An Interview with Lisa Appignanesi, author of Mad, Bad and Sad Women and the Mind Doctors
by Brenda Webster

Brenda Webster: Lisa, your book, Mad, Bad and Sad: Women and the Mind Doctors, is wonderfully thorough and rich, spanning two centuries of the history of women’s treatment by mostly, at least at the beginning, male mind doctors. Right from the start we sense it is going to be unusual. Instead of starting with Bedlam and women in chains, you start with an example of the unexpectedly humane treatment of Mary Lamb, the 18th century writer who stabbed her mother with a carving knife and then went on to live a relatively full life in the care of her brother.

Gender seemed not to have been, at least in her case, an issue. Later on you describe ways in which mind-doctors have colonized our ways of thinking about behaviour and the inner life, the ways in which diagnoses which not only spread through western society but particularly today have enmeshed sufferers in a life-long condition which is one of illness. Do you think that in some ways the idea that a person can be only intermittently mad is helpful and allows more potential for improvement?

Lisa Appigananesi: I set out to chart the way in which the mind-doctoring professions – from the early moral managers and alienists through to the neurologists, psychiatrists, psychoanalysts, psychotherapists, psychopharmacologists – grew into positions of power. I was interested in the ideas, which underpinned their changing understanding of the human mind and emotions, particularly in its states of what we could call excess. I was interested in placing that side by side with patients, particularly women’s experience, to see how life, madness, and doctoring meshed, or didn’t. I also wanted to see how it was that in our own period, now with the help of the drug companies and the brain imagers, the mind doctors have come to dominate and provide the principal narratives and pictures through which we understand the self. These have of course changed over the course of two centuries. Today we’ve arrived at a point where sanity has become an increasingly narrow place, while a huge range of human feelings and behaviour have found their way into the capacious pages of the DSM, (Diagnostic and Statistical Manual of Mental Disorders) so that more and more of what we experience has taken on the classification of illness. Illness demands cure, which is as we know hard to find, particularly where so many of our more extreme ups and downs are concerned, though Big Pharma is keen to convince us that it’s out there.

But to go back to your question about intermittent madness. It was only when doctors such as Pinel and Esquirol and their parallels in Great Britain at the beginning of the 19th century began to think in terms of partial madness, that a notion of therapy was born. You can’t escape either hereditary or god-given madness, or ‘evil’ which was largely how madness was understood earlier (of course, heredity in a more complicated and less totalizing way continued and still continues to be part of the picture). You can’t escape an understanding that dooms. Mind-doctoring, and this is where it becomes science rather than salvation, comes into being with an idea of madness as a shifting and shiftable condition, one with which the doctors can help. And they do want to help, though they may often have strange notions about how this help can come about – anything from uterine surgery to still mania or what was called neurasthenia, to chemical or talking interventions. Since we’re talking about illnesses of the mind, and the mind is also in many cases open to suggestion and individuals always benefit from that important quality of attentiveness, many cures we now think are mad, also sometimes worked.

In the case of Mary Lamb after she had stabbed her mother in a moment of manic frenzy – a mania brought on by penury, overwork, lovelessness, and horrendous family conditions – she managed to live a good enough life, though one, which continued to be interrupted by periods spent in some kind of madhouse. The perpetual care of her brother, the writer Charles Lamb, certainly helped her through. Like Virginia Woolf’s husband, Leonard, Charles was good at spotting when her "madness" was coming on and would trot her off somewhere where she could be distant from society and stimulation. I use her case to illustrate a time before the professionalization of mind-doctoring.

BW: As a writer, I was fascinated by your vivid portraits of such famous patients as Zelda Fitzgerald, Sylvia Plath, and Marilyn Monroe. Was the special sensitivity of the artist part of their problem? Or was it a gender issue--the conflict between women’s roles and their ambitions?

LA: Needless to say, each of these woman was different and had her own very particular trajectory. Certainly their sensitivity was an issue: whether that was directly linked to their talents is difficult to say. Many who suffer in the way they did are not writers or artists, and vice versa, of course. I would be the last person to say that artists have a propensity to madness, though it’s clear that writing or art can have a therapeutic value; as can any form of valued activity.

For a long time there was an intrinsic conflict between what was expected and socially permissible for women, and their youthful dreams. Reading or study were considered to be bad for women by the Victorians, since it over-stimulated what were thought to be their smaller brains; let alone gave rise to imaginings, sometimes sexual. Zelda, it’s pretty clear, toppled into breakdown as a result of the very ways in which she tried to control her unhappiness, her lack of boundaries, and her aspirations: alcohol and a rigid, disciplinarian dance routine. Marilyn, too, in a way which has become common in our current celebrity culture, was trapped in excess, a fuddle of pills, and a sexual image which rebounded on her own sense of her sexuality. If we buy into the psychoanalytic story, and in our times it’s very difficult not to since it provides the most encompassing of available narratives, it’s also clear that Marilyn’s childhood left her with scars that were constantly re-opened in her experience of men. Both for her and Sylvia, the absent, and thus far more powerful Daddy, was never altogether available or to be found again in the men in their lives.

BW: These iconic celebrity patients had particularly caring analysts who stood in as mothers and fathers. Marilyn Monroe’s analyst even deviated from technique to make Marilyn part of his family. But this didn’t save her or Plath from suicide. And afterwards you say there was a decline in belief in miraculous cures from psychoanalysis. Do you agree with the national health services idea that lifetime support and treatment is the best way to treat such patients? Would a combination of drug therapy and talk therapy be the most effective as some American studies have suggested?

LA: A caveat: the British National Health service has only tried out one model programme for treating the so-called borderline personality disorders (which is also perhaps the classification that best suits Marilyn). This was an attempt to give people who have few life skills formed in childhood, who are seriously damaged, and are often addicts, a way back into life: a mixture of education and talking treatments, sometimes with an added drug treatment. It’s certainly a way forward. I have less and less faith in the drug therapies (and I’m not talking about psychosis here) on their own, in part because as recent statistics show, they work in the longer term on only a small proportion of people. (Though, perhaps, as with so many new treatments through history, they seem to work best when faith in them is high, when they’re new; and so they have to keep changing). The talking or listening treatments, as I sometimes think they should be renamed, really do help, but they don’t necessarily help if you’re with an analyst or therapist who doesn’t work for you. Certainly, it can rarely harm anyone – particularly, perhaps, troubled adolescents or anyone at times of crisis – need to have a better understanding of the quandaries of life and what triggers their responses to it. Then, too, having the undisturbed attention of another person who has little to do with your everyday family tangles, usually has some benefit. There are various so-called evidence based studies I cite in the book which support this. Nor should it be forgotten that Plath’s and Monroe’s suicides came after they had lived full and productive lives. Then, too, they were taking prescription drugs, in Marilyn’s case a cocktail of them, which acted negatively on them.

BW: Since early times men have considered women subject to madness associated with birth and lactation. Time away from the family--and kindness-- was often curative.
Do you find a swing back to the idea that women have special hormonal problems—in books like The Female Brain for instance-- and that present day women's problems are often connected with post-partum depressions and difficulties of child raising?

LA: There’s little question in my mind that the hormones women (and indeed men, you have only to think of testosterone-fuelled youths) produce at various times in their lives act on their minds and emotions and can have an unbalancing or intensifying impact. It might be useful to think of these as life difficulties – and all lives have difficulties. One of the problems of our epoch in the West is that we’ve been schooled to think that happiness is a right and anything which swings our ‘moods’ away from that falls into the terrain of the mind doctors. It’s the mirror image of the street drugs which abound to give us ‘highs’ or take us ‘down’. One of the reasons I continue to find Freud interesting is that he has a fundamental stoicism about life: it’s never altogether easy and problems will occur.

Having a child become real always marks a radical change. Hormones are part of that: there may also be a great many other reasons, economic, familial or in the woman’s past history, which occasion an attendant depression. There are various cases in Mad, Bad and Sad which exemplify how hormones and life before the child’s arrival produce, on birth, that concatenation of events which result in depression. With care, often of the talking and listening kind, people get through.

BW: Women do not present as hysterics any more— but you suggest that some component parts of hysteria like anorexia--which takes up one of your concluding chapters—and multiple personalities-- continue. What do you think of Elaine Showalter's idea that our age is one of mutating forms of hysteria? Would false memories of abuse be an example of this? Are women therapists who encouraged women to discover memories of abuse actually helping spread a false diagnosis? Do you think that even the more benign concentration of women therapists on women’s body image encourage "body madness?"

LA: That’s a great many questions in one and would take me through half a book to unravel. Women are not diagnosed with hysteria very much anymore (except in some parts of the world) since the diagnosis has largely disappeared, as have some of the more flamboyant symptoms evident in Charcot’s and then during Freud’s earliest practice . As my book shows there are cultural fashions in diagnosis and illness. Ian Hacking memorably said, "every age has strict rules on how to behave when you’re crazy."

These days we produce symptoms, which get selected out as, say, depression or anorexia. MPD after a huge surge in the eighties and nineties has largely vanished, recovered memory of abuse having been amply discredited as a suggestion implanted by therapists. (This does not mean that people don’t suffer sexual abuse. They simply don’t forget it in the way that was so fashionably asserted some years back. Sadly, they remember it all too well). In the loosest sense, if we think of hysteria as the most plastic of conditions, one which changes according to the needs (patients’, institutions’, doctors’, media) of the time, then yes, we live in an age of global mimicry, and are therefore all potentially hysterical.

What I call "body madness" in the book, that array of symptoms which put the body in peril –bulimia, anorexia, all the dysmorphias – are very much part of our focus on the body as the site of our most individual production – something all the various media – and virtuality, itself – alongside the fashion and diet industries compel us towards. In the book I trace how this has grown up alongside the women’s movement and its focus on woman’s body. In a sense, the body has displaced sexuality as a discourse which encapsulates our ills, our aspirations, and all our conflicts.

BW: Freud described the basis of women’s personalities as being passivity, masochism and penis envy. The feminists deplored it and some went on to re-formulate penis as power or the “phallus” -- have there been any serious theoretical advances on the subject of what constitutes femaleness? Also, do you think that the fact Freud allowed women such a large part in his movement was simply that he found them easier to deal with, particularly because most of them had a very positive transference to him whereas the men tended to rebel.

LA:I don’t really accept this formulation and it would take too much space to untangle it. Freud rarely talked of personality. He was describing the way in which women became women through a developmental process which necessitated turning away from their original love object, the mother. Like Simone de Beauvoir, he never prescribed an essentialism to them. It was Helene Deutsch who did that and she influenced American thinking. Psychically, for Freud, we are all bi-sexual. But as I say, this would take time to unravel – and that was really part of the subject of another book, Freud’s Women.

As far as rebellion goes, it was Freud who gave us the case of the arch-rebel, Dora, and he did so, I suspect, to underline the importance of counter-transference (the analyst’s projections onto the patient) and his own blindness. It’s true, as historians have documented, that in the early days of the psychoanalytic movement there were a great many squabbles over theory and terrain, but I suspect that’s true of any movement that gathers a lot of intelligent people together – think of Marxists, or a gaggle of academics, let alone politicians. And Horney apart, many of Freud’s women followers (Klein and Riviere amongst them) were hardly slow to correct his initial hypotheses on women’s (or men’s) psychosexual development. If they sometimes did so with more relational tact than the men, and Daddy Freud was kinder to them, well that’s just the way of families, as Freud, himself, described.

BW: You quote me as saying in The Last Good Freudian that Marianne Kris was a kind and empathetic analyst to my artist mother. I did say that but I have to add that I came to believe treatment that goes on for 30 years continually promising cure, is counterproductive because it keeps the patient dependent and incidentally costs vast sums of money. Do you think your national health service would pay for such a treatment now?

LA: Certainly not. At the moment we’re grateful that the National Health subsidizes any talking treatment, even of the minimal behaviorist kind that is CBT, about which many people have severe reservations because of its often limited and restricted benefit. Many would like more talking treatments on the NHS: the expense, which is always a question, some studies have shown is over the long term no more expensive than recurrent illness and use of drugs. (Then, too, many people in talking therapy don’t get ill in other costly ways)

Nor would managed care in the US subsidize life-long therapy, but I guess if an individual feels she benefits in some way from the therapeutic care and perhaps needs the dependency, and can afford it, it may be a better way of getting through life than, say, becoming an alcoholic. Cure in this scenario is, of course, that holy grail of happiness, which is always more in the pursuit than in the arrival.

Post-war America, the heyday of one particular kind of analytic moment, was particularly prone to an idealization of the analyst, who also stood in for the best of (European) civilization – the bit that hadn’t been destroyed by Hitler. I describe all this in the section of the book called

BW: Finally, you suggest that one of Freud’s greatest achievements ws destigmatizing mental illnes. What comes though at least for me when I finished your book is your humanity. You convey the feeling that there is a thin line between madness and sanity that we all cross over from time to time. We have made progress in our understanding…perhaps certain diseases like schizophrenia and manic depression can be helped by drugs but we can’t expect to control our moods completely with drugs. To expect to be made “happy” by our doctors, is simply too much.

LA: Absolutely. As I said before, happiness rarely comes from pills or treatment, except momentarily. They may help, but so do friends, work, lovers, pets, children - the ability to engage with is what Freud thought analysis was all about. My underlying suggestion in the book, having examined two hundred years of understandings, treatments and encounters with mental disorder, is that we’ve come to a point where too much of our experience – the kind which involves, pain, passion, complexity, excess, unhappiness – has been given over to the domain of illness. It would be good to take some of that back. Life just isn’t, even now, a bowl of ever replenishable cherries.