Mad, Bad, and Sad: A History of Women and the Mind Doctors

by Lisa Appignanesi

  CBT, or cognitive behavioural therapy–the subsidized health services’ therapy of choice because of its limited length and apparent high success rate–is also said to have some initial success with anorexia and other eating disorders. CBT takes its model from the behaviourists’ experiments with animals and conditioning in the first part of the twentieth century. It is based on the simple principle that if behaviour has been learned, it can be unlearned. Brainwashing is the popularized political version of the science, visible in a thousand films in which spies or soldiers are frazzled, punished or drugged into adopting the ideology of their enemies. CBT practitioners think of the unconscious as a woolly and unscientific idea. For them, thoughts determine emotions. Sort out the correct thoughts and beliefs about phobias or anorexia, encourage them, and health will follow.

  The brainchild of a dissatisfied psychoanalyst, Aaron Beck, and a clinical psychologist, Albert Ellis, CBT has thrived under managed care in the USA and is on the rise and rise in Europe. Health services want treatment plans with visible goals, boxes with symptoms that can be ticked off as soon as eradicated–as if the troubled human mind and psyche were easier to treat than chronic diabetes, more like a leg with a fracture that resetting will fix in a matter of months with only the slightest trace of a scar left behind.

  Focusing on the present and the future rather than the past, and on symptoms to be eliminated, CBT sharpened its tools on depression and anxiety. Patients were shown the fallacy of negative thoughts and low self-esteem, how to cope with irrational thinking and misperceptions, dysfunctional thoughts and faulty learning. Therapists often give patients a series of inner exercises and homework to do so that their mental processes through callisthenics can be rejigged into a more positive form. Claims are that depression, often with a side treatment of SSRIs (selective serotonin re-uptake inhibitors), is lifted, anxiety and phobias disappear. Beck has now gone on to treat schizophrenia and personality disorders. With anorexia, CBT therapists highlight the significance of the disorder as a means of gaining a sense of self-control. They focus in on the girl’s eating patterns and weight, attempting change here, but leave aside the unconscious components that bind into the condition and give it its individual shape. Anorexia, like so many disorders, is not simply a behaviour, but a response to inner knots and tangles invisible and individual to the young woman.

  In America, the National Institute of Mental Health (NIMH), in its advice to anorectics, has become a little cautious about CBT, specifying that it is best used in conjunction with other therapies. With anorexia, which results in twelve times more deaths in the eighteen-to twenty-five-year-old female population than any other single cause, they recommend a procedure which includes hospitalization in conjunction with ongoing CBT or other interpersonal therapies, individually or in groups, to combat perennial low self-esteem, social difficulties and dysmorphia.

  BULIMIA

  In 1987, the revised DSM-III for the first time included the diagnostic category of ‘bulimia nervosa’. More fully fleshed out in DSM-IV, bulimia entailed ‘an awareness of loss of control’ in recurrent episodes of binge eating; compensatory ways of preventing weight gain, in particular vomiting and misuse of laxatives, and a ‘self-evaluation unduly influenced by body shape and weight’.

  Bulimia, the binge–purge cycle, comes in several forms, which can slip into one another. One is its noisy adolescent manifestation involving group bingeing and group vomiting. This can have a fashionable air of adolescent defiance, parallel to binge drinking and other stormy weekend excesses. Another form is the secret, ritualized vomiting after meals that often begins in the later teens. More troubling, this bulimia can persist as a lifelong extension of dieting. The most serious form, which prodded the change in the DSM entry, has a compulsive aspect: binges are built up to over weeks, thoughts of them increasingly insistent, the urge and the final experience felt as a possession. Once the secret binge begins, the woman can consume gallons of ice-cream and pounds of food. With the giving in to the food comes both a release of tension, almost sexual in nature, and an accompanying shame, compounded by the guilt of inevitable weight gain. The vomiting that follows brings momentary peace.

  Bulimics are not the saints of eating disorders, but the impulsive sinners. They’re garrulous, often as incontinent in their relationship to words as they are to food. Bruch notes their ‘exhibitionistic display…their lack of control or discipline…a deficit in the lack of responsibility’. They blame their symptoms on others, and often claim to have ‘learned’ the behaviour. They characterize themselves as victims. Sometimes they steal the food they binge on and explain this as ‘kleptomania’, similar to bulimia in the compulsive force which guides it. Interestingly, kleptomania is a disorder at the end of another women’s spectrum of behaviour, this time related to shopping and its attendant need to acquire, loosely interpreted as a need for love. Despite the compulsion involved in the act of a kleptomaniac’s theft, courts in Britain and America will not accept it as a plea to reduce sentences. With the eating disorders, and particularly obesity and bulimia, it shares, as Bruch’s own tone underlines, a low status, as if the disorder also entailed self-indulgence, or a disreputable moral falling-away from civilized standards.

  Robert Lindner, that brilliant teller of tales from the consulting room, describes his unstoppable patient Laura and his overwhelming feelings of disgust when she arrived in his consulting room following a binge. Her face was ‘hideous’. ‘Swollen like a balloon at the point of bursting, it was a caricature of a face, the eyes lost in pockets of sallow flesh and shining feverishly with a sick glow, the nose buried between bulging cheeks splattered with blemishes, the chin an oily shadow mocking human contour, and somewhere in the mass of fat a crazy-angled carmined hole was her mouth.’ Out of that foul-smelling mouth come curses, a spout of grievances and accusations, and finally a call for help.

  Laura’s case was first told in the fifties in the United States, before eating disorders had gained in prominence and notoriety. Lindner’s description captures his patient’s own sense of disgust, which is one Hornbacher echoes, emphasizing how disgust and need in the bulimic are part of her excessive emotion and inner violence. But she sees the bulimic’s impulse as more realistic than the anorectic’s because the former knows the body is inescapable. Lindner eventually tracks his own patient’s pathological craving for food back to a startling Oedipal desire for her father’s child: a father whose abandoning of an already impoverished family when she was a mere girl she blamed on her chair-ridden mother. The bingeing is an enactment of pregnancy, correcting a childhood lack–her overwhelming need for her absent father–coupled with a disgust for her crippled mother.

  Such interpretations and indeed enactments can seem florid amidst the current understandings of bulimia, which some say is endemic amongst teenagers in the West, though numbers are hard to come by since treatment is not regularly sought. But Lindner’s case provides a glimpse of the unconscious elements which can activate a binge–purge cycle. This old ‘tale’ also underscores the compulsive nature of the condition and the displaced meanings which food can hold for the individual–the way in which food, particularly for women, can stand in for love.

  Bulimia has had some high-powered women in its thrall. The condition allows for a controlled, successful, pleasingly thin façade beneath which a secret world can swing wildly into messy rage. Often the bulimic feels this is her true self. Unlike the killing anorexia, and like alcoholism, bulimia doesn’t necessarily visibly impede work patterns or even family relations. The quotient of inner malaise, however, is high. Princess Diana was a bulimic and sought treatment. Indeed, psychotherapists see bulimia in a wide range of women: some suffer from a false self; others have passing adolescent problems; still others are borderline personalities who engage in savage fluctuations of behaviour from self-harm to sexual promiscuity to alcoholism, and who have often had childhoods in which abuse features.

  In her autobiography My Life So Far, actor a
nd political activist Jane Fonda describes how with her thirteenth birthday a sense of her own imperfection attacked her, and centred itself on her body. Her father estimated it ‘fat’. It was ‘the outward proof of my badness’. Her mother, who had a history of breakdowns, had recently committed suicide. Around the time of her divorce from Henry Fonda, she had shown Jane the ugly scar left by a kidney operation and the botched effect of a breast implant. Eleven-year-old Jane associated these with her parents’ divorce and vowed that she would be flawless.

  In retrospect, her overwhelming desire to make her body thin and thus perfect also emerges as a way of postponing a womanliness that was associated with being a victim like her mother. The perfection of thinness was her aim. At school she responded to a newspaper advertisement for a ‘tapeworm’, which never arrived. With a friend who had similar problems with her body image, Fonda binged and purged. The school secret grew into an adult ritual enacted alone. She would go into a grocery store and buy ‘comfort’ foods, ice-cream and pastries, all the time telling herself this would be the last time, her breathing quickening, fear and excitement mounting together. No sooner was the secret feast finished than ‘the toxic bulk which had seemed so like a mother’s nurture’ had to be got rid of. Eliminated before it took up residence inside her. Otherwise it would kill her. Only years later did she overcome her denial of the addictive nature of the illness. Like alcoholism, bulimia is an addiction, which the addict lies about to herself, saying she is in control, that the addiction can be stopped at any time by an act of will; couching it in moral terms, equating it with a sense of weakness and worthlessness.

  Fonda’s secret food addiction sometimes expressed itself as bulimia, sometimes as anorexia. It persisted into her forties and through two marriages and two children. No one knew about it. She became expert at dining in the best Beverly Hills restaurants and retiring to the toilets to puke, before returning, smiling, her make-up perfectly in place. The condition would grow worse when she was sustaining ‘inauthentic’ relationships. Increased anxiety about food and numbness would then take her over, cocooning her from life, so that the toilet became the only place where she felt she was herself–not the false self which acts as a defence against the chaotic, undeveloped, needy infant within.

  Fonda’s case exhibits the characteristic persistence of the eating disorders, their deep hold on their sufferer’s psychic structures. In a study carried out by the Massachusetts General Hospital in Boston, women were seen again after three years of various treatments: out of thirty only 69 per cent were diagnosed as fully recovered. In another study at the University of Minnesota, after a ten-year period, 30 per cent of the women continued to engage in bingeing and purging.

  During all those years when she herself was part of the flagellating body industry and encouraged women through books, audio and seventeen million video tapes to work out and ‘let it burn’, Jane Fonda was a ‘recovering food addict’. The paradox here is of women’s complicity–even a feminist’s, which Fonda is–with the social coercion of her time. Fonda’s ringing voice, together with her super-svelte form, did indeed burn itself into the minds and eyes of eighties women who worked out to find a semblance of her outward perfection.

  Always emblematic of her times, it is interesting that Fonda, a consummately successful woman in every sphere she has engaged in–as an actor, political activist, exercise guru, film producer, mother, high-profile wife, writer–couches her life in the victim narrative so crucial to American feminism and popular culture since the 1980s. In her sixties, at last ‘recovered’ from a lifetime of feasting, vomiting and fasting, still slender and beautiful, she has entered ‘the infancy of her new adulthood’, a new beginning where she at last feels ‘embodied’ and can acknowledge her mother’s part in her life. A life story is also a therapeutic tale in which the woman is a patient who at last recovers. There is evidently hope for us all.

  Fonda’s story underlines the way in which the lives, particularly of women, have now become therapeutic tales. Their confessional tone and the stepping-stones they choose to chart are not, however, the Freudian narratives of mid-century in which struggle, part of which is linked to rampant desire, leads to insight and stoical resignation to a civilization in which discontent is inevitable, but achievement possible. Now the therapeutic women’s narrative has a religious thrust. Born into a doomed world in which mothers, like Eve after the Fall, are never, and can’t be, good enough, daughters are wounded in their bodies and emotions, suffer the slings and arrows of fortune, and are eventually redeemed, often with the help of a replacement good-enough mother-therapist. Under her aegis, they are healed and born again into a wholeness which also means peace. Interestingly, the inflection here is on the life of the body and the emotions.

  Therapeutic feminism rightly added the missing cultural dimension to women’s psychic ills and put eating disorders, as well as others prominent amongst women such as self-harm, into an appropriate social perspective. It nudged medical psychiatry and traditional psychoanalysis into an awareness of the way in which the cultural emphasis on thinness and on women’s bodies played into illness; how treatment had to take into account a woman’s wish to control her body. In the process, feminism seems to have given back to women what they always had: the body, emotions, and a penchant for the softer sides of religion as the prime means of self-definition.

  14

  ABUSE

  Trawling through the sizeable psychiatric and psychoanalytic literature of the twentieth century, it is surprising to find that the mind doctors rarely put their minds to matters that today are prominent above all others. Rape, incest–that whole package compounded within child abuse, trauma and its ensuing disorders–hardly surface in their writings until the mid-1980s. Abuse, neglect, the mistreatment of children are a social matter: the fact that love, compassion and understanding, let alone warmth and food, are necessary to development is a question of common sense, not material for the investigation of mind doctors. When rape and incest do appear in the literature, they’re most often linked to anthropological matter, to investigations of myth; or to theoretical discussions of unconscious fantasy. In considering hysteria, Freud notes that rape is a ‘severe trauma’ which reveals ‘to the immature girl at a blow all the brutality of sexual desire’. But in the consulting room it emerges that such trivial matters as the tender stroking of a hand or the rubbing of a knee under a table can prove as traumatizing an event in one young girl’s psychic life as the far more serious rape in another’s. Some individuals, it seems, can digest the assault of triple Macs and milkshakes, while others have trouble with thinly pared celery.

  Transmuted in memory, screened by a bundle of emotions, the real of the individual’s history, the external and documentable events of a life, most often become for the analyst what the patient has ‘experienced’. Except in dealing with child analysis or full-blown episodes of mania when psychiatrists take histories from family or witnesses, what is remembered, represented and re-enacted in the consulting room is the principal stuff of therapy. What is crucial within analysis is the way in which the mind manages the relationship between inner and outer reality. Damage, the manner in which the individual has responded to or been stopped in her tracks by the blows of life, the meaning she makes of them, is what is on the table for treatment. As the American Psychoanalytic Association’s plenary meeting heard in 1992, data gathered by the researcher William D. Mosher had shown that there were only nineteen articles mentioning either sexual abuse or incest in English-language psychoanalytic journals from 1920 to 1986. Since rape, abuse and incest have hardly been absent from human history until the 1980s–were indeed well documented throughout the late nineteenth century–clearly, the mind doctors considered these as social problems to be dealt with by social workers, the police and politicians, all those professions that contend with the order of the social world and real events, rather than the meanings the mind can generate from these events and the disorders of the inner life.
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br />   Then, in the last decades of the twentieth century, several forces came together to alter the concerns of the mind doctors radically and to put precisely these matters centre stage. The West became more inclined to find individual solutions to what were often social and political matters. Poverty and deprivation were repressed as categories in favour of identity and fitness. There was a shift, too, of demarcations and focus in the professions. The old talking-cure dividing lines between social work, psychiatric social work, clinical psychology, any number of therapies, psychoanalysis and psychiatry began to blur. Particularly in America, the high status of analysis in its link with psychiatry was disappearing, and analysis had to catch up with the other talk therapies if it was to find patients. The psychiatric world began to organize itself around the diagnostic schema of the DSM which fell in with the bureaucratic needs of ‘managed care’ insurance or welfare services.