Most recent work on the history of psychiatry has tended to focus on the history of institutions, of ideas, and of the psychiatric profession itself, and to ignore those for whom this vast infrastructure has (at least ostensibly) been erected. It is a historiography, as David Ingleby wittily put it, ‘like the histories of colonial wars’: it tells ‘us more about the relations between the imperial powers than about the “third world” of the mental patients themselves’. For this reason, among many others, Elaine Showalter’s The Female Malady is to be welcomed, for its primary focus is upon this neglected group – for the most part, on female patients.
Her account makes it plain that in the psychiatric domain, as in the conventionally-defined Third World, the position and treatment of women consistently turn out to be even less enviable than those endured by men. Can this, however, justify a move to label madness ‘the female malady’? Not, surely (and contrary to what Showalter sometimes seems to suggest), in any straightforward statistical fashion. One may plausibly contend that, for much of the past two or three centuries, women have outnumbered men in the ranks of the mentally disturbed. Still, for the most part, this has not been in such gross disproportion that one could sensibly call the disorder a pre-eminently feminine one; and there have even been occasions when men have constituted a substantial majority of those officially identified as mad.
For example, against the fact that nearly two-thirds of those who consulted the 17th-century astrological physician Richard Napier for treatment of their mopish or melancholic moods were women, one must set the observation that, as best one can judge from the admittedly defective data, men greatly outnumbered women among the inmates of 18th and early 19th-century madhouses. It was only after the middle of the 19th century, when the madhouses of the Gothic novelists had supposedly been transformed into the domestic retreats favoured by the Victorian lunacy reformers, that women began gradually to outnumber men among those legally designated as mad – first among the pauper residuum who contributed the bulk of the rapid rise in the ranks of mad folk, and not till the end of the century among their genteel and affluent cousins. Nor, among the institutionalised insane, did the imbalance ever amount to more than a few per cent, and this itself was quite possibly attributable to the greater longevity of the ‘weaker’ sex and to the disposition of the asylum authorities to keep female lunatics institutionalised longer than their male counterparts. And from the late 1960s to the present, men have formed the clear majority of mental hospital populations in the United States, while the best modern research can find no consistent differences by sex in the prevalence of psychotic symptoms or in rates of schizophrenic breakdown.
It would perhaps be more supportable to suggest, on a more expansive view of what constitutes mental illness, that women are more frequently troubled in mind. If women were only marginally over-represented among the ‘Bedlam mad’, the rise of a non-asylum psychiatry, ministering to the neurotic, the neurasthenic and the hysteric, quickly found itself catering to a more heavily female clientele. On the late 19th-century borderlands of insanity, women were disproportionately represented among the clientele of rest homes, water-cure establishments, Mesmeric salons, and the mind cures of the Christian Scientists. And in the present, women are found to be more prone to neurosis and manic depressive symptoms, and are much more likely to be taking psychoactive drugs.
Yet these figures, too, demand to be treated with some caution. For alongside the greater reported frequency of symptoms of mental illness among women, and their more extensive utilisation of psychiatric facilities, one must note that an identical pattern holds for physical illness and the use of non-psychiatric physicians and hospital services. Puzzlingly, women exhibit higher rates of morbidity and lower rates of mortality than men of comparable age and social circumstances.
Still, if the statistical evidence is at best rather ambiguous, the assertion that our culture views the female of the species as more prone to irrationality and mental imbalance is not without foundation; and our organised responses to these maladies repeatedly turn out to be influenced, in ways both gross and subtle, by questions of sexuality and gender. One appreciates, then, an attempt to explore what is distinctive about the female experience of madness. Drawing upon an extraordinary array of sources (literary and pictorial representations of the mad, in painting, photography and film; asylum records; the recollections of ex-patients; the words and practices of their physicians; and the private papers of eminent women who did not become psychiatric casualties – materials which provide eloquent testimony about the tensions and tribulations faced even by exceptionally talented and apparently successful women trapped within the confines of a patriarchal social order), Elaine Showalter has constructed a powerful (and only occasionally overdrawn) portrait of the contributions of psychiatry to the wrongs of women.
Our images of madness, she argues, are disproportionately female: ‘women, within our dualistic systems of language and representation, are typically situated on the side of irrationality, silence, nature and body, while men are situated on the side of reason, discourse, culture and mind.’ Romantic portraits of Crazy Jane, a poor servant girl seduced and abandoned by her lover; Lucia di Lammermoor with its picture of female sexuality as insane violence against men; Bertha Mason and Gothic madness – violent and hideous animality kept caged in Mr Rochester’s attic lest a ‘clothed hyena’ be let loose upon the world: in novels, in drama, in poetry, in painting, in popular ballads, in opera, it is women who stand as emblems and exemplars of irrationality.
Moreover, there has been much traffic between these cultural images and psychiatric ideologies. Notwithstanding the nearly equal propensity of the two sexes to go mad, Victorian alienists developed different explanations of why men and women became deranged, elaborate accounts of women’s greater vulnerability to insanity, and even speculations about their tendency to experience madness in peculiarly feminine ways. In keeping with their professional preference for somatic accounts of the aetiology of mental imbalance, mad-doctors increasingly emphasised the biological, and ignored or were indifferent to the social and the psychological sources of their patients’ distress. But if mad men and mad women were both biologically-defective degenerates, the latter were doubly flawed. For in reductionist fashion, woman’s ‘natural’ place in society – her capacities, her roles, her behaviour – was held to be ineluctably derived from and controlled by the existence and functioning of her reproductive organs. As an organism dominated by her uterus and ovaries, and hence by crisis and periodicity, a woman necessarily possessed greater capacities for affection and aptitude for child-rearing, a preference for the domestic hearth and a ‘natural’ purity and moral sensibility: but she was also inescapably a creature in whom the emotional predominated over the rational, someone whose physiological equipment was of surpassing delicacy and fragility, at any moment liable to give way under the strains of modern life or the unavoidably perilous passage through puberty, pregnancy, parturition, lactation, menstruation and the menopause. The constriction of women’s lives, their legal powerlessness and economic marginality, the central features of existing social relations between the sexes, thus received the sanction of science. And confronting such weak and fragile vessels, Victorian psychiatry, as Showalter puts it, ‘defined its task with respect to women as the preservation of brain stability in the face of almost overwhelming physical odds’.
Theories of a differential, gender-based aetiology for mental disturbance corresponded, in some important respects, to differential expectations and treatments for men and women. The Early Victorian period saw the creation of a whole new network of public asylums, coupled with a system of national inspection of receptacles for the mad by the Lunacy Commissioners. Such changes reflected a revulsion against earlier methods of managing the mad, and an astonishing (and in the event sadly misplaced) optimism about the therapeutic effects of the new system of moral management. In institutions containing several hundred, even a thousand and more inmates, alienists struggled to produce a simulacrum of the domestic scene, in the process revealing and reproducing, as Showalter describes it, ‘structures of class and gender that were “moral”, that is, “normal”, by their own standards’. Classification was quite central to the production of a docile and harmonious community (essential, in the words of the Scottish alienist W.A.F. Browne, if one were ‘to inspire that respect for order and tranquillity which is the basis of all sanity and serenity of mind’); and rigid segregation of the sexes was equally central to their classificatory schemes. The Commissioners in Lunacy even objected to the mingling of male and female corpses in the deadhouse at the Cambridgeshire County Asylum.
Kept constantly separated from their male counterparts, save at the carefully stage-managed asylum balls that were a weekly demonstration of the powers of moral management over the sexual passions, women endured an even more passive and circumscribed existence than could be found on the men’s wards. The idle monotony of their daily round was relieved only by work at quintessentially feminine tasks: the cleaning, laundry and sewing that were vital to the upkeep of these ever larger museums of madness. And their improvement was measured, as often as not, by their ability to manage their dress and their appearance. In a striking analysis of the work of Hugh Diamond, the pioneer of psychiatric photography in England, Showalter points out how it allows us to see the moral management of female insanity; how the supposedly objective lens of the photographer instead reveals, in the choice, the posing, the staging of its subjects, the imposition of cultural stereotypes of femininity and female insanity, a capturing of the madwoman in the straitjacket of her keeper’s gaze. In image after image, ‘women were given props that symbolised, often with pathetic futility, the asylum superintendent’s hope of making them conform to Victorian ideals of feminine decorum.’ Humanitarianism had, as its hidden face, new forms of paternalistic domination.
As the hopes of the asylums’ founders dimmed, and their institutions silted up with the chronically crazy, ‘the waifs and strays, the weak and wayward of our race’, so cracks began to appear in the façade they presented to the world, providing glimpses of a moribund system, overcrowded, inefficient, ever more demoralised. Showalter adopts Veida Skultans’s term, ‘psychiatric Darwinism’, to describe the parallel evolution of medical theories of insanity, towards a grim determinism that emphasised madness as the product of a process of mental and physical degeneration. In the words of Henry Maudsley, the dominant figure of Fin-de-Siècle English psychiatry, the madman ‘is the necessary organic consequent of certain organic antecedents: and it is impossible he should escape the tyranny of his organisation.’ The physical signs of physiological decay were written particularly plainly on the bodies of women, and given the hopelessness of curative efforts, and the vital significance of healthy offspring for the future of the race, prospective husbands were urged to inspect the merchandise carefully, searching for ‘physical signs ... which betray degeneracy of stock ... any malformations of the head, face, mouth, teeth and ears. Outward defects and deformities are the visible signs of inward and invisible faults which will have their influence in breeding.’
Such rigid somaticism coincided with a barely-disguised contempt for the mad, and appeared to leave little scope for expert intervention. In response, the leading alienists sought to widen the scope of their authority, to move outside the asylum walls, and to obtain a mandate to patrol the mental frontiers of society on the look-out for ‘incipient lunatics’ whose disorders, hidden from less trained eyes, threatened future trouble and a further dangerous dilution of the quality of the breeding population. It was these shadowy inhabitants of what Mortimer Granville dubbed Mazeland, Dazeland and Driftland who now drew the attention of the most eminent mental specialists of the day – provided, of course, that their families possessed sufficient resources to pay for such expert attention. And in most instances, these mental cripples and invalids turned out to be women. Some were diagnosed as neurasthenics or anorexics (a condition recognised for the first time in 1873): but the most common diagnosis was unquestionably hysteria.
In two central chapters, Showalter examines the relationship between hysteria and women’s lives, and the nature of the psychiatric response to this puzzling, infuriating, recalcitrant condition – a syndrome the prominent American neurologist Silas Weir Mitchell preferred to call ‘mysteria’. With its associations with capricious physical symptoms and emotional lability, here was a disorder which epitomised feminine fickleness. Its very name associated it with female sexuality, and English alienists characteristically attributed it to some combination of sexual inhibition, enforced passivity and thwarted maternal drives, allied to faulty heredity and the biological crises of the female reproductive system, and exacerbated by any attempt to transgress the ‘natural’ limits on women’s participation in society. Too much education was a particularly dangerous thing. Adolescent girls needed all their mental and physical energies to negotiate the treacherous shoals of puberty. Add mental strain, and one could expect, warned Maudsley, ‘the degeneration of the reproductive capacity, beginning with the atrophy of the breasts and ending with a total loss of “pelvic power” ’ – not to mention the prospect of epilepsy, chorea, or mental breakdown.
Showalter rightly notes the persistent blindness of even the most sympathetic male physicians to the connections between psychosomatic disorders and the constricted and powerless lives of their middle-class patients. In the impassioned words of Florence Nightingale:
To have no food for our heads, no food for our hearts, no food for our activity, is that nothing? If we have no food for the body, how we do cry out, how all the world hears of it, how all the newspapers talk of it, with a paragraph headed in great capital letters, DEATH FROM STARVATION! But suppose one were to put a paragraph in the Times, Death of Thought from Starvation, or Death of Moral Activity from Starvation, how people would stare, how they would laugh and wonder! One would think we had no heads or hearts, by the indifference of the public towards them. Our bodies are the only things of consequence.
But if hysteria was hidden protest, a rebellion against the stifling demands of a patriarchal social order, Showalter insists it was a feeble form of resistance. The secondary gains – ‘the sympathy of the family, the attention of the physician’ – were quite incommensurate with the far more extensive primary losses: ‘the costs in powerlessness and silence’.
Nor was this the only price paid by the female hysteric. For English psychiatrists ‘found their hysterical patients personally and morally repulsive’, and their treatment of them was suitably ruthless, uncompromising, even brutal. Viewing their patients as a cowardly, histrionic, deceitful and morally wretched lot, many responded in kind, advising ‘observant neglect’ or even active intimidation, blackmail and threats. ‘Ridicule,’ noted F.C. Skey, ‘is a powerful weapon ... but there is no emotion equal to fear and the threat of personal chastisement.’ And for some, threats might give way to action: stopping the patient’s breathing, pouring water on her head, slapping her with wet towels, exercising pressure ‘on some tender area’. All too frequently to no avail. In the understanding and treatment of hysteria, as with psychosis, English psychiatry found itself in an impasse.
Elsewhere, first through Charcot’s work, and then in Freud and Breuer’s Studies on Hysteria, there were experiments with a more psychologically-oriented approach. In picturing hysterical symptoms as the product of unconscious conflicts beyond the individual’s control, in beginning to take ‘women’s words and women’s lives seriously’, Showalter sees psychoanalysis as potentially a major advance: but one whose promise soon dissolved, as Freud’s increasing theoretical rigidity and obsessive ‘insistence on the sexual origins of hysteria blinded him to the social factors contributing to it’. In any event, Freud’s ideas met with a particularly hostile response from many English psychiatrists, notwithstanding, in Leonard Woolf’s words, the ‘desperately meagre ... primitive and chaotic’ state of English medical knowledge of insanity on the eve of the Great War.
The final, and in some ways the least successful, section of The English Malady deals with developments from the First World War through the demise of Laingian anti-psychiatry in the late 1970s, a period Showalter labels the era of psychiatric modernism. Her analysis opens promisingly enough, with a harrowing comparison of the treatment of shellshock by Lewis Yealland and by W.H.R. Rivers. The epidemic of war neurosis among the British troops was a wholly unexpected development. First interpreted as quite literally the product of the physical or chemical effects of a shell bursting at close range, and assumed to have a physical cause, it gradually came to be seen as the product of emotional disturbance, a male form of hysterical conversion. In effect, as Showalter puts it, ‘when all signs of physical fear were judged as weakness and where alternatives to combat – pacifism, conscientious objection, desertion, even suicide – were viewed as unmanly, men were silenced and immobilised and forced, like women, to express their conflicts through the body.’
Men’s unconscious resistance provoked some of the same negative reactions as greeted their hysterical sisters – made harsher by the ‘unmanliness’ of those who failed to fight. Many took a harshly moralistic view of the emotionally incapacitated, suggesting that shell-shock cases should be court-martialled and shot for malingering or cowardice. Yealland’s ‘disciplinary therapy’ gave barely disguised expression to these feelings, stressing, in Showalter’s words, ‘quick cures, shaming and physical re-education, which often involved the infliction of pain’, and extending to the use of cigarette burns, ‘hot plates’ thrust into the mouth, and the application of painful electrical shocks to the neck and throat. But war neurosis was four times more common among officers than among men, and for the most part, there was reluctance to treat gentlemen in such overtly harsh and brutal ways. Instead, the treatment of officers brought the first breach in English psychiatry’s commitment to organicism. Siegfried Sassoon’s ‘Soldier’s Declaration’, for example, a forthright denunciation of the war, could have brought him a court-martial and imprisonment. Instead, he was diagnosed as neurasthenic, and shipped off to be ‘treated’ by W.H.R. Rivers at Craiglockhart Military Hospital. Here, as Showalter points out, the treatment was kindly and gentle, and the surroundings luxurious (though the outcome was to invalidate Sassoon’s political protest by redefining it as a nervous breakdown, and to manipulate him into resuming his role at the front as ‘an officer and a gentleman’).
The world fit for heroes now saw a bifurcated psychiatry: psychotherapy (usually some variant of psychoanalysis) for well-to-do outpatients and a renewed commitment to organicism for the multitudes who continued to be packed off to the asylum. Psychoanalysis, notwithstanding its sizeable cohort of female therapists, ‘hardened into a discourse that devalued women’. Meanwhile, in a veritable paroxysm of inventiveness, asylum psychiatry experimented with malarial therapy, metrazol-induced seizures, insulin comas, electroshock treatment, lobotomies and finally ataraxic drugs, notably Largactil, the ‘mighty drug’ that was to be our culture’s magic potion against the ravages of schizophrenia. A number of these therapies, Showalter argues, reduced patients treated with them to a state whose passivity and dependence constitute extremes of typical female experiences; and incomplete evidence suggests that women were indeed disproportionately the beneficiaries of lobotomies and shock treatments. Some of the episodes she uncovers are so extraordinary that they practically beggar belief: the suggestion by Sargent and Slater, for instance, in the 1972 edition of their standard British psychiatric text, that a depressed woman ‘who may owe her illness to a psychopathic husband who cannot change and will not accept treatment’ be given a leucotomy. She will then, they assure us, be able ‘to return to the difficult environment and cope with it in a way which had hitherto been impossible’.
Both here, and in the parallel discussion of literary representations of female madness, much of what Showalter has to say is disturbing and insightful. But these chapters also contain some overstated passages, and a tendency to violate her own earlier warning about the dangers of romanticising madness. It may be that women’s autobiographical novels ‘transform the experiences of shock, psychosurgery and chemotherapy into symbolic episodes of punishment for intellectual ambition, domestic defiance and sexual autonomy’: but this is surely too crude and self-serving a portrait to accept at face value. Or, to take another example: to assert that ‘during the post-war period, the female malady, no longer linked to hysteria, assumed a new clinical form: schizophrenia’ is to damage one’s own case by engaging in polemical excess. Though Showalter briefly acknowledges that the incidence of schizophrenia is ‘about equal in women and men’, the whole thrust of the discussion that follows is to emphasise the ‘parallels’ between ‘schizophrenic symptoms of passivity, depersonalisation, disembodiment and fragmentation’ and ‘the social situation of women’; and to present, with apparent approval, literary accounts ‘of schizophrenia as a protest against the feminine mystique’.
A final chapter on R.D. Laing and his epigones seems rather anti-climactic. Their anti-psychiatric follies, after all, are by now rather thoroughly discredited. The intellectual vapidity of Laing’s later work, the transparent hucksterism and political opportunism he paraded as his star began to set, and the disastrous track record of Laingian therapy, have all combined to make him a yesterday’s man. Feminists, as Showalter indicates, had once seen in Laing’s notion of ‘ontological insecurity’, and in his analysis of the effects of the double bind on female adolescents, ‘important new ways of conceptualising the relationship between madness and femininity’. But these hopes were chimerical: ‘in retrospect, it seems clear that despite vivid representations of women’s suffering, anti-psychiatry had no coherent analysis to offer women.’ Its radical promise dissolving into David Cooper’s advocacy of ‘bed therapy’, i.e. sex with Cooper, as a contribution to the cure of schizophrenia in women, it adds yet another chapter to her collection of sad tales.