The Myth of Mental Illness of 1960 launched the first conceptual missile at the burgeoning ranks of American psychiatry and exposed the hollowness of the category itself.

  The notion of mental illness derives its main support from such phenomena as syphilis of the brain or delirious conditions–intoxications, for instance–in which persons are known to manifest various peculiarities or disorders of thinking and behavior. Correctly speaking, however, these are diseases of the brain, not of the mind. According to one school of thought, all so-called mental illness is of this type. The assumption is made that some neurological defect, perhaps a very subtle one, will ultimately be found for all the disorders of thinking and behavior. Many contemporary psychiatrists, physicians, and other scientists hold this view. This position implies that people cannot have troubles–expressed in what are now called ‘mental illnesses’–because of differences in personal needs, opinions, social aspirations, values, and so on. All problems in living are attributed to physicochemical processes which in due time will be discovered by medical research.

  Mental illness as a category was being questioned and criticized as the self-serving creation of an ambitious profession which sought to medicalize the very troubles being human brought in its train. Also under attack were the diagnostic ineptitude and the dangerous coerciveness of treatments within asylums. Ken Kesey’s One Flew Over the Cuckoo’s Nest (1962) vividly satirized the asylum’s straitjacketing of the scope of human experience, its disciplinary use of ECT and lobotomy. The novel was based on Kesey’s LSD trials and employment in a veterans’ hospital in Los Angeles: its point of view is that of the giant native American ‘paranoid-schizophrenic’ Chief Bromden, who pretends to be a deaf mute and sees the action as a contest between good, as embodied in anarchic R.P McMurphy, and the evil psychiatric order of Nurse Ratched. The 1975 film of the book took the action to a state hospital in Oregon and had actual patients playing secondary parts to wisecracking Jack Nicholson–the seductive individualist at war with frigid Nurse Ratched.

  Erving Goffman’s Asylums (1960) arose out of the time he spent in 1955–6 at St Elizabeth’s Hospital in Washington DC, where he observed at first hand the daily life of mental patients and staff. He concluded that in the ‘total institution’ the asylum was, doctors and patients were bound in a masquerade in which the first had to behave in an authoritarian fashion while the second enacted variations on the theme of manic craziness: even if power lay with the doctors, both colluded in a social order which perpetuated madness rather than the vaunted and hoped-for cure.

  Meanwhile in France and in a different critical register, but prompted by the same liberatory impetus, Michel Foucault’s Madness and Civilization (1961) explored the ways in which the very discourse and ‘scientific’ discipline of psychiatry–a form of knowledge–had defined madness, and instituted its own power over its forms. Simultaneously its ways of seeing had become naturalized. Unreason had been bound into cases and diagnoses and lost its oppositional force to ever-narrowing understandings of ‘reason’.

  Even without having recourse to Foucault’s overarching critique, it is clear the asylum system had reached a nadir in its chequered history. Scientific hypotheses about cure, a desire to experiment with surgery or drugs, coincided in many hospitals with ‘snake pit’ conditions and growing numbers of patients. Andrew Scull’s Madhouse (2005) charts a compelling and emblematic microhistory which begins in the first part of the twentieth century: the story of Henry Cotton, superintendent of the Trenton State Hospital, New Jersey. In the name of a scientific theory postulating that the source of psychosis was ‘focal sepsis’ or chronic pus infections which poisoned the brain, Cotton carried out an obscene campaign of surgery on the tonsils, stomach, colon and uterus of patients, alongside removal of teeth. In the process he maimed and killed thousands.

  One of Trenton’s patients was a certain Martha Hurwitz. Her case, culled from hospital records, charts the tragic trajectory of a woman subjected over the course of half a century to every change of treatment asylum fashion dictated. Born in Russia in 1902, poor but intelligent and adept in three languages, she had been abandoned by a drinking, gambling husband and had fallen into a depression which brought with it occasional bouts of violence. This violence seems to have been simply troubling acts, inappropriate female behaviour in the eyes of old-world Jewish parents. After a short stint in a private hospital, and temporary improvement, Martha Hurwitz had broken her ankle and became so ‘talkative and restless’ that her parents had her admitted to Trenton. Here she was diagnosed as a case of ‘Septic Psychosis Schizophrenia’, for which she was treated with typhoid vaccine, tonsillectomy and had several teeth extracted.

  Released within a few months, Hurwitz was back in the asylum in the late summer of 1929, ‘nervous and excitable’ and depressed after she had broken a leg. In a state of panic about readmission, she was also ‘violent’. This time the same diagnosis resulted in the extraction of her remaining teeth. Hospital notes talk of her being ‘rational’ but ‘restive and uncooperative’–a resistance, as Scull notes, which was defined as pathology. Twenty colonic irrigations were followed by a course of ‘surgical bacteriology’–puncturing of the sinuses in search of sepsis, and Lane’s bowel operation in which a section of the colon was removed. This assault on the body defeated Hurwitz’s resistance; becalmed, she was sent home six months later. ‘Cure’ lasted for almost two years, then on 4 April 1931 she was readmitted for five years, discharged, but after a short remission came back to Trenton, this time to stay, in March 1938. During the coming years she was given fifty insulin treatments. Hospital transcripts record her feeling that these are punishments for her good health, which is resented by others: ‘the people here resent the fact that she is so healthy so they give her needles to make her sick’. Her ‘flattened emotional tone’ and near-muteness now led to fever treatment–inoculation with malaria–and then, in 1949, to a series of electro-shocks.

  Martha’s condition had now become chronic, and no treatment made any discernible difference. In September 1951, notes showed her ‘greatly deteriorated’, but not selected for the course of lobotomies the hospital was then undertaking. Instead, in 1955, her mental faculties in decline so that she now claimed to have been born in the Trenton State Hospital, but still quarrelsome, she was given the new treatment for psychosis, Reserpine, but on double the recommended level and escalating. By November, she was receiving seventy times the ‘therapeutic’ dose. Still psychotic after forty-two doses, Martha was selected in 195
6 for a trial of the new drug Thorazine, and six months later a further escalating course of Reserpine. Early in the 1980s, she was, as Scull vividly notes, ‘a burnt-out case, a demented old woman who had somehow survived repeated surgeries, the extraction of all her teeth and tonsils, fever therapy, insulin comas, electric shocks and massive overdoses of drugs, during a confinement that had stretched over five decades’. It was now that the powers that be decided Martha Hurwitz should be de-institutionalized and released into a community she had left in 1938. Luckily, she fell and broke her hip, contracted pneumonia and died on 7 May 1982, fifty-four years after her first admission.

  This distressing example of a patient whose chronic craziness was more than partly induced, and certainly exacerbated, by the tortures of asylum life shores up both the broad and narrow claims of the anti-psychiatrists by highlighting the power of the asylum as a total institution, the dangers of unchecked medical experimentation on vulnerable people and of the treatment fads the profession is prone to. By the fifties and sixties the catch-all diagnosis of schizophrenia had become so widespread–and most decidedly so in America–that any ‘normal’ person could find herself incarcerated and unable to leave the institution once its threshold had been crossed. This was what David Rosenhan’s famous experiment showed.

  In the early seventies, Rosenhan and eight friends, including one psychiatrist, 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’.

  All eight were admitted and all, save the one who with the same symptoms was labelled manic depressive, were diagnosed as paranoid schizophrenic. They were given drugs, which they had learned not to swallow. Despite their subsequent pleas of normality and truth-telling, they were kept in for varying lengths of time. 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. Only other inmates seemed to suss that they were not ‘mad’. They saw them writing notes, after all.

  Rosenhan published the results of his experiment, ‘On Being Sane in Insane Places’, in the influential Science. His charge that the profession misdiagnosed and held ‘patients’ against their will plunged the American discipline of psychiatry and asylum practice into a nosedive. Psychiatric diagnosis was clearly a dangerously inexact and unreliable science, capable of making ‘massive errors’. Shock therapy, the treatment of choice in institutions, was used far too indiscriminately, as were a whole range of stupefying drugs. Despite the profession’s good intentions, it was clear that labelling a patient insane and bracketing him with a diagnosis resulted not only in the stripping of the usual rights of a citizen, but in a depersonalization which was difficult to correct.

  In Britain, well before Rosenhan’s experiment, a series of case histories had been published which set out to show how families, not biology, produced the pathology of schizophrenia. On the way they made it brazenly, if inadvertently, clear that women in particular were trapped by the neat fit of family and doctor’s expectations of female behaviour. Psychiatric illness emerged as the diagnosis of choice for a great deal that might now look like defiance or adolescent unruliness. These women are the pseudonymous contemporaries of Marilyn Monroe and Sylvia Plath. They painfully reveal how the difficulties of becoming and being woman during these years, combined with a rebellion against broadly held, constricting expectations, both induced and shaped what doctors, families and society were all too ready to label as ‘schizzy’.

  R.D. Laing and Aaron Esterson’s ground-breaking Sanity, Madness and the Family (1964), without drawing attention to any specificities of gender, focused on the cases of eleven women in two pseudonymous institutions, East Hospital and West Hospital. Laing and Esterson’s starting point is that schizophrenia is not a biochemical, neurophysiological or even psychological fact. Seen within the ‘phenomenology’ of family life, it emerges as an ‘intelligible’ response to the interaction of its members. The experience and behaviour of women labelled as ‘schizophrenic’–the wildness, the content of the voices, the non sequiturs–make complete sense when apprehended within the family system.

  In Britain, unlike America, the assault on psychiatry was often enough launched from a psychoanalytic stance. Since the talking therapies and their underlying hypotheses had rarely been combined with medical psychiatry in institutional treatment here, Laing’s initial position was that the first could act as a corrective to the second, which had far too long relied on medication and shock treatment, as well as damaging power relations between doctor and patient. The drug-giving, lobotomizing, ECT-using, diagnostic psychiatrists with whom Laing and his colleagues had trained and worked throughout their lives needed correction from various psychoanalytic and existential standpoints. Only thus could sense be made of what looked like madness, which was in fact a condition produced by family and society and exacerbated by the evils of confinement and psychiatric treatment.

  MADNESS, SANITY AND THE FAMILY

  Laing and Esterson’s eleven cases were aged between fifteen and forty and had been diagnosed as ‘schizophrenic’ by at least two senior psychiatrists. The women had no organic condition that might have affected their actions, nor were they of ‘subnormal’ intelligence. They had had no brain surgery and had received no more than fifty electro-shocks in the last year (which effectively means one a week) and no more than 150 in all. After that, the suggestion is, there would be visible deterioration. The coolness with which the selection criteria are noted points to the radical physical treatments that patients were submitted to as a matter of course in the mid-fifties, the era from which these cases come.

  Maya, twenty-eight, had spent nine of her last ten years in West Hospital. An only child, initially very close to her father, the manager of a general store, she had lived with her parents until the age of eight, had then been evacuated and returned home at the age of fourteen. A month before her hospital admission, she had suddenly told her parents that her headmistress wanted her to leave school. She had also begun to imagine her father was trying to poison her, certainly get rid of her. Unravelling the clinical description of Maya’s ‘affective impoverishment’, her ‘autistic withdrawal’, lack of ego boundaries, depersonalization, auditory hallucinations and impulsiveness, Laing and Esterson describe a young woman who experiences herself as a machine rather than a person. She has no sense of her ‘motives, agency and intentions belonging together’. She speaks with ‘scrupulous correctness’: her thoughts are controlled by others; her voices often do her thinking for her.

  Almost fifty hours of interviews were held with the patient and her family in different configurations, the majority of them with mother and daughter together. What emerges is a riveting portrait of how a girl’s need for autonomy once she returns to the family home at the age of fourteen fills her parents with alarm. Maya’s desire to read alone, her refusal to swim or walk with her father, her efforts to separate herself from them, are interpreted as her being difficult, or selfish, or greedy, or as part of her frowned-on ‘forwardness’, and in retrospect as ‘illness’. She in turn experiences her parents as intrusive, complicit, disapproving, at once patronizing and anxious about her so that she has to assuage their concern. They are ambivalent about her cleverness, both want it and see it as ‘too clever perhaps’. She feels they laugh at her when she wants to read, though they deny this, only to ask, ‘Why do you want to read the Bible, anyway?’

  In interview, they enact the double bind. They continuously disavow Maya’s lived reality, both past and present, contradicting her perceptions and experience, so that she grows confused. They exchange glances, winks and gestures which they deny exist, so that Maya ‘mistrusts her own mistrust’ of them. When she has tried in the past to tell them her
sexual thoughts, they asserted that she didn’t and couldn’t have any and even during interview when she acknowledges it, they deny that she masturbates. They insist so regularly she has powers of mind-reading and telepathic exchange with her father, that she no longer trusts her own thoughts as her own.

  It emerges that all the ‘signs’ and ‘symptoms’ that the psychiatric world would regard as ‘caused’ by Maya’s pathology are induced by her parents, who undermine her at each possible occasion and refuse to acknowledge her separateness:

  Not only did both her parents contradict Maya’s memory, feelings, perceptions, motives, intentions, but they made attributions that were themselves curiously self-contradictory, and, while they spoke and acted as though they knew better than Maya what she remembered, what she did, what she imagined, what she wanted, what she felt, whether she was enjoying herself or whether she was tired, this control was often maintained in a way which was further mystifying…The close investigation of this family reveals that her parents’ statements to her about her, about themselves, about what they felt she felt they felt, and even about what could directly be seen and heard, could not be trusted.

  It is hardly surprising that Maya withdraws to repudiate a world in which she can’t read the signs. Her schizophrenic behaviour is a response to the social reality she has experienced.

  Laing and Esterson structure their reports of these cases so as to underscore that what in an ordinary family might be seen as normal development or reaction on a child’s part is here understood and reinforced as aberrant and gradually becomes the ‘illness’. Lack of recognition or acknowledgement of the growing child’s experience and need for independence can indeed induce that ‘illness’, which the doctors, in unwitting collusion with families, then label schizophrenic and proceed to reinforce.