Women, interrupted
Authors: Gwen Adshead
Journal: BMJ (2008)

Some people seem unfairly talented, and Professor Appignanesi is one of them. She is both a historian of ideas and novelist and, together with John Forrester, previously wrote a book entitled Freud’s Women, about the important female figures in the history of psychoanalysis. Here she returns to the themes of psychiatry, history, and gender, but in a broader context and with a bolder aim: to examine how and why women seem to have been the focus of so much psychiatric attention over the past 200 years and why this is still the case in the present day.

This hugely readable book provides an overview of the historical development of ideas in psychiatry, without superficiality or glib generalisations. The contents include not only remarkable case histories but also discussion of different topics that have generated psychiatric debate in the past, such as sleep, sex, mother-child relationships, and child abuse as a cause of disorder. Many of the case histories are forensic in nature, which made me realise afresh how the history of psychiatry is closely tied to the philosophy and psychology of rule breaking in general, especially in the context of bizarre and violent crime that demands an explanation.

Like all good books this one made me think and want to ask more and related questions. Firstly, it still seems very difficult for any type of psychiatric discourse to take male distress seriously: femininity and associated mental problems as alienism have clearly preoccupied psychiatry since its inception, but masculinity and its attendant problems (violence and addiction to name but two) seem to slither away from the medical gaze and retain a dreadful normality.

Secondly, I was struck by how many of the women in the case histories had been exposed to sudden bereavement and losses of important figures, either in childhood or adulthood. The power of grief to disorganise the mind and give rise to pretty much every psychiatric symptom known to classification seems hardly to have been acknowledged by the mind doctors of each time period who dealt with these women. Yet the 19th century had Robert Burton’s classic account of melancholy; the 20th had access to the research of John Bowlby and Colin Murray Parkes; and the 21st has Allan Schore’s work, setting out exactly how grief, and the loss of attachments, drives people mad. This work may be especially relevant to the question of why women are over-represented in psychiatric populations. If women’s autonomy is in some part relational, not indexical—that is, some aspects of their identity are located in external relationships and roles—then (to paraphrase Donne) any person’s death diminishes and disorganises some woman’s identity.

Lastly, I found myself maddened by the persistent tendency of any psychiatric discourse to embrace reductionist and essentialist theories of how humans work. Time and again psychiatrists claim to have the found “the” cause of mental distress (especially in women), and this “cause” lies in the uterus, the teeth, the colon, the diet, the unconscious wish to sleep with your father, the conscious wish to be educated or have the vote. All of these at one time or another have been seen as the sole explanation for female psychological distress and the basis for often quite inhuman interventions called “treatment.”

The human mind is arguably the most extraordinary, unusual, and glorious manifestation of organic life on this planet, and yet we still take ordinary mental functioning for granted. Like spoilt children we do not realise what an extraordinary thing mental health is. Equally, we still do not treat mental illness as being a disorder of the most complex biological system: a system that manages to integrate internally and externally generated experience into a consistent whole that is unique to each person. The scale of the complexity is staggering—as is the scale of the disaster when things go wrong. Yet psychiatrists seem to be drawn to simplistic accounts of experience like extremely dim moths to an artificial light.

Appignanesi says something very important at the start of the book. She says that as a historian she is sceptical of present certainties. This seemed to me to be an important message for scientific researchers and therapeutic practitioners in the field of mental distress. It is not likely that there will be one solution to human distress, any more than there is one source of human creativity and joy. Therefore dichotomies such as nature or nurture and genes or environment are not only silly, they are as mad as the pathology they seek to explain. Equally, there is unlikely to be one treatment that suits all, as we will no doubt discover when the money for the “cognitive behaviour therapy for everyone” programme runs out. Taking uncertainty and complexity seriously is something that the human mind is good at; it is only psychiatry that seems sometimes to have been a little reluctant to be this human.

Psychiatrists seem to be drawn to simplistic accounts of experience like extremely dim moths to an artificial light