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

by Lisa Appignanesi

  If the pharmaceutical companies took over street drug manufacture and marketing, would we find ourselves listening in a different manner to the ‘better than well’ way people occasionally feel on them, as we did with Prozac? Is feeling ‘better than well’, in any case, something of an aspiration to ‘mania’–that ‘up’ in which mind, imagination and emotions race and inhibitions fall away that those with bipolar disorder say they are loath to relinquish, particularly before it spirals too high. Unsurprisingly, urban anthropologists have indicated that big American financial firms see a certain degree of manic behaviour as an asset in their employees, who most often effect it by recourse to the more expensive illicit drugs.

  Our times have produced a terrible confusion about drugs, mood, illness and behaviour. The licit and the illicit, big medical science and street traders, have combined to create a chemical view of the human which traps the full range of human possibility into categories of mental disorder or criminality, with little in between. While both classes of drugs have attractive aspects and simultaneously carry a stigma, both inevitably reduce the fullness of human life and put a stress on mood, on upness or downness and whatever produces it, above all else. The neuro view of life with its accompanying psychological tick-list is simply not enough to see most people through its many phases. Even Spitzer, creator of the contemporary DSM, has acknowledged as much in the 2007 television documentary, The Trap.

  If our chemical society, with its erratic flare-ups of faith in magic-bullet cures, at times gives the illusion to patients, doctors and researchers that conditions can be got rid of or be easily controlled, reality usually insists on another picture. Nowhere is this clearer than in the stories of those self-and medically categorized as depressed or bipolar. Here pain is palpable, together with confusion and a sense of life gone awry, ever teetering on the brink of suicide. Even when these narratives are structured around the poles of illness and recovery, life seeps through with its inevitable messiness to produce a far larger picture. Depression stories like Wurtzel’s Prozac Nation or Lauren Slater’s Prozac Diary, or even the remarkable Kay Redfield Jamison’s various books on manic depression, or bipolar disorder, which link the condition–perhaps just a little aspirationally–to the many ‘geniuses’ Western culture has produced, reveal nothing so much as that life escapes the current medical categories and what is labelled as cure. Of course Sylvia Plath–whose trajectory is much emulated–can be thought of as depressive or even manic-depressive, but that hardly sums up the entirety of either her life’s achievement or the many moods, emotions, aspirations, responsibilities taken and work produced in between. There is a temptation to ask if a chronic condition, whether its causes are understood as genetic, constitutional, chemical or environmental, might not be better considered simply as part of the human condition.

  The late and famous French analyst Pierre Fedida, sometimes known as an existentialist, wrote his last book on depression. Worrying about the rise of a condition which affected only 3 per cent of the population in the seventies but which had risen by the turn of the century to 15 per cent, he noted that depression could not but be inherent to a rapidly changing society which demanded performance and enterprise at all cost despite the fact that technology and codes of love were both metamorphosing at an exceptional rate. In such a world, being depressed is a way of going underground, holding oneself quiescent, refusing performance, while desires are rekindled. If drugs are now less toxic and can have an effect, the real work, Fedida suggests, is still that of understanding, through the talk and listening of therapy, where you can get to know yourself better so as to be able to confront the frontal shocks of our times. Happily there are still some within the psychiatric professions whose worlds are not summed up by diagnostic manuals.

  It’s useful to be reminded, as history is prone to do, that today’s ‘conditions’ have been both seen and lived otherwise. Freud might well have thought of some of the contemporary sufferers from depression–with their energy, vivacity, intelligence and suicide attempts–as hysterics; and one or two transported to mid-century America might well have found themselves classified as schizophrenics. In the pre-psychiatric world that Mary Lamb inhabited, with all the horrors of its asylum life, they might have had little choice but to rely on time and the love of a responsible ‘carer’ to help them through.

  This book is not a condemnation of our psychiatrically medicalized times. Much of the care, medication, therapeutic talk available does make life better for people in distress. But the trip through history provides a cautionary note: mental illness is also the name given to a set of ills by various sets of mind doctors. The illness may provide meaning and definition for a time for the sufferer; or it may inflict a stigma. There is certainly no basis for the last: in most people’s lives at some point they will live through aspects of some of the states we now call mental illness or chronic mental conditions. But nor are there, for most mental conditions, however they are named, absolute cures or chemical cures that produce lasting equanimity or happiness. Recovery, salvation, healing, are neither absolutes nor a simulacrum of heaven.

  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.

  If in recent years the proportion of the doctors and therapists who are women has grown, this can only be to the good: they bring to their task a greater understanding of what growing up woman means. But it is perhaps too early to tell whether their place in the profession will ease the lot of women, or substantially shift the mind doctors’ historic recruitment of women to ‘illness’.

  EPILOGUE

  Ten days after the birth of her second child, the author Fiona Shaw, a young, vibrant, well educated and literary young woman in the north of England in the 1990s, found herself in a ‘mood of unease’ she couldn’t shake off. The tears came and engulfed her. So did screams, self-loathing, a fear of the outside world, stretches of numbness, and an inability to understand why she was in a state of despair when she had nothing to be depressed about. She could barely bring herself to feed and bathe her baby. People talked of ‘baby blues’. Her general practioner told her to ‘grin and bear it’, unless she wanted antidepressants, which might mean giving up breastfeeding. It would pass, he said. It didn’t. A second doctor came to the house, kinder, and recommended the Mother and Baby Unit of a psychiatric hospital.

  She spent the next months there, suicidal, surreptitiously burning and cutting herself, refusing food. The psychiatrist gave her an explanation of her condition which was hardly different–in its mix of environmental, biographical and physiological causes–from what Esquirol might have offered two hundred years earlier in considering that oldest of those madnesses specific to women. Dr A, an intelligent, matter-of-fact woman, talked of a combination of factors: a traumatic event (the birth) ‘triggering a reaction to past history, perhaps compounded by drastic hormonal shifts’. Her treatment, however, was more radical than what Esquirol had on offer, though his cases did not seem to go on any longer than contemporary ones. Hers was no regimen of purges and hot baths. When Shaw didn’t respond to antidepressants and chlorpromazine, and was still not eating (Esquirol’s post-partum patients mostly didn’t, either), she was sectioned and given ECT, twice a week for four weeks. She suffered from the inflicted brutality of the treatment and a severe accompanying memory loss.

  When she returned home after two and a half months, she was still in need of help. Psychotherapy, which she wanted, wasn’t available. Only the shocks were, now as an outpatient. For a total of six amnesiac months, the substance of life
was eviscerated for her. After that came another six on antidepressants. When she came off these, the depression returned, debilitating and difficult to bear.

  Shaw decided not to go back on pills. ‘They would simply have delayed the dilemma. They enabled me to survive an impossible crisis and helped me compose myself sufficiently to begin life again. But they had no answers for me and they hadn’t erased the questions.’ She stopped eating again and eventually found the money to go to a therapist. She wanted some understanding–of herself, the breakdown, what had led her there. She wanted meaning. Alongside looking after her children well, she also wanted to write, which is another form of exploration and understanding.

  Human beings are odd animals. Whereas they’re sometimes pleased to give over responsibility for an illness to a ‘physical’ explanation or remedy, with illnesses that involve mind, emotions, behaviour, the physical is rarely enough. After all, we may be our bodies, but our bodies are hardly all that we are: for some this even extends beyond the corporeal limit of death. And though our bodies largely inhabit a present, the mind roams through time. The past affects it: so does the (im)possibility of a future. Even when pills or hot baths (and, as some swear, even the barbarism of ECT) help, there’s a residue of questions and needs.

  Shaw met some of these by psychotherapy and some others by writing. Both fleshed out a story in which her own early childhood abandonment by her father at the moment that a sibling was born produced a flurry of conflicting emotions, which replayed themselves in the self-hatred, defensive aridity, even mourning over an old loss, when her own second child was born. We are not simple creatures.

  Recently, though the figures on depression continue to rise, there has been something of a patients’ backlash against the easy and sometimes loose prescription of antidepressants for all forms of ills. A report from the Healthcare Commission in Britain stated that of the eighty-four thousand people who had used mental health community services in 2005, a third had not been able to get access to the talking therapy they wanted. An expansion in the availability of clinical psychologists and primary care therapists is a government priority. This can only be a good: on the whole, talk therapies of most kinds are a huge advance on the physical therapies such as insulin coma or psychosurgery, with their sadistic component. But here, as in the USA and to a certain extent in France, there is a sense that cognitive behavioural therapy, with its forward thrust, its vocabulary of aims and self-esteem, is the only therapy that provides a so-called evidence base of success. With its supposedly limited term, its spoken therapeutic goals, its ‘proven’ cost-benefits in relation to patients’ lowered use of other parts of the health services, CBT seems to share a language of government targets and savings.

  If nothing else, the history of these past two hundred years of the growing psychiatric and psychological imperium should make us sceptical of any single ‘therapy’ suiting all situations for more than a brief period. Therapies, after all, can create their own best patients, though once created they have the human creativity to change and need other therapies. If government were cagey, or rather, intelligent, it would hardly be putting all its therapeutic eggs in one basket, no matter what the supposed evidence base or financial saving. Evaluations of various kinds of therapy, from CBT, to interpersonal, to attachment-based family therapy (ABFT)–which works on ‘relational reframe, alliance-building, parent education, re-attachment, and promoting competency’–to simple educational interventions, show that all have had their degrees of success with depressed adolescents and also their families. The only substantial differences in success are seen in those people who experience some kind of intervention as against a control group who are on a ‘waiting list’ and fare worse.

  Since often, after a first ‘acute’ intervention, further therapy is called for, it is probably not far-fetched (as other studies have shown) to imagine that the more traditional psychotherapies which attempt an understanding of the self that marries past with present might also serve a purpose, and provide some form of cost-benefit. After all, anecdotal evidence has it that while people are in psychotherapy, they rarely fall ill or go to their GP.

  There has been a recent move by some practitioners in even the most traditional psychoanalytical wing of the therapies to provide an ‘evidence base’ for their work–partly in order, perhaps, to police the boundaries of a profession that too often spills over into quackery, partly to keep pace with the needs of government health programmes. Though psychoanalysis–with its individual, long-term and confidential nature and its aim of dealing with inner conflicts that may have the accidental benefit of getting rid of symptoms–hardly lends itself to the kind of replication that evidence-based studies need, the Stockholm Outcome of Psychoanalyis and Psychotherapy Project (STOPPP) set out to provide just such a study.

  Designed for a Swedish national health programme that wanted to test the viability of providing insurance for such therapies, STOPPP set out to measure the effectiveness of therapy. Seven hundred and fifty-two patients–202 in subsidized analysis or psychodynamic therapy with known clinicians, the rest on a waiting list–all of them diagnosed and rated on DSM-IV criteria, were followed over a period of three years. Comparisons were made between the two kinds of clinical work and the group on the waiting list. ‘Outcome was assessed in terms of symptoms, social relations, morale or existential attitudes, general health, health care utilisation, working capacity etc., by qualitative interviews, self-report inventories, questionnaires and official records.’

  For ‘norming’ purposes, a well-being questionnaire was given to the participants and to a non-clinical group of 650 people in Stockholm. The results indicated that both therapy and analysis saw a substantial improvement in terms of morale and relief from symptoms. The surprise was that analysis effected the greatest improvement–though not in social relations. This was despite the therapists’, a proportion of them cognitive behaviourists, far greater emphasis on curative factors: stated aims, concrete goals, adjustment to prevailing conditions; helping the patient avoid anxiety-provoking situations. Surprisingly, given prevailing assumptions, it seems that the therapists’ stress on kindness, supporting and encouraging the patients, and their own self-disclosure, had little beneficial effect on the therapy, whereas the supposed neutrality of the traditional (and often older) psychoanalysts did.

  Of particular moment in this context is that STOPPP patients with female therapists had significantly better outcomes than patients with male therapists, irrespective of the patient’s own gender and the kind of treatment involved, though the difference was not so substantial amongst the psychoanalytic patients. Indeed, the manner of the psychoanalyst mattered far less to the outcome of the analysis than the manner of the therapist did to the therapy. It may be that insight–which the study designated as ‘helping the patient to understand that old reactions and relations are repeated in relation to the therapist; helping the patient see the connection between his/her problems and his/her childhood; encouraging the patient to reflect, in the therapy, on earlier painful experiences’–may after all have more to do with Freud’s invention of the analytic technique than with the immediate personality of the analyst.

  Later ‘evidence-based’ studies of therapeutic outcomes–such as those conducted by Peter Fonagy and Mary Target of the Anna Freud Centre and the University of London’s Psychoanalysis Unit in collaboration with the Yale Child Study Center–have investigated the impact of therapy on diabetic children who need to resolve conflicts in order to control their insulin levels better. Substantial and lasting improvement has been found here. A study of 352 children in therapy for depressive and anxiety disorders showed marked improvement in 72 per cent of those treated for at least six months, with the best results in serious cases for those treated intensively and daily. Another, of adolescents, not yet complete, showed amongst a plethora of results that girls responded far better than boys to both analysis and therapy.

  Such results can only give way to speculatio
n: is it possible that women, who made up so talented a portion of Freud’s early patients, have a gift for the talking therapies and/or for pleasing their therapists? One needs to beware of generalizing too much on the basis of a confined study, but the thought is tempting, particularly given that in Britain in 2004 there were an estimated nineteen thousand suicide attempts by depressed adolescents, one every thirty minutes, and the majority of the ‘attempts’, though not of their successful and tragic conclusions, were made by girls, who outnumber boys in suicide attempts here by nine to one.

  The mind doctors may indeed be helping women. Then, too, the simple presence of an interested ‘other’, whether an interlocutor, an attentive friend or spouse, has been shown to have far-reaching effects on our immune and nervous systems as well as on our emotions and minds. So why not, after all, an attentive therapist? But perhaps we cannot rely on a single profession to cover all bases on its own. If the mind doctors over these last two hundred years have shown us anything, it is that our model of the human mind needs to be capacious. Narrowing or medicalizing definitions too much limits the boundaries not only of so-called normality, but of human possibility. Lacan observed that some of his ‘mad’ would have functioned quite well in a religious community, in closed networks or in social organizations or political parties. Such possible lives might have kept them from stumbling into prison or madhouse.