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

by Lisa Appignanesi

  Mitchell’s stance, which refused a reading of women as passive victims and redeemed Freud as an important thinker, was more influential in Europe than in America until, through the eighties and nineties, academic feminism there took on and talked back to the masters of French theory. Mitchell herself, after a degree in literature, trained at the British Psychoanalytical Society and became a practising psychoanalyst. But even in the United States, where Freud often acquired demonic proportions, a fair number of the early feminists took up one of the psy professions or returned to the field for theoretical formulations. In America, on the whole, they didn’t train within the conventional institutes which, until 1989, required a medical degree. Instead they joined the looser, more multidisciplinary, university-based post-doctoral programmes, such as the one at NYU where Jessica Benjamin worked.

  With their diverse backgrounds in the social sciences, literature or anthropology, these feminists brought new optics into psychoanalysis. From within the existing institutes women, emboldened by the wider social movement, challenged old models of therapy and began to insist on more ‘relational’ practices, an empathy with the patient’s needs. They helped to transform American psychoanalysis. Freud, who had been quite clear that he didn’t like being the mother in transference and that women analysts worked better with pre-Oedipal matter, would have been pleased. He would also have applauded the rupture between psychoanalysis and medical psychiatry.

  Chesler became a psychotherapist, and often appeared as an expert witness in cases where mad and bad needed distinguishing. The prominent feminist theorist Nancy Chodorow became an analyst. She found her mentors not in Freud, but in Karen Horney and Melanie Klein. Her highly influential The Reproduction of Mothering (1978) traced her contention that the gendered specificity of the mother–child relation made it harder for girls to separate from their mothers and made women more alert to relations so that they reproduced the mothering bond. The boy’s core identity was constructed out of a repudiation of the mother and lay at the origin of the fear and hatred of women in Western culture. The only solution to this vicious circle was mothering by both sexes.

  In Italy, the educational psychologist Elena Belotti in the bestselling Little Girls analysed the ways in which girls are prompted into secondary status and into little-womanhood by their mothers and teachers, their time at the breast briefer than boys’, their hugs less ardent, their toys a preparation for mothering, which will entail the greater orderliness already demanded of them. Back in America, the psychologist Carol Gilligan conducted research which underlined how gender-specific mothering created the different modes of being in the worlds of boys and girls. She showed how girls’ morality is based on a sense of responsibility to others, whereas boys have a more mechanical ethics of rights and abstract notions of justice. Dorothy Dinnerstein’s The Mermaid and the Minotaur argued that the power of the mother in infancy resulted in adults of both sexes in fear of women, and an internalized misogyny which made men repudiate closeness while women hated their own bodies and distrusted female power. In 1981 Alexandra Symonds founded the American Association of Women Psychiatrists, which looked at sexism within the profession.

  Everywhere in Europe and America there was a refocusing on the female body and sexuality, so that old and all-but discarded diagnoses, such as Esquirol’s puerperal madness and the links between erratic behaviour and menstruation, came back in a newly emphasized manner. To look at woman as woman, after all, meant to re-examine her difference from man, which lay first of all in the body and the way that body was lived–as the ground-breaking Our Bodies, Ourselves by the Boston Women’s Health Book Collective did in 1971. In an opposing motion, by the late seventies and into the eighties other feminists–particularly those influenced by Lacan, such as Juliet Mitchell and Jacqueline Rose–refused gendered categories and set out to expose the arbitrary and constructed character of the binary opposition between male and female. As it was in language, gender here became an assigned and then internalized identity, not an essential or biological given.

  With the spur of an increasing number of women in the profession, female madness from the seventies also took on a new variety of symptoms and diagnoses, as well as treatments. If these didn’t always turn out to be very much kinder than the ones poor Mary Lamb had received two hundred years before, then at least symptom and diagnosis often came with a support group–modelled in part on the women’s consciousness-raising groups of the seventies–rather than a solitary brother. What that astute critic of late-twentieth-century society, Philip Rieff, had called the ‘emergent democracy of the sick’ was taking hold. If the Freudian revolution had ushered in a stoical psychological model of the self, the ‘therapeutic’ model was now in ascendancy, with its newly trained hordes of professionals poised to answer and explain all needs.

  Meanwhile, in a shadowy inversion of the trajectory in which midwives had historically been displaced by doctors, as women moved increasingly into the talking therapies in America the profile of the profession itself fell. The psychiatric wing emphasized its scientific and medicalized aspect and gradually shifted away from therapy into a ‘harder’ drug-rather than talk-oriented definition of mental illness and cure. Here the body of illness reverted to its centre in neuro-wiring and chemistry, and away from the ‘softer’ model of relational triggers or the search for meaning.

  And although the number of women doctors increased many-fold in this period, and in the USA by 2002 women made up half of the medical student population (up from 9 per cent in the 1960s, when quotas for women were still in operation), the overall number of doctors specializing in psychiatry fell. In 1979, Time had already noted: ‘The U.S. has 27,000 psychiatrists in active practice, up from 5,800 in 1950. But now the bloom is off the therapeutic rose. Today only 4% to 5% of medical school graduates go into psychiatry, vs. 12% in 1970. Says one doctor: “Psychiatry is not where the action is.”’

  Applications to the prestigious Columbia Psychoanalytic Clinic for Training and Research fell by 90 per cent from 1960 to 1980. In 1989, a resisting New York Psychoanalytic Society, propelled by the trend, had to open its doors to training lay analysts.

  But if the American marriage between psychiatry, psychoanalysis and the psychotherapies was temporarily over, separation hardly dissipated the importance of the mind doctors overall. On the one hand, with the rise and rise of the new drug cures, there was a rush towards psychopharmacology. On the other, the psychotherapies proliferated. In December 1985, over seven thousand practitioners from around the world gathered in Phoenix, Arizona, for a meeting dedicated to the ‘Evolution of the Psychotherapies’. They represented some twenty-seven different schools, from behavioural therapy to Freudian psychoanalysis. Heavyweights like R.D. Laing, Bruno Bettelheim and Thomas Szasz were there, along with Carl Rogers, the ‘guru of Human Potential’, and Virginia Satir, a Palo Alto family therapist who regularly drew audiences of two thousand.

  The anti-psychiatric rebels may have attacked the face of the profession. The result was that it had grown a few more. Group therapy received a new boost from the women’s movement and was increasingly used in hospital as well as in outpatient and private settings for any number of psychological ills. Family therapy burgeoned, spurred by pre-war work with troubled children, but also by the anti-psychiatrists’ findings about schizophregenic families. Each of these had a variety of orientations.

  Meanwhile, patients or clients seemed increasingly in need or in pain. The very speed of cultural change in women’s roles and expectations, the impact on men and assumptions about masculinity, the continuing contradictions of demands, desires and needs, the increase in images that bombarded the sex that had always been the object of the gaze–all this made the helping hand that therapy of any kind offered seem essential. New freedoms made life more interesting, but not always any easier.

  At the end of her history of women’s mental illness in Britain, The Female Malady, Elaine Showalter had raised the hope that a new feminist psych
ology of woman together with a feminist therapy movement would liberate women from the chains of madness which ‘obtuse and misogynistic’ medical practice had kept them in, whatever their leading doctors’, from Pinel’s to Laing’s, claims to freeing them. Whether that hope can still be kept in place is an open question. What is clear is that the increasing number of women involved in mind-doctoring both responded to, and helped create, new clusters of illness.

  13

  BODY MADNESS

  I was just struggling to find my place, like anyone experiencing change, and nothing seemed certain anymore, except what I did or did not eat.

  Grace Bowman

  The dizzy rapture of starving. The power of needing nothing. By force of will I make myself the impossible sprite who lives on air, on water, on purity.

  Kathryn Harrison, The Kiss

  Over a century has passed since Charcot had the Salpêtrière hysterics photographed. Posed for and captured by the new technology of the camera, their passionate attitudes, simultaneously erotic and saintly, played a part in initiating a local fashion in hysteria. These expressions and gestures also affected the actors of the silent screen, where they were in a sense normalized into histrionics and disseminated once more. Hysteria became every woman’s expression of intense passion. Though now occasionally re-enacted as spectacle, the hysteria that has been transmuted into the disorder the DSM classifies as ‘illness behaviour’ has taken on other bodily manifestations. Simultaneously, the interaction of disorder, image and unconscious mimicry has taken on a new intensity.

  Images now suffuse daily life in the West. From the high street to the shopping mall, from public to private space, from big to small to tiny mobile screen and all the paper surfaces in between, images surround us and invade our imaginations. Increasingly, the very same images circle the world, implanting themselves in minds and within cultures distant from their source of production. Whole new professions, technologies and burgeoning industries–from fashion to film, advertising to the World Wide Web, diet to food processing–depend on their unstoppable flow. Women’s bodies, blown up to be larger than life or reduced to the smaller-than-lifeness of everyday TV screens, but always incarnating an idea of beauty, are a key part of that flow. They are also used to confer magic, that ineffable charm which is glamour, as elusive as a will o’ the wisp to those who might be seduced into thinking that the bought commodity contains its extra-special happiness within itself. These immaterial bodies constantly seen, present from cradle to grave, inevitably impact on material ones. They can engender body madness.

  Over the last thirty years, as the West’s plenty increasingly separates it from famine and war zones, glamorous images of women have shed weight. In the victim-chic of post-colonial guilt, they echo the gaunt faces and shapes of famine-struck children–the ones who might somehow have survived into pubescence. Curves have disappeared, to be replaced by countable vertebrae and pin-thin arms and wrists. A once voluptuous turn of a shoulder is now a sharp-angled jab. The rounded, procreative body of a living woman has been displaced by that of a hunger-artist. By twenty-first century standards, the Marilyn Monroe of Some Like It Hot or the Brigitte Bardot of And God Created Woman are fat. They weigh in a good thirty pounds heavier than the clothes-hanger models of catwalk and soap screen.

  These stars, from Calista Flockhart to Victoria Beckham, whose eating disorders are ever mooted and ever negated, or given that fashionable label of ‘recovery’, are the envied celebrities of teen magazines. Anorexia is the pet disorder of the fashionistas, invading the minds of girls as young as seven who, doctors report, are already affected by eating problems. On the Internet chat rooms of ‘pro-ana’ sites, ‘thinspiration’ is available for anorexics who would prefer to categorize their condition as saintly protest against the consumer culture rather than a mental disorder. Dieting for a hungry planet is confused with dieting for a smaller jeans size. Lost weight is celebrated, descriptions of fasting states and their attendant highs and lows exchanged, together with notes on how to hide unwanted food. Friendship is provided where it might otherwise not exist and, dangerously, that ultimate stage in the campaign, which is death, is cheered on.

  Anorexics become the suicide bombers inside the bourgeois family. Their refusal of appetite and consumption marks them out as the perfect anti-capitalists.

  In more conventional Net support groups for anorexia, fasting girls or their parents can obtain information on doctors and clinics, exchange notes on how to get help and how to survive an illness which kills in the region of 20 per cent of its subjects. For bulimics, that other even faster-rising category of food disorders amongst women, there are ‘pro-mia’ sites which specialize in tips on how to vomit more effectively and keep the condition secret from family and friends.

  Meanwhile obesity, from young to old, is on the rise in America and Europe. In 2004, reversing a prior policy, the US health department named it a ‘disease’, making health insurance and medical research monies available for its treatment. Using the Body Mass Index, defined as the ratio of the weight of a person in kilograms divided by the square of their height in metres, the World Health Organization in 1998 came up with a definition of overweight as a BMI of over 25 and obesity as a BMI of over 30. Marilyn Monroe’s BMI moved between 21 and 24, so she was verging towards the overweight by today’s standards. According to this scale, to be underweight is to have a BMI below 18.5. In the past twenty years, the BMIs of Playboy’s centrefold have gone down from 19 to 16.5, while the average weight of an American female is un unprecedented 163 pounds (75 kilos); and 3.8 million people weigh in at over 300 pounds (136 kilos).

  This imposition of measured norms, backed by experts and by a pharmaceutical industry searching for the magic capsule of certain weight loss is one more way of ‘making people up’ as a classification, in this case ‘obese’, on the pretence that this is some kind of total identity. In the UK the Royal College of Physicians, participating in the Western moral panic around obesity, has warned that ‘if current trends continue, conservative estimates are that at least one-third of adults, one-fifth of boys and one-third of girls will be obese by 2020’. Being overweight, they underline, harms ‘health, self-esteem and social life’. In Germany, obesity was declared an epidemic by the Consumer Affairs Minister in 2004: ‘Every third child and every fourth teenager is massively overweight’, as a result of inactivity and the fast food industry. In the West, it seems that obesity is a property of the working class, or of ethnic groups who don’t suffer from the compulsion to disavow the fleshy fruits of imperial gain.

  Clearly, discrepancies between the idealized image of glamorous womanhood and the realities of fat and everyday life are huge and growing. Constant warnings from health authorities, prepared foods that carry contents lists more detailed than a lab report and flash their low-carb or low-fat banners, the fashion and diet industries–both worth billions–have all combined to create a situation in which fat is, for many girls, a nearer and greater terror than war; while thin is perfection, a dream sphere to be constantly sought in which all problems will magically vanish. With ‘thin’ come men, wealth and happiness. Fairy godmothers for the contemporary Cinderella carry slimming tablets rather than a wand.

  Bodies may be made of hard matter but we perceive, understand and shape them in coded ways. A thin pop star with shorn hair on a billboard carries different meanings from a concentration camp survivor, no matter what the intended references. So, too, does the illness she may have. Our zealous concentration on food, on feasting or fasting, and the attendant body image, has given rise to a series of culture-bound psychopathologies, which, like hysteria, fold in crucial contradictions and core anxieties of time and place. Most categories of mental illness, by their very basis in classifications which separate off sick from well, sane from insane, healthy from ill, are culturally linked. But particular illnesses, from their spiralling proportions in given historical periods together with the spiralling literature which surrounds them, are mor
e clearly visible as expressions of the malaise of their times.

  Since the 1980s this has been the case with anorexia nervosa, bulimia and the various conditions which rotate round their borders. They now have their own specialists, clinics and scientific apparatus, including (since 1981) an International Journal of Eating Disorders to investigate and communicate a field that has grown globally, shadowing the rise of McDonald’s. They have a popular culture of diet and self-help books, magazine columns and pop songs that lyricize the condition alongside that other teenage disorder of self-harm–again, more prevalent amongst women–to which eating problems are often linked: both are expressions of a woman’s attack on her own body. Meanwhile, an academic culture has grown up alongside: histories–such as Catherine Bynum’s Holy Feast and Holy Fast or Joan Brumberg’s Fasting Girls, which uncovers the meanings of past fasts; and literary criticism which looks back, as Maud Ellmann writes in The Hunger Artists, to Kafka, Byron and Richardson (who, incidentally, was told to slim by that first great dietitian-doctor, George Cheyne). The eating disorders are illnesses of the McLuhan age, as Ellmann aptly notes, ‘disseminated by telecommunications rather than contact’.