July 2008

Jason B. Jones


An Interview with Lisa Appignanesi

How crazy are we? Can it really be the case that over half of Americans are mentally ill? Lisa Appignanesi's new book, Mad, Bad, and Sad: Women and the Mind Doctors, speaks to this question by turning to the historical record, showing how women and their doctors have collaborated -- sometimes willingly, other times not; sometimes to good effect, other times disastrously -- to alleviate mental and emotional anguish.

Tracing the stories of the famous -- Marilyn Monroe! Zelda Fitzgerald! Virginia Woolf! -- the infamous -- the pharmaceutical industry's shaping of modern American psychological research! -- and many others, Appignanesi reminds us of the ways that "the shape of our unhappiness or discontent can... be morphed to fit the prevalent diagnoses," and that, advertising budgets to the contrary, "the percentage of cures through care or simply the passage of time does not seem to have changed all that much over the two hundred years" of her story. Instead, she laments, we have allowed aspects of our lives to become "colonized" by the mind doctors, "when they might more aptly belong in a social or political sphere either of action or of interpretation."

In the interview below, Appignanesi explains her interest in these questions, why talk therapy should be more appreciated, how women's bodies affect their minds, what the effect of women mental health professionals has been, and many other topics.

Appignanesi is a writer, translator, and novelist, the author of such novels as The Memory Man and Sanctuary, an acclaimed memoir (Losing the Dead), as well as studies of Simone de Beauvoir and of the cabaret. With John Forrester, she co-authored the classic study, Freud's Women. Appignanesi currently is the president of English PEN, as well as the chair of the trustees of the Freud Museum in London. She spoke with me by telephone in May.


What prompted you to revisit the question of women, mind doctors, and mental health?

It's always hard to remember the initial impulse for these things, but as you know it's material I've been looking at for a long time. I think that the immediate prompt was simply all those extraordinary statistics that we've seen over these last years -- things like half of all Americans may meet DSM-IV criteria for mental disorder; one in five women develop clinical depression; the WHO report predicting that by 2010 depression will become the single largest public health problem after heart disease. These huge statistics having to do with mental illness made me wonder whether we'd all gone mad, or whether we were counting things we hadn't counted before and starting to see all that terrain differently.

And, actually, over the past year, or maybe eighteen months, there seems to have developed a little cottage industry of books examining those statistics and the very cozy alliance between DSM-IV criteria and the pharmaceutical companies...

Well that's right. One of the other staggering things that I discovered while doing this research is that in 1800 or 1810, the head of Bedlam, the first great public mental health asylum in Britain had sixteen causes of mental illness, or thereabouts, and they were very general things, like misfortunes, troubles, grief, love, jealousy, pride, drink, intoxication, and -- I love this one, religion and Methodism. They were genuine causes. And now we have over 950 pages of very specific diagnoses, which seem to handle every aspect of lived experience, and a lot of them seem to have pharmaceuticals attributed to their potential cure. That's rather staggering, because one of the other things that my research made clear was that cure is a very loose concept. There are treatments, and treatments work and sometimes don't work, and they don't work necessarily forever, and there will always be remedies, but none of them are absolute, and nowadays we treat them, because of the injunction of the pharmaceutical companies, as if they were going to be forever, and would always work. In fact, various studies have shown that in any kind of relief from acute mental distress, a placebo effect comes in as strongly as most medications. And talk helps, listening helps, and of course time helps. But nothing helps in a necessary and absolute rolled-out kind of way.

You argue early in the book that symptoms and treatments both arise from cultural forces, and sometimes the treatment precedes the diagnosis, sometimes it’s the other way around -- I wonder if this is related to the psychoanalytic point about the protean nature of hysteria?

I wouldn't necessarily call everything hysteria...

No, of course not...

I'm careful to be historical about this, and it doesn't always help to just roll out one set of understandings. But, again, it became quite clear for me that there are rather strict rules about how to behave when you're crazy in any given epoch, as Ian Hacking has so pithily put it. There are ways in which the cultural understanding of mind and body at any given time plays into the nature of diagnoses, along with historical and sociocultural forces. The way in which we express our discomforts, dissatisfactions, excesses, madnesses is through those particular understandings. So symptoms will feed into diagnoses, diagnoses will feed back on symptoms. Institutional forms, media, and everything else all comes into play, and you end up having a model, or "most-expressed" disease for any given period. So, for example, towards the late part of the nineteenth century, many explanations had to do with nerves, and you had a disease called neurasthenia, which actually covers a great gamut of problems and disorders. Following on that you have hysteria, that very interesting set of ways of behaving which actually shows women suffering from anesthesia -- they can't feel their skin -- and various forms of paralyses and mutisms. In a way, all of these reflect the kinds of things that are wanted of women in that period, and also the kinds of prompts fed to them as they live their condition. And so once a particular kind of liberty for women comes into play, hysteria begins to alter, to change into other things. Today we have one of the dominant ways for women to express discomfort with who they are is to develop a body illness such as anorexia or bulimia. Many things come into play, but one of them is that we live in an increasingly virtual age, where the body itself is problematic. Body disorders are one way of expressing our misery. So, yes, there's a cultural expression to symptoms and indeed diagnoses.

Inasmuch as symptoms feed into diagnoses and diagnoses feed into symptoms, it almost seems as if, given the medicalization of mental health, you would expect a huge proliferation of syndromes, and this alleged explosion of mental health disorders in the population.

I think that's right. We sometimes find what we look for, and as the mind-doctoring professions have really colonized our mental and emotional life, we have more and more things that are disordered, that are seen through those spectacles. We find more and more depression, where at one time we would have found unhappiness, or poverty, or any of a multitude of emotional and social problems. But we look to the mind doctors for their cures. At the moment, at any case, mind doctors would rather be released from being the omnipotent source of remedy because of course they can't cope with all these things. They'd like to help in many cases, but often they just really don't know how. So they, too, are caught in a kind of bind over this. Various studies have shown that if you go walking in a group that can alleviate depression. Well, of course! Because we're sad, and we're lonely, and that doesn't have to be diagnosed as something that can be cured by pills. It can be seen in many other ways.

One of the interesting things for me about this research has been to really clarify that, because of seeing the ways these patterns emerge over time -- seeing these things that haven't been illnesses before becoming illnesses. The easy one, of course, is ADHD (Attention Deficit Hyperactivity Disorder), where more and more children are being diagnosed with an inability to pay attention. Well, it's very hard to pay attention when the kinds of quick cuts you have on your television and films, or in computer games are such that you're not asked to pay attention in a particular way. It is quite possible that we develop emotional and neurological ways of coping with this which to an older generation will look like a disorder! But in fact it's a much wider social imperative than it is simply an individual's problem.

Christopher Lane makes a related point about so-called "Social Anxiety Disorder" in his recent book Shyness [see my Bookslut interview with Lane].

Yes, that does sound similar -- and in fact there are many such examples. For instance, in Japan, more and more retiring men come home and their wives don't know how to deal with a retired man, and develop all sorts of anxiety disorders to cope with the new situation. Again, one wouldn't always want to put that in the domain of mind doctors, but that's where it's gone.

One of the distinctions you make as you review the history of mind-doctoring is that between therapeutic optimism and therapeutic pessimism. Can you explain that briefly?

I think that therapeutic optimism is not a bad thing in the original history of mental illness. In the early 1800s, when moral management came in, it's quite clear that an understanding of madness as partial, and as something that would come and go, was a boon and meant that people were far better treated than they had been before. It's much better to go into an institution where you have some sort of occupations and your life is regularized and you are paid attention to. It's much better to do that than to be put in chains or in the attic. So it's a good thing to have therapeutic optimism. And optimism helps patients, helps sufferers.

I think where I develop an intellectual pessimism is when I say that there aren't any magic cures, or quick cures, or evidence-based cures (as we like to call them now), which will solve everything -- because they won't, and it just makes them sicker.

I've been thinking about this a lot: One of the consequences of medicalizing mental health is that it kind of stigmatizes you. Once you have a diagnosis, it is, from a certain point of view, who you are. (For example, "you are someone with ADHD.")

Well, that's right, but I think this goes two ways as well. I don't like attributing blame; I try to stay very poised and balanced in looking at this history. I think also that people want diagnoses, patients want diagnoses. Because if you're told you have something, that takes a lot of the burden off having these terrible feelings that produce these extremes of pain, mental suffering, and so on. So you do want a kind of classification. I think patients want it.

The negative side of that is simply that then you may have the stigma of having been given this diagnosis. I mean, to have been called a schizophrenic, or a manic depressive, has a certain stigma in terms of one's social life still attached to it, even though it's been rolled out so far that so many of us are now sufferers! So there are both sides: One may be relieved, and certainly families may be relieved, to know that you have something that is tangible and real in the world, and is recognized in the world. At the same time, it's a two-way thing -- you also don't want this, because it means that you have something in perpetuity, or at least it sounds like you have something in perpetuity. But people do develop conditions. I guess one of the ways of looking at this, if we could be more casual about it, is to say that particular kinds of propensities -- not at the extremes -- may be more like chronic diabetes than anything we should have a stigma attached to, or that you would have to live your life totally as someone who is depressive or manic-depressive. One doesn't want to totalize all of life.

Lacan says somewhere that, at least in terms of clinical work, being absolutely right theoretically is way less important than you might think, and, likewise, when I was reading your book, I sometimes got the impression that, in terms of treating mental illness, the exact theory mattered less than being decent to the ill person. Is that right?

I would probably say that's largely right. I don't want to say absolutely right, because there are some things that one would want to be righter than wronger. But in terms of any elaborate theory from the psychoanalytic mind-doctoring people, I certainly suspect that attentiveness to people's ills, and the ability to hold them (in a Winnicottian sense), to provide a regularity of a kind of help, is probably as useful as any theory that comes into play. I don't think the theory, as long as one is alert to the individuality of the patient, is as important. It's the alertness and the attentiveness rather than the prescriptive nature of that kind of theorizing.

One of the things that's amiss here in Britain -- I don't know how it is in America at the moment -- one of the things that we've done here is to roll out cognitive-behavioral therapy as a cure-all for everything. And of course it's not. It's merely a form of self-control over the mind. It obviously helps adolescents to order their lives in some ways, but may not help much more than that, and to think of it as a cure-all is not going to help many people. It may make an intervention in the first instance but it won't work over the longer term. And CBT has a very technically prescriptive method to it, and I'm not sure that's terribly helpful.

As for other kinds of theorizing, well, the history shows, certainly in terms of the patient's experience, that the attentiveness of the doctor, the attention the doctor pays to the patient, the openness to the wide gamut of feelings that a patient may have, rather than saying "No, that's a bad feeling," as sometimes happens with CBT, is far more important than anything else.

One of the things you suggest in the second half of the book is that while theory might not matter, gender might -- that an important change has been the rise of women mind doctors.

Yes. That's one of the things that I wanted to explore, and it's one of the reasons that I looked at women, because there had been a great hope held out, certainly in the 1980s and in the women's movement, that this terrible classification and confinement of women into the domain of mental illness, or madness as I prefer to call it, had actually worked against them in many ways, and with women entering the profession, this would change.

Well, there have been certain changes. We have much more relational forms of psychotherapy going on, and those kinds of alertness to women's experience. Perhaps not more than Freud himself had, but a different degree of it. But the overall classification of women into disorders hasn't changed. And certainly women don't seem to become less ill than they used to. So that hope hasn't paid out. In fact, in some ways, and the book tries to explore this, it seems that certain kinds of diagnoses have taken over rather more, and many of these have to do with bodies and therefore women's bodies. We end up with a run of anorexias and bulimias, at one point MPD [multiple-personality disorder] and so on. And so there's a sense in which women have been co-opted into putting women into the confinement of mental disorder classifications, and the hopes haven’t altogether been borne out.

My 5-yr-old enjoys your title a great deal -- small rhyming words -- and so we spent some time playing games with it, and I ended up wondering what role glad women -- that is, women experiencing pleasure, broadly conceived -- play in this story.

I think that's another book, about the glad women! One of the things that's clear, about the glad side, is that the late 19th- and early 20th-century focus on sex and desire has been a double-edged notion. One would like the gladness to come out of sexuality to some extent, and certainly that was one of Freud's projects, and certainly there has been a great liberation on that side. I think one of the things that has happened, though, is that the gladness has become almost an imperative in itself, a kind of superego injunction, and so one is told to be happy. Certainly in America, and indeed the West, the pursuit of happiness carries its own burden of guilt when you're not happy, or experiencing dissatisfaction, because you haven't attained the ideal of happiness. So it has played back on itself, and the pursuit of gladness drives people mad as well.

Please tell your son that for me...

I will do...

But maybe not quite yet!

You alluded to this earlier, but one of the most interesting aspects of your book is its tone. We've seen a lot of histories of the mental health profession, especially gender, that are polemical and angry, and your book is absolutely not.

Well, I was trying in part to re-investigate the terrain. It's been twenty years or so since Elaine Showalter's The Female Malady, which is one of the pivotal ones in English mental health history, and it seems to me that there is a lot of ground to be angry with historical wrongs and to want to right them. But it seemed to me that as I looked at the mind doctors themselves, and some of the women they dealt with, that they hadn't necessarily in all cases set out to do ill. They hadn't set out to confine women. Women do suffer mental problems and emotional problems, and in many cases the doctors had done the best that they could do. And so I'm not interested in attributing blame -- though I do think, and I point this out, that some of the mind doctors were completely scandalous, going out on their own, riding their hobbyhorses into mis-diagnosis. The whole surgical intervention into women's private parts, which was theorized would alleviate stress in fact confined women even more into their designated roles -- I don't think that's a good! I wouldn't want to be mad in that way!

But I do think, on the other hand, that there have been many doctors in the history of the profession who have actually tried, as well as they could, within the circumscription of the time, to do what they could. And, you know, neither do I hold that women are wholly innocent and wonderful at all times, nor that they will always do their best at all times or will always and ever be victims. I don't think of women as victims. They quite often play an active part in the search for a classification, the search for the secondary benefits of illness.

It's quite clear that there are secondary benefits to illness. It's quite clear with a lot of so-called sufferers of neurasthenia, or indeed hysteria, that this could be a way of managing difficult lives.

Right -- you had the example of Elizabeth Barrett Browning...

Elizabeth Barrett Browning, Alice James -- one could go on. I don't like to think of women solely as victims; I don't think they were or are, and I am one. Women are also active partners in these processes. The social conditions of course come into play, and it's quite clear that in the heyday of the Victorian period, the range of possible behaviors for women was so narrow that it was far better to develop the secondary benefits sometimes than to play into the demanded roles.

On the other hand, today there are equally secondary benefits to illness and to thinking of oneself as a victim, and those benefits also play their part in this whole problematic.

I wonder if you -- and given your topic this is a slightly strange question, perhaps, but -- had favorite stories that struck you, either about the women or about their doctors, during your research?

Gosh, I like all of the stories -- it's one of the reasons I like looking at patients and their cases in great detail. I look at a lot of iconic cases because they write so well from the midst of what their condition is. They describe the extremes of emotion and thought in a very vivid way.

I guess one of my favorites is this women I've called Celia Brandon, from just around the time of the First World War -- she actually asked to be committed to the Edinburgh mental hospital. She spelled out her case in a very, very long letter, which goes through her life. And she's obviously suffering, and wants relief of some kind, but the language with which she describes her case is done with such intelligence that one can almost see through her the ways in which people are permeable to the kinds of understandings of mental illness at their time. And in her case, it was very early for Britain, she describes herself as a complete Freudian case, without ever having, as far as we know, read Freud, or indeed having been diagnosed before that as suffering from sexual problems, or a history of childhood punitive behavior by her guardians in place of her mother. And so that's an extraordinary story, one that detailed her own trajectory from China in the colonial period back to Britain.

I think other cases are very interesting, too. I think Marilyn Monroe is very interesting because she becomes not only a celebrity but she's iconic for the travails and the mental and emotional stresses that celebrities have been prone to in our time. I mean, Britney Spears is not a million miles away from Marilyn Monroe. We see this extreme way of leading a life played out quite a lot at the moment, and that's very interesting to me.

God, there are so many -- Mary Lamb, the case that starts my book. She is herself a writer and she ran a sort of salon for the romantic movement, but who also happened to have murdered her mother in a manic fit, after great ordeals of poverty and being the sole breadwinner for the family and having to earn her keep by sewing shawls and so on. It's another extraordinary case, partly because over the course of a very long life she and her brother managed her mental distress, and it's a very good example, if you like, of the symbiosis of managing mental distress within the family but also a kind of prototype of way the kind of care that you receive means that when you do suffer you can live a very full and productive life. Virginia Woolf is another of that kind.

I had wanted to ask about the Mary Lamb story because it seemed quite provocative to open with a matricide and an infanticide.

Yes, well, there are bad women here. The infanticide really sets up the legal discussion throughout the book. There are laws that come into play governing leniency, and what we do about people who are mad, that is, deranged, and who perform harmful acts, whether to self or to others. And starting with the matricide was interesting because in a sense, Mary Lamb, in her own stories, tries to look for a genesis of the way she has behaved, of what brought her to this peak of destructive behavior, and finds it, very interestingly, in her childhood, in the way her mother treated her. Not that the way her mother treated her was a direct cause for that, but it certainly plays into her understanding of how she got there.

It is provocative, but then people do bad things.

Right, but since women are so profoundly identified with motherhood and childcare -- it just seemed that, by starting with these two, everything was going to be on the table.

Yes. But one of the things I learned, or I think I learned -- I may change my mind again -- is that it seems to me that during the heyday of the women's movement, we really didn't want to think about the ways in which the biological life cycle of women played into their mental distress. I think it's quite clear, and that almost all doctors have described, that there are moments in a woman's life when she may be more susceptible to certain forms of disorder, which don’t need to last for the entirety of a life, or which don’t need to be stigmatized in any way, but which can actually provoke extreme states. One of these is obviously childbirth, and another one is menopause.

I don't think anyone who's been around someone with even mild post-partum depression could deny the influence of the body on these questions.

Yes. There's definitely a susceptibility brought about by hormonal change. And we see this in adolescence, too. Adolescents, without being mad, lead very extreme lives, and that is partly to do with this moment of change in the body.

It's like a five-year scheduled madness or something.

Absolutely. And if I have anything left to say at all, after all this interesting history, it's that we have to draw our understanding of the inner life quite broadly, and much more broadly than we're prone to at the moment, without necessarily classifying or stigmatizing in terms of disorder. Our idea of what the norm is has grown far too narrow, somehow. It cuts away a lot of the richness of life, and it does confine people, especially women, into the straitjacket of diagnosis. And there is a stigma attached to certain diagnoses.

I wonder if that's why you stick up a bit for the varieties of talking cure, whether it's analysis or therapy, because they might be more flexible about what normal is?

Absolutely. I do think that the talk therapies are the least harmful, partially because they're also listening therapies. One would like to put the accent on listening, because it's an important process. And because they do deal case-by-case, they try to think of patients as individuals, and there's no radical intervention, which could actually make people far worse, rather than better. And, so, yes, I do have time for the talk therapies, especially the psychoanalytically-oriented talking therapies, because they don’t try to force people into a norm. Although they too have -- as in the heyday of American psychoanalysis -- moments when the norms are too narrowly drawn, or can be narrowly drawn. Potentially, though, it is the best one that we have. And certainly, I think the medicalizing psychiatrists here would say that any form of drug treatment needs to go hand in hand with a talking therapy if there's going to be any kind of longer term good result.

Shifting gears a bit, currently you are chair of the trustees of the Freud Museum in London, and I wonder if you could comment at all about the status of Freud today as a source of public interest?

I think there's still certainly -- and I think this is still the case in America, as well; it's clear when I go there -- that Freud has been a very influential figure, and he's been influential in a lot of ways. But one of them is simply that he's given us a narrative of the self, which shows a developmental process, which gives meaning to many aspects of life, and which makes us interesting to ourselves. There's a way in which it's very hard to break out of the Freudian narrative. That's not altogether a bad thing, because it's a very interesting narrative of the self, and the way the self moves from childhood through time and contains that childhood as a moment that can be revisited, either as the source of things or just to look at the person you might be. Freud in that sense remains an important figure. The fact that people come to the Freud Museum points to that -- and not only because there are a lot of great jokes and cartoons about Freud and he's omnipresent in popular culture. He's still fertile soil for artists and writers, and indeed for all of us as we live through our lives. Every time I read him I think, "Gosh, what a wonderful writer!" He's still very, very good, like Proust is still very, very good.

That actually leads directly to my last question, which is whether you have a favorite Freud text?

Oh, dear -- there are so many! I rather like The Psychopathology of Everyday Life. I think because it is about the everydayness, it's about urban living, it's about the kind of accidents and forgetfulnesses and surprises we live with, and the kinds of meanings that are always there for us to grapple with. There are lots of short things, too -- I still like very much "Gradiva." I think it's a wonderful piece of literary analysis which plays into Freud's idea of the cure through love.