Symptoms and diagnoses are inseparable from the era in which they arise. Lisa Appignanesi sketches the changing patterns: mania was prevalent during the revolutionary period of the 19th century; at the turn of the century it was sexual neurosis and hysteria as women sought liberation; more recently multiple personality disorder reflects our fashion for re-inventing the self. Currently we have a ‘diagnostic epidemic’ for a variety of ‘attention deficits’. Anorexia is an illness of plenty. Depression accompanies times of peace and prosperity. The autistic spectrum occurs amidst information overload.
In spite of the title of this work, there is no automatic assumption of women as victim to male mind doctors. There were cruel treatments, and the author cites many celebrated examples of women as patients, but with more women entering the field of mental health as practitioners during the last century, there has been a massive expansion of the consciousness of suffering amongst women in particular with the discovery of hidden abuse.
   
More generally, illness and cure are symbiotically connected. Illness and cure need each other – ‘this incessant growth in illness might be linked to the unstoppable growth in potential cures’. Cures go in search of illnesses to cure: gone is the clear-cut notion of an objectifiable illness which will act as a cause for the production of a cure. In the field of mental health, more life problems and crises are ‘medicalised’, leading to more (pseudo-) cures, although Appignanesi does not draw the necessary conclusions here. Are we creating a sick society, increasingly unable to put up with hardship?

Appignanesi takes us from lunatics in madhouses at the end of the 18th century, where inmates could be abused, chained, beaten and their teeth knocked out, to the earliest attempt to differentiate the ‘mad’ from the ‘bad’, with the former being deemed to require help rather than punishment. Mary Lamb, who stabbed her paralysed mother, was spared the worst abuse because her confinements were carefully monitored by her brother Charles and she was surrounded by key figures of the burgeoning Romantic movement. With the first ‘alienists’, however, comes the what Foucault called the ‘medical gaze’. Madness enters the field of scientific observation and care. It was early on characterised as a delirium, ‘a sickness of the soul’, or, ‘extreme emotions stirred by the traumas of life’. Pinel and Esquirol are early key exponents, in France. Among the famous cases were the ‘revolutionary Amazon’, Théroigne de Méricourt and Henriette Cornier, who killed a child in cold blood. 

The growth of asylums occurred during the 19th century, to enable the ‘moral management’ of the insane. Dr Willis’s asylum and the famous York retreat of William Tuke were models of asylum life. However, their early therapeutic promise altered during the century as their populations swelled to bursting point and the care in them deteriorated. Gradually, heredity and degeneracy, rather than life trauma, came to the fore as causative factors in mental illness. In Britain, Henry Maudsley was a leading alienist and a Darwinist, but unlike Darwin he was, ‘beset by a visceral misogyny’. The widespread belief at the time was in favour of a division of labour along gender lines: ‘women were understood as being fashioned by evolution for the home and maternity, nervously fragile, intellectually inferior’.

It is arguable that no coherent or rationally credible theory of mental disturbance existed prior to Freud with his new understanding of hysteria. Freud’s work fleshed out what the great practitioners of the time, like Charcot, were unofficially saying about the mentally ill, ‘in such cases it is always the genital thing [La chose génitale], always, always, always’. Charcot had developed a whole iconography of hysteria at the Salpêtriére in Paris. The hypnotism used by Charcot had been popular from the time of Mesmer’s healings with animal magnetism at the end of the eighteenth century. Trance states and double consciousness were key themes in the 1890s bringing together, for instance, William James from Boston, Hippolyte Bernheim from the Nancy School outside Paris, and Pierre Janet, who was a contemporary of Durkheim and Bergson. Splittings, doubles and multiple selves were popular in the literature of the time, with, for instance, Stevenson’s, Dr Jekyll and Mr Hyde. Janet concluded from his research that there was ‘no single consciousness’, but that parts of the mind could exist alongside each other in mutual ignorance.

What distinguished Freud’s approach, however, was his emphasis on listening to what women told him: speech was the key, rather than the Charcotian clinical gaze. However, while Freud was dealing with neuroses, his contemporary, Emil Kraepeli in Munich, profiled the psychoses believing that they demonstrated the early stages of dementia, while Eugen Bleuler at the Burghölzli in Zurich, an early reviewer of Freud’s Studies in Hysteria, believed schizophrenia to be reversible. He saw his patients twice a day for talking therapy. Jung joined later and for a number of years contributed to the psychoanalytic project until the famous split with Freud over the pivotal role of sexual desire. However, Zelda Fitzgerald, who began treatment in Prangins, a sanatorium on the shores of Lake Geneva, diagnosed as schizophrenic and Virginia Woolf, who maintained a hostility to analysis, went through the span of treatments that the earliest twentieth century had to offer and none of them seemed to work. Zelda died in a fire; Virginia committed suicide.

Appignanesi takes us through well-worn territory, post-Freud, where with Melanie Klein, Anna Freud, Donald Winnicott and John Bowlby, the mother assumes central importance in the psychical health of the infant and the role of the father and the Oedipus complex is eclipsed. Appignanesi’s achievement is very sharply to delineate the complex battle lines drawn around women at this time by the professional establishment. On one side there were the alientist-psychiatrists who wanted women to continue to be wives and mothers at home, and considered intellectual activities to be bad for females. On the other side, the progressives, like the Bloomsbury group including Freud, understood womens’ desire for liberation.

But the irony is this: with new research on the importance of the mother-child relation coming from British psychoanalysis, attachment theory and biology, especially Harlow’s work with monkeys, women as mothers were becoming more pivotal in the mental well-being of the child and adolescent. American ‘moms’ were accused of being so smothering that their castrated sons could no longer fight in war without succumbing to shell-shock. Mothers (and the nuclear family) could make their children schizophrenic according to RD Laing and the anti-psychiatry movement, or, as Bettelheim believed, traumatised children became ‘autistic’ as if like concentration camp survivors. Or, mothers, like Winnicott’s ideal, with her exemplary and instinctive telepathic, ‘primary maternal preoccupation’ could give rise to a spontaneous creative individuals. But one way or another, the woman as mother, is under pressure like never before from the mind doctors, just at the time they wanted also to be especially sexually liberated.

While Freud provided a listening space for women and ‘Anna O’, Bertha Pappenheim, for instance, campaigned against the sexual exploitation of women and children and later, and de Beauvoir praised Freud for separating biology from destiny, the second wave of feminists during the 1970s regarded Freud, in the words of Kate Millett, as ‘the strongest individual counter-revolutionary force in the ideology of sexual politics’. However, Juliet Mitchell, with reference to Lacan, corrected former simplistic notions of the phallic economy. The new emphasis on language and the ‘constructions’ of gender, further undercut the alienist and patriarchal biological essentialism, paving the way for queer theory in the 1990s, not mentioned in this work. The drift all the while has been away from biologically and culturally fixed roles for women (and men), where, the double bind for women was, if you protested about your role you were diagnosed ‘mad’ or ‘neurotic’.

But the term liberation should perhaps be put in quotes. For ‘liberation’ brings with it an excessive preoccupation with the self and the body: the author refers to ‘body madness’. The excess thus liberated and apparently unstoppable is exemplified by the gaunt figure of the anorexic - ‘suicide bomber in the family’. Then horrendous abuse suffered by women was discovered, and in the last decades of the twentieth century overtook the earlier feminist preoccupations with freedom and social and sexual equality. Abuse takes on the horrific quality of the Shoah – today’s victims being called ‘survivors’. However, there can be no serious comparison with the Holocaust without doing grave injustice to the victims of that planned genocide. That does not stop the suggestion that being in an abusive relationship is equivalent to being in a totalitarian regime. While not wanting to minimise in any way the suffering of those trapped in very dysfunctional violent relationships, they should not be compared with a totalising, terroristic culture where fear, torture and death are everywhere.
                                                               
What started as ‘battered child syndrome’ in 1962, was augmented by incest and sexual abuse by 1977, then ‘child abuse grew to encompass everything’. As Appignanesi suggests, ‘being alive as a woman at the end of the century meant to be an incest survivor’. Not only that, but there was the abuse that you had forgotten which is the hidden cause of all your current symptoms! This single cause for suffering was put about by the hypnotherapists and the publication in 1988 of The Courage to Heal, with its handy checklist of 78 effects of abuse. All this makes work for the burgeoning therapeutic class of psychologists, counsellors, social workers. Appignanesi cites Ian Hacking who points out that four formerly distinct types of harm done to children are now run together. There used to be quite distinct and differentiated moral revulsion against a parent, who, for instance, neglected a baby, as distinct from a parent who savagely beats a child, as against a stranger molesting a child, as against abuse by incest. Running them together creates a powerful overdetermined effect of ‘moral evil’. I remember the head of a child support group here in Dublin suggesting that to slap a child was on the same continuum as child murder.
Countering the notion of rampant abuse perpetrated by men, Appignanesi considers the increase in sexual violence and brutality over recent decades with reference to Margaret Tsaltas’ work, linking abuse to real social breakdown. However, in less ideologically driven times, it was possible to entertain Phyllis Greenacre’s more psychoanalytically nuanced view that in all the abuse cases she has seen, ‘prepuberty trauma was induced by the child generally…under the stimulus of an adolescent or older woman’. The traumatic situation could also be ‘precipitated’ by the child who was curious and preparing for puberty. Appignanesi concludes therefore ‘that all sex is not an irreparable violation, rape, insurmountable evil’.
   
Just as the Law, St Paul says, creates sin, so too, analogously, does the cure create illness. The anticipation of cures from the asylum to modern psychopharmacological products and treatments, starting with the use of chloral-hydrate as a seditive at the end of the nineteenth century, to the more than thirty different kinds of antidepressant today, has led to the massive expansion of and bureaucratisation of potential illness. Bringing madness and suffering from the madhouse into the realm of scientific discourse and management has culminated in the massive cataloguing of medicalised suffering described in DSM IV. Add to this widespread self-medicating via street drugs and alcohol and what emerges is an unprecedented chemo-regulation of mood.

A second line of argument implied in this work is the shift away from the notion of human responsibility. With the rise of secularism that parallels the rise of the mind doctors, bad or criminal behaviour is increasingly ‘explained’ in diagnostic, morally neutral terms. Covertly, science is made to do the work of social control and perfectibility.

Thirdly, the two waves of feminism have had a complex and somewhat paradoxical results in women’s lives. Appignanesi herself does not want to appear ‘reactionary’ when she says that, ‘it isn’t as clear as we once thought that equality, however unequal, would erase the misery that topples women either towards anorexia or what our times understand as ‘depression’’. She omits to emphasise the new visibility of women in post-feminist image-saturated culture has lead to widespread concerns about the over-sexualisation of young women and girls.

The final question raised implicitly by this work can be formulated thus: has our explicit faith in rationality – the rationality of liberation and the mind doctors enlightened view of mental illness, run up against, again and again, the implacable real of irrationality and madness that has haunted the project from the beginning?