When I set out to research and write the book that became Mad, Bad and Sad – from which an extract follows on the next pages – I wanted both to inquire into the ways our current understandings of madness – what in our highly medicalised age we call mental illness – had come into being. What I discovered in the process were the ways in which various diagnoses – together with the dividing lines between what is considered normal, what aberrant – were historically specific and depended greatly on a time’s expectations of behaviour.
This was perhaps more the case for women, a gender that has always been subject to description by male experts and thinkers. Such description, together with the male medical gaze, inevitably impacts on women’s self-understanding.
At no point in my research was I tempted to make the romantic leap into thinking that all forms of inner disorder and consequent behaviour were simply fabrications either on the sufferer’s or on the doctor’s part. From the first written records, it is clear that people, however they may express their ills, suffer from versions of extreme and debilitating melancholy which are more than sadness, from painful, disabling symptoms which have no known physiological base (this is true even in the age of scientific scans and superior mapping technologies), from hallucinations, dislocation, anomie, and so on. What changes, and changes emphatically through time, are the causes we attribute to often enough evolving symptoms and the attendant forms of treatment. Doctors and interventionist drugs do not always need to be the first point of call.
Whether we have now, as some psychiatrists may wish to claim, reached a high point in understanding and treating mental disorders, is open to question. There must be an irony to the fact that while we pretend to greater knowledge, to better and more scientific medicine, the toll of sufferers nonetheless seems to rise and rise. Diagnoses, themselves not impervious to movements and fashion, can amass followers. We want names for the things that are difficult to bear.
I hope Mad, Bad and Sad sheds a little light on these perplexing matters.
“I have long been aware of the shallowness of sanity”
The simplest way to begin is to say that this is the story of madness, badness and sadness and the ways in which we have understood them over the last two hundred years. Some of that understanding has to do with how the dividing lines between them were conceived and patrolled, in particular by a growing group of professionals or 'mind doctors', who came to be known, as the nineteenth century turned into the twentieth, as 'alienists', psychiatrists, psychologists, psychoanalysts and psychotherapists. They were also sometimes neurologists, pathologists and latterly neuroscientists and psycho-pharmacologists. All of them thought they were in one way or another illuminating the dark corners of the mind and amassing crucial knowledge. In that sense, and appropriately, they thought of themselves as scientists. They were helped along the way by criminologists, judges, statisticians and epidemilogists. Crucially, they were also helped by patients.
So this is also the story of the way in which madness, badness and sadness - and all the names or diagnoses these states of mind and being have been given as time went on – were lived by various women. Frenzies, possessions, manias, melancholy, nerves, delusions, aberrant acts, dramatic ties, passionate loves and hates, sex, visual and auditory hallucinations, fears, phobias, fantasies, disturbances of sleep, dissociations, communication with spirits and imaginary friends, addictions, self-harm, self-starvation, depression - are all characters in the story this book tells. So too are the Latinate and Greek designations they took on as diagnoses - monomania, melancholia, hysteria, dementia praecox, schizophrenia, anorexia - and their often casual, but scientising shorthand today, MPD, ADHD, OCD and so on.
Since mind-doctoring, for better or worse, is not only about understanding and exploring the mind or psyche, emotions and acts, but also sometimes about making them work better together, treatments are also players in this book, whether they are 'moral', surgical, galvanic, electrical, pharmaceutical or talking - sometimes even writing.
I have long been aware of the shallowness of sanity. Most of us are, in one way or another. Madness, certainly a leap of the irrational, is ever close. We have all been children and can remember a parent's or sibling's sudden rage - even, though less well, our own explosions. We all sleep and wake and sometimes the dream lingers, won't be shaken off, incomprehensible with its ruptures of time, space and sometimes shape, so that we're as small as Alice confronted by the caterpillar, let alone party to the languorous visions of that opium pipe.
We drive along in our cars and suddenly emerge from a trance in which we can't remember who we were. At other times, our dead won't let go of us and shadow our days, as if they were there, in the room, too close. Or we or a partner wakes and simply can't rise. The light has suddenly gone out on the world. It feels as if it will never go on again.
Everything is too big, too difficult, too miserable. No pulling up of the socks will fix things. Those negative, persecuting screams of all that is wrong in our lives are so loud only suicide feels as if it might blot them out. All this is common enough - as are physical symptoms for which the doctor can find no organic base. If any of this persists, or grows exaggerated, in partners, children or ourselves, we feel fear and perhaps shame. The fear that our minds have grown alien to us, the shame that our acts, words or emotions can slip from our control, are often combined with a wish to disguise both states if at all possible, or to find a simple physical reason at their base. In our therapeutic society, we may equally feel that a trip to GP or mind doctor will provide us with a pill that cures.
This made me want to know whether we had entered a century where sadness and madness, let alone attendant badness, had really grown to terrifying proportions. Or whether we had begun to count things we hadn't counted before and certainly not in the same way. In other words, had what we now term a mental disorder come to encompass something more than, or different from, what it had while I was growing up in what now seems like a distant last century, let alone in the century before? Since the business of history, like novel-writing, makes one distrust present certainties. I also wanted to know whether this incessant growth in illness might be linked to the unstoppable growth in potential cures. There is nothing like the discovery of a much publicised set of pills to invoke a mirroring illness. To put this another way, the shape of our unhappiness or discontent can, proteus-like, be morphed to fit the prevalent diagnoses.
Sometimes the pills, like other cures, work. At other times, they can make things worse – no matter what the scientific imprimatur they wear.
There is a battle being waged in the area of mental health. As more and more of our unhappiness is medicalised, as diagnoses are increasingly attached to conditions or aspects of behaviour and the number of sufferers grows, people want more service - either more pills or more therapy, even of the kind that comes as a computer program. They want doctors to cope with their wild, inattentive (ADHD), suicidal or self-starving children. They want some kind of control or overseeing of those who may be 'perverted', dangerous to others or themselves when in the midst of a frenzy which is also an inner anguish. Or they want help to see them through what they can't get through alone.
At the same time, there's a rising disenchantment with our mind doctors, from within their own ranks, too. The medical imperialising of all parts of our mental, emotional and psychic lives, the pills that promised to make us 'better than well', may now, it seems, have overreached. To assume that sadness, even in its malignant form, is caused by a chemical imbalance may not be an altogether useful hypothesis or a particularly true one. I feel sad when my dog dies. That causes a change in my brain. The emotion isn’t caused by the brain. Everything animate beings do or feel from watching a football match, to kissing, to eating – causes complicated chemical change. But no amount of serotonin will bring Mr Darcy to the door, make England win the World Cup, bring peace to warring neighbours or end global warming. Nor – any more than God –may the latest much publicised cure-all: cognitive behaviour therapy.
There are many aspects of our lives which have ended up within the terrain of the mind doctors when they might more aptly belong in a social or political sphere either of action or of interpretation.
Exploring the history of madness and mind-doctoring brings all this into focus. Putting historical periods, old diagnoses and symptoms side by side might, some would imagine, give us a bright sense of the rise and rise of science and of our present medical and pharmaceutical miracles. We certainly know far more about our neural and biochemical make-up than Pinel, the founder of 'alienism', or Freud dreamt of. We have more efficient drugs and more elaborate hypotheses. But where we have what may arguably be more sophisticated, certainly more ordered diagnoses, disorders proliferate and also grow in complexity. Therapeutic ideals have so penetrated our Western world that there is sometimes a sense that the 'psy' professions can fix everything. What much of the ensuing history puts into relief is that cures are rarely absolute or forever.
In one of his pithy, throw-away remarks, the philosopher Ian Hacking noted, “In every generation there are quite firm rules on how to behave when you are crazy.” Anthropologists have long charted the different expressions of madness and the forms cure may take in unfamiliar cultures. Nor are modern cultures, however globalised, altogether homogeneous where disorder is in question. A BBC program about Japan, where the population is ageing, recently explored a prevalent and debilitating form of ‘stress’ characterised by medics as ‘retired husband syndrome’, an illness that could turn a wife's repressed worry about a salarymanhusband's imminent return to the home, where habits of obedience and servitude would have to be reinforced, into a round of skin rashes, ulcers, asthma and high blood pressure.
As I was amassing material for this book, I realised that symptoms and diagnoses in any given period played into one another in the kind of collaborative work that all doctoring inevitably entails. Often enough, extreme expressions of the culture’s malaise, symptoms and disorders mirrored the time's order – its worries, limits, border problems, fears. Anorexia is usually an illness of plenty, not of famine, as depression is one of times of peace and prosperity, not of war. It is perhaps no surprise that an age in which the sum of information available in any given minute is larger than it has ever been in history should find a condition in which attention is at a deficit. This is not a simple matter of mind doctors spotting, shaping, naming - in a word, 'diagnosing' – or even suggesting an illness, though all that happens too. People, and it is people who become patients, are not utterly passive. We are talking here of mental or psychic illness, and, mad or sane, patients are as susceptible to knowledge as doctors and often know how to hide from or use it.
As historians of medicine have increasingly argued, illness is the product of a subtle interplay between cultural perspectives and what is also a shifting biological reality. This is particularly the case with mental illness. In the 1820s and 1830s, George Man Burrows was as certain that he had proof of the links between the uterine system and the disordered brain as some doctors and drug companies are today that what is known in the psychiatric manuals as 'Female Sexual Dysfunction' is a question of specific hormones. There was a sense during the last years of the twentieth century that certainty had been arrived at and that the causes of mental illness had been located in brain chemistry, or so the pharmaceutical companies had led us to believe. The new century has brought altered perceptions about biology itself.
If symptoms or disorders can sometimes have aspects of a collaborative production between patients and doctors, this does not make the torment, the anguish of a mind gone awry, any the less real. And intervention by mind doctors can make illness better, though the kind of intervention - care or pill or talk or time away from the family – may not always be instrumental in the process as is sometimes thought. I was surprised to discover that - in so far as people might be counting the same thing - the percentage of cures through care or time does not seem to have changed all that much over the two hundred or so years that this book's story charts. But our managing of the most extreme forms of mania or delirium has.
I decided to focus on women as a way into this history of symptoms, diagnoses and mind-doctoring for various reasons. Perhaps the first is simply that there are so many riveting cases of women, and through them a large part of what we recognise as the psy professions was constructed. With John Forrester, I had explored some of this terrain in Freud's Women.
There is more. Contemporary statistics always emphasise women's greater propensity to suffer from the 'sadness' end of madness. Go to any hundred websites and this will be reiterated, and perhaps not only because women buy more self-improving drugs.
These figures may be true enough. Certainly if they aren't 'true', the cultural illusion prevails. A magazine like Psychologies, which looks at the softer side of psychic order and disturbance, always carries a woman's face on its cover, as if psychology, that whole business of understanding the (troubled) mind and relations, were uniquely a feminine undertaking, whatever the gender of the doctors. Hardly surprising to find that two out of three clients for the talking cures offered by Cambridge University's Staff Counselling Service are women.
The study of women, madness and mind doctors has its own history, and one which has gone through several shifts since Simone de Beauvoir first explored the terrain in The Second Sex. What came clear in that major study was that a particular period's definitions of appropriate femininity or masculinity were closely linked to definitions of madness. Not conforming to a norm risks the label of deviance or madness, and is sometimes attended by confinement. For Friedan, Millett, Greer, the great feminists of the second wave, mind doctors constituted the enemy, agents of patriarchy who trapped women in a psychology they attributed to her, stupefied her with pills or therapy, and confined her either to the 'madhouse’ or the restricted life of conventional roles. The promise was held out that women's rise in the professions would change all this.
Historians of the 1980s and 90s showed us that not only were there hidden prejudices in the way in which women were conceived of and treated, but that easy notions of historical progress and objectivity were themselves to be interrogated. It became clear that disease as much as gender and biology were hardly fixed universals, free of their time's, or our, ways of seeing. The history of psychiatry was not just the history of a great march down the Boulevard of Science towards immutable scientific laws and better drugs for everything. Today, we might want to question whether brain scans and neuro-chemistry, whatever else they may teach us, really do hold the keys to ultimate knowledge of the mind and its disorders.
“Contemporary statistics always emphasise women's greater propensity to suffer from the 'sadness' end of madness”
People have asked me why, after writing fiction, I have chosen to immerse myself in the history of a science and practice which has so many of its own writing professionals. Have I been a practitioner? Am I a patient?
I could answer that, as a writer, I simply have a faith in the outsider's view and have always had a fascination for the vagaries of the human mind. Or, since there are many ways of tracing one's trajectory, I could say that an interest in madness was also a form of survival. My early family life - which I evoked in Losing the Dead – amongst people chased by the Holocaust to peaceful Canadian shores had its own strangeness, one that was hardly reflected in television sitcoms. Retrospectively, it makes sense that I wrote an MA thesis on Edgar Allan Poe and his hauntings by the dead and undead; and that I worked part-time for a psychoanalytic publishing house in New York, turning what was often expert babble into prose.
My doctorate, though in literature, already contains some of the strands of this book: how femininity was constructed and understood by the great writers of the turn of the nineteenth century, in particular, Henry James, brother of Alice, who features in these pages; Proust, still the greatest literary psychologist, and Robert Musil, a near-neighbour of Freud's, who also came into that modernist literary picture with its everyday psychopathologies.
Freud's Women is, of course, part of this trajectory, as are several of my novels, from Memory and Desire to Sanctuary and Paris Requiem, where mind doctors somehow seem to intervene to strut their stuff. Finally, my mother's Alzheimer's vividly reminded me both how fragile and how extraordinary the human mind is. It sent me on a journey into the harder side of the brain sciences. I spent two years shadowing the world of the Brain and Behaviour Lab of the Open University. Here, neuroscientist Steven Rose led research into memory. I was forced, through what sometimes felt like supervisions, alongside reading and conferences, to confront a biochemical approach to brain and mind. All this is partly reconfigured in my novel The Memory Man. Of course, it also prepared me for the work in these pages.
In a way, Mad, Bad and Sad is a book I have been writing all my life.
Grief monument, Rock Creek Cemetery, Washington DC. Flickr.com/people/martinpro.
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Lisa Appignanesi OBE is a prize-winning writer, novelist, cultural commentator, and Chair of the Royal Society of Literature. She is the author of the non-fiction books Trials of Passion; Mad, Bad and Sad; and Freud’s Women (with John Forrester), an acclaimed family memoir, Losing the Dead, and nine novels, including The Memory Man and Paris Requiem. In September 2018, Fourth Estate will publish her latest work of non-fiction, Everyday Madness: On Grief, Anger, Loss and Love. She is a visiting Professor in Literature and Medical Humanities at King’s College London and was made a Chevalier de l’Ordre des Arts et des Lettres in recognition of her contribution to literature. She is a former President of English PEN and former Chair of the Trustees of the Freud Museum in London. Appignanesi was awarded an OBE for services to literature in 2013.
Photo: Martin Prochnik, © 2009