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

by Lisa Appignanesi

  Josetta tells doctors that since the ‘trouble’ between her daughter and her last live-in boyfriend, she has been suffering from intense ‘flashbacks’ of being abused by her uncle. This was not in her files because she didn’t think it worth mentioning before, and in any case assumed no one would believe her. Her mother certainly hadn’t when she had complained of him at the time. But then, when her mother wasn’t ‘silent as the grave’, she was usually blinded by a haze of alcohol.

  A diagnosis of borderline personality disorder was made.

  Roxy a slim, pixie-like twenty-three-year-old was admitted to a psychiatric unit after a serious suicide attempt. Her parents and ten-year-old stepbrother were away on holiday and she was home alone, depressed and desperately lonely. She mixed herself a killing cocktail, downed it, then rang the therapist she had been seeing erratically over the past months.

  Roxy had been the family darling until her thirteenth birthday when she took up the clubbing life and fell in with a slightly older crowd who did an assortment of drugs and drank to excess. At sixteen, she ran off with an older boy, lived with him in a squat for several months, and dropped out of school despite her parents’ pleading. The ‘couple’ returned to live with her parents when their other accommodation fell through. After a few weeks here, their relationship ended in tempestuous recrimination, accompanied by the destruction of much of Roxy’s attic rooms. She made her first suicide attempt.

  At her parents’ and the hospital’s insistence, Roxy started to see a therapist three times a week. She also saw any number of men and played out scenarios of great passion and excitement, some of them violent. The serial polygamy left her feeling increasingly vulnerable. She hid the helplessness in drink, binge eating and drugs, had flings with women partners, but here too, her therapist noted, the relationships ended in dramatic confrontation. Her narratives displayed a manipulativeness which she also replayed with her therapist. She showed little capacity for the insight the therapy demanded of her. She spent sessions complaining about family and friends, and the insults she suffered. She railed at the therapist for not listening to her well enough or sympathizing appropriately. She rang him often between sessions, her moods fluctuating wildly. When he went on holiday, she felt utterly abandoned, and punished for her worthlessness.

  Roxy had started to work in her stepfather’s office and was by turn competent and absent, depending on her night life. Her parents complied with all her erratic demands, fearful that she would once more try to kill herself. But one day, when she complained of the boredom of her job, her stepfather grew angry and exploded, firing her on the spot. She locked herself in her room. After a while, when her mother didn’t hear her and feared the worst, the door was broken down. Roxy was mixing herself a cocktail, which hadn’t yet been drunk. The family debated as to whether she should be institutionalized for her own safety. Roxy refused, promised she would get her life in order and enrol in a sixth-form college.

  After some weeks of low-level depression, she started to see a new therapist. An antidepressant was prescribed. The pattern of drink and drugs and clubbing started again. A particularly violent and exciting bout of sexual activity with a new acquaintance resulted in her refusing to accompany her family on holidays. Just after Christmas, she found herself dumped with a black eye on the pavement. She went home and tried to kill herself.

  The hospital diagnosed borderline personality disorder

  Dawn, twenty-eight, was admitted to a secure unit after her conviction for the infanticide of her eleven-month-old son, Gabriel, who had been living with foster parents from birth. Quiet, with a polite, girlish and whispering quality to her speech which drew people near, Dawn had a long history of severe depression, suicide attempts and hospital admissions. In and out of children’s homes through her childhood, she had been abused by residents as well as, in one, a staff member. Her mother had a history of psychotic depression. Dawn’s husband, baby Gabriel’s father, had abandoned her when she was four months pregnant.

  On the night of the murder, Dawn had paid a visit to her son’s foster family. Pitying her predicament, Gabriel’s foster mother had broken the rules and allowed her to go up and spend time with the babe alone. She wasn’t aware that Gabriel’s father had recently asked Dawn for a divorce, thereby setting the seal on her sense of rejection and abandonment. In Dawn’s eyes, Gabriel was intimately linked to his Dad, in some sense stood in for him. So she suffocated, then strangled, the boy. During the police interview, she betrayed no emotion about her act. Even six months later, with the therapist in the secure unit, that emotion was still absent.

  Before coming to see Gabriel, Dawn had rung the police and announced her intent to kill unless she was stopped. But she had given no address and her warning went unheeded. The lack of help enabled her to feel like the passive victim of her own violent act.

  In psychotherapy, she had vivid recall of waiting for her mother to come and take her away from her children’s home. Yet she still showed no remorse whatsoever or, indeed, any understanding of the murder she had committed. When she talked of her son, there was no sense of his having an identity separate from her own.

  Anna Motz, the forensic therapist who saw her, observes that Dawn was incapable of ‘mentalization’, that fundamental process which permits a person to imagine what another feels or thinks. Psychoanalysts relate this ability to a stage in self-development where the child looks for a reflection of her own inner states in her mother or primary care-giver. Dawn had never found this mirroring in her mother; thus her inner despair couldn’t be converted into understanding. Instead it manifested itself in violence. During the act, she was herself the abandoned infant rejected by a mother she had never been able to separate herself from. In the infanticide, she compounded her own child, her husband, her mother and the child she herself had once been. The act was also a tragic request for containment by psychiatric services.

  According to Anna Motz, Dawn, though psychotic while committing the murder, had features of borderline personality disorder.

  Josetta and Roxy are my own inventions based on a cross-section of cases given the designation ‘borderline’. They have in common with Dawn a certain wildness or impulsiveness of action and what used to be called ‘deviance’. Together these women demonstrate what has been a historical category problem: are people like them mad, or simply bad? I could have written Mrs Marino as a mother trapped in a dysfunctional and impoverished estate–a woman who needed not a psychological diagnosis, but help with a life she was leading in a way that harmed her own life and her children’s. Roxy could have been characterized as a relatively ordinary selfish adolescent who would–if suicide wasn’t pathologized in our society and the many lyrics which extol it didn’t intervene–eventually grow into a new and calmer phase of life. Whatever else she may be, Dawn is clearly also ‘bad’ and society has imprisoned her for her crime. But is she also sick, in the way that the champions of the new psychiatric diagnoses in the mid-nineteenth century argued Henriette Cornier, another infant murderer, was?

  What are now called the ‘personality disorders’ have long taxed both mind doctors and the legal profession. They have also called ethical categories and notions of ‘normality’ into question. What is society to do with a whole spectrum of people who may be dangerous to themselves and to others; people who don’t and perhaps can’t, without help, follow the rules of everyday behaviour that society sets down?

  Distinguishing mental illness from what some have called sin, vice or crime, the mind doctors have come up with various categories. In his Treatise on Insanity (1835) J.C. Prichard coined the term ‘moral insanity’ to describe individuals of ‘a singular wayward, and eccentric character’ who display ‘an unusual prevalence of angry and malicious feelings, which arise without provocation or any of the ordinary incitements’. At the more extreme end, such people migrated into Cesare Lombroso’s category of ‘degenerates’, then became psychopaths or sociopaths. Now we have the ‘antisocial personality
’ of the DSM, with its characteristics of deviance, deceitfulness, aggression, impulsiveness, reckless disregard for others and failure to feel remorse.

  Though, as a whole, modern Western society has tended to pathologize crime, this has hardly meant an accompanying ability to treat disorders. Nor has it meant of late an increase in the number of hospitals where treatment is provided for criminals. Quite the other way round: statistics tell us that one in six prison inmates in the USA suffer from mental illness, often accompanied by illiteracy, a rate three times higher than in the general population. American Human Rights Watch reports that ‘prisons have become the nation’s primary mental health facilities’, though without providing the kind of care that might eventually make reintegration into society possible. In women’s prisons, borderline personality disorders are rampant. An August 2006 report on women in British prisons showed that out of the 4494 prisoners, three-quarters suffered from mental health problems, half had histories of domestic violence, and a third had been sexually abused, while two-thirds were drug-or alcohol-dependent. Drug charges and theft, often enough of clothes or food for their young children, were the main reasons for their imprisonment.

  In 2000, the Labour government introduced a Dangerous People with Severe Personality Disorder Bill in an attempt to establish legislation which would enable people who ‘might’ commit serious violent crimes to be preventatively arrested. The idea behind the legislation was to take ‘psychopaths’, violent sex offenders or potential murderers off the streets before they committed a crime, rather than having them turned away by mental health services as ‘untreatable’.

  Many psychiatrists relegate the personality disorders to a diagnostic dump bin. ‘Psychopathic disorder’, for example, is a legal term used in the current mental health legislation to refer to people who have ‘a persistent disorder or disability of mind…which results in abnormally aggressive or seriously irresponsible conduct’. It is not a psychiatrically agreed condition. There was an outcry from much of the psychiatric profession when the bill, which had sizeable costs attached to it, was brought forward. The Royal College of Psychiatrists contended that there was no ‘entirely satisfactory’ diagnosis of antisocial traits that threaten public safety. The Lancet warned that dangerous severe personality disorder (DSPD) was so vaguely defined that six people would have to be detained to prevent one from acting violently. The concern for civil liberties meant the bill was severely amended so that patients’ rights were respected alongside the concern for public safety. Historically, the mad or bad conundrum has swung between the two poles as much as a result of social demand and governmental attitude as of psychiatric fashion. It has proved ever intractable and in need of correction. Alienists who, in the early days of the profession, might have wanted to extend their domain now feel wary of taking responsibility for what seem non-medical imperatives or social rehabilitation, for which they may have few skills.

  The category of borderline personality disorder–neither quite mad, nor altogether bad–is another diagnostic dump. Until the precisions of recent DSMs, it designated an individual whom traditional therapies had found it all but impossible to treat, though they often asked for treatment or were assigned to it by social agencies. According to the NIMH, 2 per cent of American adults, most of them women, are borderlines: emotionally unstable, they may attempt to seduce, manipulate, attack the therapist or simply leave the treatment. They have a pattern of rapid emotional fluctuation, as well as of shifting aspirations, jobs and relationships. They account in America for some 20 per cent of psychiatric hospitalizations, often because of suicide attempts or threats.

  In the early days of the women’s movement, the analytic characterization of borderlines was derided. It was understood, in parallel with hysteria, as a controlling classification–a label to be applied to any woman who wouldn’t conform–from Dora to Marilyn Monroe. Wildnesss, desire, extreme language, excessive, impulsive, indeed rebellious behaviour were simply not allowed into the feminine repertoire; and so its expressions were categorized as mad, morally insane, hysterical, borderline.

  More recently, as classifications in our therapeutic society become something of a desirable attribute, a sanctioned identity which can confer meaning and a lifestyle to misery, ‘borderline’ has become an acceptable, certainly accepted, classification. It describes an illness and holds out the hope of recovery, even if often it is a condition linked to certain social determinants: poverty, drugs, violence.

  Patients designated as ‘borderlines’ have now also been recognized as suffering in many instances from PTSD. This link to childhood trauma or neglect has rescued the diagnosis from the untouchables pile. Judith Herman offers a description that has fed into the diagnostic manuals. ‘Borderline patients find it very hard to tolerate being alone, but are also exceedingly wary of others. Terrified of abandonment, on the one hand, and of domination on the other, they oscillate between extremes of clinging and withdrawal, between abject submissiveness and furious rebellion.’ Often understood as suffering from a failure of development in their early years because of parental neglect or abuse, borderlines–the professionals now agree–have never managed to form an inner representation of trusted people. They feel empty, need others to fill that emptiness, and so may frantically seduce or please. This need, however, can all too soon transform itself into a feeling of being invaded, combined with the contradictory terror of being abandoned. Unstable, with no sense of boundaries or inner security, their intimate, sexual or parenting relations often fail. Their precarious inner state is one in which good and bad, ideal and demonic, are split off from one another, so that no links between the two exist.

  Forensic psychiatrists and analysts in Britain, while accepting that the symptoms of the borderline patient can lie in early abuse, often find its perpetrator not in the father but in the mother–the point where the cycle of neglect or violence starts. Estela Welldon, Juliet Mitchell and others after them have postulated that violence of the kind enacted by women can best be understood as a form of female perversion, a perversion of motherhood: its site is the whole body and its extension, the child. When women attack their own bodies by self-mutilation, starvation or bingeing, by repeated placing of their body in relation to an abusing male, they are avenging themselves on a perverse or cruel mother whose extension they are, just as the child is theirs. Child abuse, or chronic infant neglect, is the reproduction of perverse mothering.

  Recent treatment methods for borderline patients recommend a mixed package of therapies. No longer considered unreachable, patients are now understood to need SSRIs for their depression or anxiety, particularly if they are threatening suicide; a talk therapy, and thirdly, a measure of re-education and support over the years while they learn to deal with their volatility, which is often exacerbated by drug or alcohol use. England’s National Institute for Mental Health (NIMHE) has recently put forward a plan which attempts to rescue borderlines from exclusion. This plan for a ‘personality disorder capabilities framework’ combines psychological treatment with a programme of education for employment alongside vocational or professional training, and continuing therapeutic support services. What is effectively a life-support system is seen as useful because the alternative is a sequence of failed drug rehabilitation programmes, erratic hospitalizations, and damage or danger to the woman and her children.

  The favoured psychotherapeutic approach to personality disorders is Washington Professor of Psychology Marsha Linehan’s dialectical behaviour therapy, or DBT. This sets out to teach patients how better to control their lives, their emotions and themselves through self-knowledge, emotional regulation and that cognitive restructuring which is a feature of all the behavioural therapies. New ways of coping with the world, with social and intimate relations, and in particular how to handle stressful situations without recourse to drugs or violent upheaval, form a key part of the therapy, which also imports ‘mindfulness’ training from Eastern religions. The use of the word ‘dialectical’ in th
e name of the therapy signals that this treatment both takes the patient as she is and ‘validates’ and supports her while confronting the imperative of change–which is the therapeutic aim.

  The therapy assumes that on top of an ‘invalidating environment’, the patient’s condition has a biological underpinning in the failure of her ‘emotion regulation system’, which may be due to genetics, intrauterine factors, and/or traumatic events in early development that permanently affected the brain.

  It is clear that recent neurological studies of trauma have had an impact on the treatment of borderline patients, who, it is reported, share the predisposition to aggression because of impaired regulation of the neural circuits that modulate emotion. ‘Impulsivity, mood instability, aggression, anger, and negative emotion’ are characteristics supposedly implicated in the malfunctioning of the amygdala, and dependent on those key chemical messengers serotonin, norepinephrine and acetylcholines. Happily, we’re told, ‘such brain-based vulnerabilities can be managed with help from behavioural interventions and medication, much like people manage susceptibility to diabetes or high blood pressure’.

  Over the last twenty years, the work of the mind doctors has increasingly fallen into line with the more medical and neurochemical side of the profession. Physical, even genetic, explanations of illness have predominated. These made a sideshow of more diffuse dynamic arguments that placed less emphasis on classifiable symptoms and diagnoses and more on the patient’s history, relations, and her unconscious. But in order to attract patients or research monies, theoretical leg-work needed to be done by the talking therapies. Diagnoses changed, proliferated and acquired a precision, hand in hand with the new drugs. Some would even say that symptomatology and diagnosis tailored themselves to the pharmaceutical industry. But this was in part what increasingly savvy patients, who could self-diagnose from Web, book, memoir or magazine, wanted.