Susan Sontag observes in Illness as Metaphor that when a disease's cause and epidemiology are mysterious, humans make the disease a repository for their culture's anxieties. I would add that the metaphorical weight of an illness is limited by its physical reality: Syphilis was "about" sex, tuberculosis and cancer "about" death. Insanity, however, is not physical: its cultural meaning is uncontained. Over time, it has been "about" everything from wombs and onanism to genes and child abuse. Since a majority of those called mad are women, insanity has often been "about" sex roles.

Sontag notes that the metaphors we give disease can worsen the victim's suffering. Those with HIV become pariahs, while those were tuberculosis are expected to be saintly martyrs. The metaphors of insanity, however, erase the illness and the existence of the ill person. Literary madmen are seldom sick, merely misfits in an inhuman world (Harvey) or victims deprived (by women) of their masculinity (One Flew Over the Cuckoo's Nest, etc). Literary madwomen are ill, but merely need to enact a properly narrow female role to be cured. The authors of The Three Faces of Eve found "Eve White" too frigid, "Eve Black" too sensual. If she were more sexual, but not wanton; less feminine, but not masculine; married, but not clinging; fertile, but not codependent -- she would be well.

Sontag argues that "illness is not a metaphor" and thinks the most productive way to regard illness is "one most purified of, most resistant to, metaphoric thinking" (3). But that view keeps Sontag from criticizing the abuses of established medicine and makes her dismiss "alternative" medicine. A medical view of insanity -- that madness is merely a disease treatable with psychopharmacology and electroshock -- is hardly better than metaphors. An either-or of metaphor versus medicine is as false as the one given Eve between "white" virgin and "black" whore.

This essay seeks to bypass that "either-or." Foucault (Mental Illness and Psychology) writes that insanity is a mere construct of culture, but treats it as an existential metaphor for the socially repressed: in Part 1, I discuss flaws in "reading" insanity this way, and suggest the tangled nature of the link between insanity and culture, repression and mental dis-ease. Part 2 shows that this tangle tangles has, however, been almost completely ignored by the various medical approaches take toward treating insanity, which have historically had more to do with neglect, social control, and abuse than with healing. Part 3 concludes by looking at the underlying medical philosophies of these traditional approaches and of other approaches that led to more or less effective therapies.

Insanity and postmodernism

A postmodern "reading" of insanity would observe that the dominant culture defines itself as "normal" only in the negative -- as not poor, not female, not gay, not insane. Abnormality is stigmatized, and those with stigmas are subject to oppression or banishment. Since there is no positive definition for who "we" are, the series of exclusions can always expand to force out and suppress any new threat to structures of established power. And the negative definition enables "us" to maintain the appearance of being simple, unified, and sensible in contrast to the frighteningly complex messiness and confusion of those disreputable "others." But expulsions are never clean: there is always a residue left behind, an essential part of "the norm" which is threateningly "abnormal." Thus a facade of simplicity hides "our" similarity to "them." Insanity, an abnormality based on invisible and arbitrary criteria, is thus doubly useful. It can stigmatize troublesome people who cannot easily be removed otherwise. Also, since the meaning of "sane" is mysterious, one can disguise the abnormality of the norm by occasionally expanding the definition of "mad."

For example, the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) has added new "diagnoses" with each revision, including ones for children who run away from their abusive homes ("runaway reaction of childhood," 1968 edition, 50) and for women who play the martyr ("self-defeating personality," also named "masochistic personality," 1987 edition, 371-74). Note that the child and the woman need fixing, not the abusive family or the society that teaches women to put themselves last.

But postmodern critiques cannot interpret my mother, Mary's, personal history. Three times between 1975 and 1978, right-handed Mary cut herself with a razor blade up and down her left forearm. Mary, a non-smoker, burned her left arm with cigarettes. Mary held her left arm against the red-hot coil of an electric stove. When her arm no longer had enough unmarked space, she marked her right leg. Her right arm is unmarked because with her clumsy left hand she was afraid she would accidentally kill herself. Mary carries the scars of a schizophrenic.

In Mental Illness and Psychology, Foucault describes schizophrenia as "an illness normally characterized by a disorder in the normal coherence of the associations" and by "a breakdown of affective contact with the environment" or with other people (6). However, he adds, "it is only by an artifice of language that the same meaning can be attributed to 'illnesses of the body' and 'illnesses of the mind'" (10). With the body, anatomy and physiology can "offer medicine an analysis that authorizes valid abstractions" and allows "the determination of a . . . real causality"; this is not so with the mind (10). Foucault's thesis is that physical medicine is based on the empirical sciences, but mental medicine has no equivalent empirically real basis.

Psychology can describe the "forms of appearance of the [mental] illness," but not its etiology (60). Causes of insanity are not "organic evolution, psychological history, or the situation of man in the world." Instead, insanity has "its reality and its value qua illness only within a culture that recognizes it as such" (60). Foucault mentions that homosexuality among the Dakota Indians was not seen as aberrant to show that the behaviors which count as "illness" depend on the culture (62). In addition, however, even when, say, Europeans and Zulus agree that the behaviors typical of Zulu shamans-in-training constitute "illness," the meaning and value given those behaviors (hysteria versus religious initiation) are dependent on the culture (62-3).

In arguing that insanity is a metaphorical creation of culture, Foucault summarizes his Madness and Civilization. He claims that beginning in the 17th century, "the mad," along with the poor and disabled, began to be locked up in "great internment houses" (67). As a result, "madness . . . disappeared. It entered a phase of silence . . . it was deprived of its language" (68-69). Foucault has anthropomorphized an idea while forgetting about the people who bleed and die from the real effects of that idea. From age 16 to 21, Mary was an inmate of those internment houses.

For four years, until her sophomore year at Viterbo College for Women, Mary lived in St. Michael's Home for Emotionally Disturbed Children. The first half of her sophomore year abruptly ended with a month (as much as her insurance would cover) in a psychiatric hospital. Pregnant, she was sent away from both college and Home at the end of her sophomore year. She spent a summer with her parents, waiting tables, then lived briefly in St. Joseph's Home for Unwed Mothers, until she burnt herself with a clothes iron and was sent to Mendota State Hospital for a five month stay. Finally discharged on her 21st birthday, she worked as a dishwasher (since no one would hire a crazy person to wait tables), until, via a state educational rehabilitation program, she entered the University of Wisconsin.

In the chapter "Mental Illness and Existence," Foucault writes that we can only understand the "anxiety," which he has deduced must lie at the center of mental illness, "from the inside" (44). He then inquires how the mental patient perceives "his" illness, to what extent "he" objectifies or identifies with the illness, how "he" perceives temporal and spatial experience, and so on (ch 4). The closest Foucault is willing to come to seeing madness "from the inside" is through the theories and observations of psychologists, from whom he extracts concepts about the generic mad "man." (1) When he does quote a first-hand account, Renee's The Autobiography of a Schizophrenic Girl, he describes and cites it as the work of Renee's therapist, Sechehaye, who "collected the impressions experienced by her patient" (49). Renee and the Zulu shamans are simply anthropological examples to him. This is gossip: a discussion among the "normal" (white educated well off males) of the intimate details of the "abnormal," and behind the abnormal's backs.

Foucault's views may have begun with his dislike, as a gay man, of psychiatry's oppression of homosexuals. It ends, however, with impersonal claims that "the world cannot acknowledge its [own] madness" (83). Similarly, Spivak's essay on "Unmaking and Making in To the Lighthouse" notes that Woolf "broke down" six times in the years following her mother's death. But Spivak instantly abandons the image of Woolf's despair and eventual suicide. Rather, she supports her thesis--that the novel's central, "hinging" section "narrates the production of a discourse of madness," or "a story of unhinging"--by noting that Woolf "unhinged" or "desecrated" reason by keeping her 1899 diary on papers glued to the pages of Watt's The Right Use of Reason (35). Woolf's depression becomes merely a metaphor, like her diary, which helps us solve an intellectual literary puzzle. Foucault asserts that "we must now place ourselves at the center of this experience" (44), but this "center" is an insulated one, where the progress of philosophy and literary criticism is not upset by tears or screams.

Foucault's work is an essential intellectual tool for me. Stripped of her language and style--which I see as acting "largely to keep the peasants from bursting into the ballroom and clumping about with you know who" (Joanna Russ 149)--I find Spivak's deconstruction equally useful. Clearly "self-defeating personality" and "runaway reaction of childhood" require a cultural materialist interpretation and a political critique. But these interpretive tools come with a context, of philosophical blind spots and of macho academic one-upping ("my theory is bigger than yours"), in which theorists and philosophers, in their pursuit of "the glossolalia of the schizophrenic" (Davis 5), use and forget about people like Virginia, Renee, and Mary.

Terminology (2)

Foucault would say that there is no there there: insanity is a label without an empirical referent. Insanity is simply behavior deemed to be so disruptive of social discipline that, in order to enforce "normal" behavior, it must be either stigmatized or banished from society; in addition, the culture deems it not to be the fault of the aberrant or disruptive person (ie, not crime). In practice, the border between madness and crime has always been uncertain. Likewise, the same behavior can be accepted or stigmatized depending on the status of the person doing it: the difference between eccentric and insane is often one of gender and money. My main interest in this essay is not with social aberrances which are stigmatized, like being gay ("neuroses"), but with disruptions of work and commerce which are banished, like chopping the heads off parking meters ("psychoses"). Society has usually banished such behaviors through confinement or (most recently) drug treatment of the mad person.

To avoid confronting the morally unacceptable nature of culture's definition of insanity, people subscribe to a "common sense" ideology that defines "insane" as mental abnormality, assuming that "normal" sanity is a self-evident category. Crazy people supposedly suffer from aberrant or inexplicable feelings or thoughts, while sane people do not. Sane people become sad or excited for a significant reason, insane people for no reason, or for a trivial one. The people who get to define what is trivial, aberrant, or explicable are those in power, for whom the problems of the powerless are not real and thus trivial. The tyrannical beauty of this ideology is that since we all, at times, experience what someone might call aberrant or inexplicable states of mind, and since the difference between significant and trivial is arbitrary, everyone is subject to the oppressive social control of being called insane.

However, Foucault's definition cannot encompass the experience of my father, who told me of coming home to find the smell of blood filling the apartment because Mary had cut herself. Even less can it encompass what caused Mary to hurt herself. Insanity does have an empirical referent, and I would say that it is when someone experiences a state of mind which, when she is lucid, she finds so distressing that it impairs her ability to live. The distress is not due to changeable outside circumstances, such as material want or social oppression. Clearly, the distinction between madness and discontent due to oppression is unstable. Nancy Mairs describes her depression as due both to her lack of feminist insight into her oppression as a woman and to the particular nature of her neurochemistry which made her distressed. Again, since everyone is hampered by baseless distress sometimes, everyone can be called mad. I am more concerned here with global, unlivable distresses, like a shattering of coherent thought ("psychoses"), than with specific, livable ones, like unhappiness ("neuroses"). However, culture decides what counts as livable -- distress that interferes with the life of a hunter-gatherer would be quite different in kind from what would impair a capitalist worker.

By neglecting neuroses in favor of psychoses, I do not wish to minimize "mere" stigmatization and internal unhappiness. Neuroses cause far more suffering and death, as the suicides of stigmatized gay teenagers and of unhappy depressed people attest. However, it is only recently that neuroses have been seen as insanity. Oppressive social discipline on a vast scale made possible the capitalist factory, giving many Westerners a level of material luxury never imagined before, in turn leading many to feel entitled to a pleasing state of mind. In addition, the division between psychosis and neurosis is unstable. A state of mind that was simply endured when survival was difficult becomes unlivable in good times. Likewise, social control, while less linked to material conditions, is still imposed in different ways and intensities in various times and places.

Causes of distress

I used the same terms in defining both cultural and internal insanity because the two are connected. Clearly what is distressing depends in part on what is acceptable (people may enter therapy because they are disturbed by their homosexual desires, but not because of heterosexual ones) while what is acceptable depends in part on what those in power find disturbing (unhappiness is as normal as happiness, but the privileged feel entitled to the latter, so unhappiness has become a disease). Being stigmatized is distressing, while distress can drive people to stigmatized acts. But the linkage is significantly deeper than this.

Some kinds of madness originate in the mad's life history. For example, what is called shell shock or post traumatic stress in men, and "hysteria" or dissociation in women, is one normal response to such horrible experiences as war, rape, and torture (Merck Manual 1587-88; also see Evans). Such experiences are produced and (especially with child abuse or rape) even encouraged by culture.

The idea that children tortured by their parents will always grow up emotionally ill has become a self-help cliche, and a false one. But to invert the cliche, the form and content of insanities like schizophrenia, whose cause is primarily organic (see below), can be profoundly effected by the personal history of the insane person. Mary as a child was physically and sexually abused. When she heard imaginary voices, they chanted "slut" or "whore" to her. Her friend H, on the other hand, who had a pleasant childhood, calls his voices his friends.

Recently, NPR's Michelle Trudeau has reported on research which shows that "schizophrenia is a brain disease" (Morning Edition 5 Feb 96). While many kinds of insanity are rooted in the brain's physiochemistry, Trudeau's story gives the false impression that insane people, from causes of genetics or prenatal maldevelopment, have "abnormal brains," and that there is a clear and sharp division between Mary's schizophrenia and a "normal" person's sanity. This view ignores how often "normal" people flirt with unreason via alcohol, caffeine, chocolate, or sugar; or seek visions through LSD, mushrooms, hyoscyamine, or religious faith. Current Medical Diagnosis and Treatment (hereafter CMDT) warns that amphetamines, PCP, or cocaine can produce "a psychosis that is almost identical to" a schizophrenic episode (917). CMDT refers to an "impairment syndrome" in which psychoactive drugs do permanent damage to the brain's "neurotransmitter receptor sites," producing "symptoms that may mimic other psychiatric illnesses" (926). So aside from organic predispositions, anyone exposed to the right substances for long enough can become schizophrenic.

Mary's friend, H, was a "normal" genius-level pianist, mathematician, and German scholar until he returned from a college party one day to accuse his parents of stealing from him. It seems someone at the party had spiked H's beer with LSD. He unwittingly drank, disliked the taste, and got a new glass, but that first sip was enough. Ever since, H has heard imaginary voices and believed that he can hold telepathic conversations with his acquaintances.

There can be no rigid division between H's brain before and after the party. We all vary in feeling, from elated to depressed, for example. However, since we cannot observe the chemical changes in our brains, we become expert at blaming all emotional shifts on psychological causes. When I move from morning confidence to evening despair over the amount of work on my desk, it is hard to remember that the change has not been in the amount of work I have but in my blood sugar levels. When her child stopped breastfeeding, Paula Caplan writes that she felt depressed. "When I noticed that I felt depressed, I then felt ashamed, because I thought that it signified my inability to let her grow up." Her pediatrician reassured her "'that's hormonal. It'll go away in a few days.' I felt relieved. My feelings had been normalized" (Caplan 164).

The moods of insanity do not lie outside the normal range of human thought and feeling. Rather, people vary, normally, in terms of which chemicals will effect their neurochemistry to produce what is called insanity. Many people ruin their livers seeking a brief insanity through the toxic hydrocarbon solvents used in paint, glue, and so on. In "Last Chance," Barbara Van Flandern describes how she began to experience muscle spasms and motor control loss, memory loss, a speeded up or slowed down time sense, and anxiety and depression after a year or so of working with oil paints and turpentine in art school (2-3). She was diagnosed with schizophrenia, but her physical symptoms sent her from doctor to puzzled doctor. After two years of searching, she and her husband found a doctor who showed her that by wiping off her lipstick, she could regain her motor control and concentration: by holding a lipstick or magic marker under her nose, she could make herself worse (7).

Everyone is constantly breathing or ingesting a wide variety of organic and inorganic chemicals which are foreign to the brain's metabolism. Such foreign chemicals can have an adverse effect on the brain's workings before they are assimilated into or eliminated from the body. Van Flandern had poisoned herself with her art supplies to the point that her body became unable to safely eliminate the toxins she was exposed to on a daily basis, so that she became hypersensitive (loosely speaking, allergic) to those toxins.

The cover to Sherry Rogers's book The E. I. Syndrome rhetorically asks: "are you allergic to the 20th century?" (3) From trichlorethelyne in drycleaned clothes and polyvinyl chloride in scents, to gasoline in car exhaust, Westerners think nothing of breathing or putting on our skin things which can kill if eaten. The idea that everyday chemicals can cause "environmental illness" is unpopular: people prefer to believe in a sharp but imaginary division between toxic and non-toxic. E. I. literature has many cases of healthy people becoming sick after prolonged contact not just with pesticides or silicone implants, but perfume, hair permanents, or common cleaning compounds. Once a body's ability to deal with toxins is damaged, everything can be toxic, from turpentine to pollen, mold, and food proteins.

On steady, low doses of an offending substance (like caffeine), the body becomes accustomed to, even dependent on, the toxin. Combined with our extraordinary ability to explain away changes in our mental state as due to psychological stresses, this makes it very difficult for people to connect their tense mood on holydays to the perfume and dry cleaned clothes they wear to worship, or their weekend lethargy to a favorite Saturday snack of popcorn and chocolate. (4) After fasting for a week, Van Flandern discovered that she felt "in charge of myself again, for the first time in over 2 years" (8-9). Breaking fast with wheat made her "very angry, and eventually suicidal" for three days. Corn (which is nearly ubiquitous in modern processed foods) made her terrified, caused her to see and hear things as magnified and distorted, and gave her paranoid fears of being attacked by strange men (9-10).

So rather than abnormal brains, it is more useful to think of a normal range of susceptibility. Some, like Van Flandern, become mad if constantly exposed to the wrong proteins or chemicals. Others, like H, can be forever deranged by a single exposure to something. Still others, like Mary, may have E.I, but at base seem to have been born with an "insane" neurochemistry. Overlay onto these variously susceptible people a range of jobs, diets, and cultural norms that lead to more or less exposure to toxic chemicals or foods. Overlay the result with individual life histories ranging from highly traumatic to innocuous. Overlay the result yet again with varying degrees of social oppression and enforcement of social norms, and we begin to see the complexity of multiple causes which contribute to mental distress (insanity), and which in turn can cause stigmatized (insane) behavior.

Treating stigma

However, as "people whose behavior the community found intolerable," or who were thought of as "the disturbing, the vaguely menacing, the unwanted, and the useless" (Scull 251, 252), the insane have historically been treated on the basis of their stigma rather than to relieve their distress or help them function socially.

History of insanity

Andrew Scull (The Most Solitary of Afflictions) and David Rothman (The Discovery of the Asylum; Conscience and Convenience) trace the history of the treatment of insane people in 19th century England and America, respectively. In pre-industrial times, madpeople (those who violated social norms) were given the same treatment as "the senile, the incurably ill, the blind, the crippled, and the maimed." Such people were cared for by relatives, and if they were too poor to provide such care, the local municipality provided "permanent pensions for their support" (Scull 15). Cities which had almshouses usually used them only as a last resort for people with no connections (Rothman Discovery 36-39). Violent lunatics were usually locked in local jails (Scull 39, Rothman Discovery 271), and madhouses were rare.

As displacements caused by urbanization and the enclosure of England's common lands increased, so did the number of people unable to support themselves who had no nearby relatives. Ultimately, Scull notes, the community approach to poverty and disability ceased to work as capitalism created a market-based society in which social obligations came to be defined in terms of wage work and nothing more (32). Wage capitalism made it harder for families to care for their non-productive relatives, and simultaneously made the community less willing see any of the poor as "deserving" of aid.

Disabilities that did not greatly interfere with work in a rural economy rendered people unemployable under capitalism. At the same time, working-class people were increasingly unable to afford the cost in lost wages of caring for a sick relative at home. Care for madpeople, along with other disabled paupers, increasingly became a state responsibility. For our purposes, the institutional systems which have developed for the insane as a result over the last two and a half centuries have evolved through three phases: that of madhouse, asylum, and mental hospital.

Madhouses such as Bethlem had existed for centuries, but they, along with hospitals and workhouses, became more common in the later 1700's (Scull 18), as poverty and madness began to be defined as social problems. Madhouses were distinguished by a treatment regime which used chains and cages to confine the mad. Lunatics were thought to have lost the reason of their souls, and thus their humanity (Scull 56). They needed "severe government and discipline" (60) to eradicate their evil impulses. Thomas Willis's 1683 Two Discourses Concerning the Soul of Brutes advised madhouse keepers to administer "punishments and hard usage," including "threatenings, bonds, or strokes [beating] as well as Physick [leeches, emetics, purgatives]." Treated thus, the lunatic's "Corporeal Soul being in some measure depressed and restrained, is compelled to remit its pride and fierceness," become "more mild, and returns in order," cured (cited in Scull 60 original italics).

In general, madhouses confined what were seen as the "acutely disturbed and refractory insane" (Scull 38). For a fee, madhouses took the mad off the hands of relatives, jailers, and workhouse managers who saw keeping such people as "highly dangerous and inconvenient" (80). Madhouses became common as workhouses, intended to jail the undeserving (able bodied) poor and teach them the value of "honest work," became the preferred method of poor relief in the later 1700's. Madhouses could remove those whose behavior disrupted workhouse discipline. Other madhouses sold "discreet silences" to well-off families who wished to make their embarrassingly insane relatives disappear (23). In either case, Scull notes that while keepers advertised their ability to achieve cures, "the fundamental orientation of the system" of madhouses was profit, which meant using chains and cages to keep order "with the least trouble [and expense] to the keeper" (40). The result tended, with a few exceptions, toward extreme deprivation, filth, and cruelty. The mortality rates in madhouses were double those in asylums (Scull 276, 340).

The first asylum in England was the York Retreat, founded by Quakers in 1792 in response to the suspicious death of a Quaker inmate at the York madhouse (Scull 97). Asylums were distinguished by "moral treatment," a term with multiple meanings. "Moral" was obviously in contrast to the assumed evil of madhouses. Asylums renounced chains and beatings, and sought to provide inmates with adequate food, clothing, shelter, and cleanliness. Also unlike madhouses, asylums segregated inmates to prevent such "immoralities" as the unsupervised mingling of different sexes, classes (Tomes 128-29), and (in America) races (Gamwell & Tomes 58).

This concern for the mad's health and comfort was an integral part of a treatment philosophy which held that the mad were "not devoid of understanding," and should be "treated as rational beings." By rousing their "moral feelings," one created "a sort of moral discipline" in the mad person's soul (Scull 98), transforming the mad "into something approximating the bourgeois ideal of the rational individual" (99). Thus asylums taught illiterate inmates to read (Walton 177), and featured prominent chapels (Scull 283, 284). An orderly, spiritually peaceful, regimented environment was supposed to encourage sane behavior. By "taking tea with their superintendent," and the like, inmates learned to "conceal," "overcome," and "confine" their "morbid" thought patterns and "deviations," so that they would no longer be "obnoxious to the family" (Scull 101). In short, the meaning of "cure" had retreated, from restoring inner order to the soul, to achieving an outer appearance of orderly behavior. Work was thought the best way to practice sane behavior, so asylum plans usually provided for workshops or farms in which inmates could (gently) be compelled to toil (102).

The York Retreat's approach to treatment is usually connected with the French Revolution's humanist ideals, dramatized by the story of Philippe Pinel going into the Salpetriere to unchain the mad (Rothman Discovery 110). I prefer to see moral treatment as a logical outgrowth of capitalism. Andrew Ure's 1835 The Philosophy of Manufactures spoke of "'subdue[ing] the refractory tempers of work people accustomed to irregular paroxysms of diligence. . . ' [ie, farmwork] and teach[ing] them to conform to the impersonal dictates of power-driven machinery" (cited in Scull 34). If such a radical change could be effected in the working classes, why not in the burdensome underclass? Commodity capital had turned the state of being poor or mad into the problems of poverty and madness. Factory discipline offered a solution: to eliminate slothful poverty through workhouse discipline and aberrant madness through asylum discipline. The possibility (which propaganda rapidly called a certainty) of cure made the immorality and neglect of madhouses all the more intolerable. English reform groups engaged in a lobbying campaign which eventually led, in 1845, to the mandatory inspection and licensing of institutions for the mad by a board comprised of moral treatment advocates, and to the mandatory construction of county asylums for pauper lunatics (Scull 165). Similar reforms occurred in antebellum America.

Because of the requirements of moral treatment, asylums were inherently more expensive per inmate than madhouses. While the madhouse was an ill-reputed place (Scull 24) of last resort, asylums had to define themselves as the place of first resort in order to remain solvent (135). In addition to proclaiming the evils of madhouses, asylum propaganda declared that relatives were unable to cure mad people, and that moreover, care in the home, "which had nurtured the disturbance in the first place," was deleterious (137). Asylums supposedly were the only environments hopeful of cure (Tomes). The main result of this propaganda was that people strained by the expense in lost wages of caring for a sick relative at home were more willing to commit her to an asylum (Gamwell & Tomes 39). In addition, while madhouses had held mainly extreme maniacs, any mental infirmity that reduced income became the province of the asylum (Scull 368, 372). So the rate of public asylum admissions grew steadily (343), and the size of such asylums exploded (369).

Since public asylums were funded by local taxes, however, staff did not expand to keep pace with the number of inmates. Institutions opened with beds for a hundred and anticipations of a 90% cure rate soon became custodial warehouses for a thousand chronic incurables. The definition of "cure" retreated again, from removing the outward manifestations of insanity to dampening and controlling them. Thus the treatment philosophy of mental hospitals, which are distinguished by using chlorpromazine (Thorazine) and other psychotropic drugs, invented in the 1950's and later, to relieve the most visible of outward symptoms. These drugs have fostered a massive shift from institutional to outpatient treatment, accompanied by the elimination of three quarters of all mental hospital beds (The Merck Manual 1635). Mental hospitals embody practices, most of which also occur in outpatient psychiatric care.

Class and gender divisions

Despite their great differences, and despite the leveling of medical insurance, a striking and still extant continuity between the treatment paradigms of asylums and mental hospitals has been a structural division between the systems for dealing with the rich (insured) and poor (uninsured) insane. These structural divisions find expression in the ease with which different groups are called insane, and in how important it is for them to not be insane. The divisions lead directly to differences in the material conditions of rich and poor insane. The differing social importance of mad people has lead to control methods based on either neglect or coercion. A secondary, and in many ways parallel division exists between madwomen and men. Because women are both socially important and unimportant, they are treated in contradictory ways, sometimes as lower class, sometimes as upper class.

Taxonomy and inclusion

In Women and Madness, Phyllis Chesler divides the diagnostic taxonomy of insanity into "female diseases," labels usually placed on women, and "male diseases," usually placed on men (42-43). I would add that there is also a division between "rich diseases" and "poor diseases." The rich are often split into ever narrower subdivisions of abnormality, making it difficult but all-important to measure up to an ideal of normal sanity. The poor are often lumped into broad, inclusive categories of abnormality which make them innately insane. Within the same social class, women are treated both as innately abnormal ("lower class"), and as an ("upper class") group for whom normative behavior is more narrowly defined.

Rothman notes that bourgeois ideas equating moral and material worth made 19th century officials reluctant to distinguish among the "groups at the bottom," who were all seen as "more or less bothersome, culpable, and" undeserving (Discovery 290). In England, moral treatment cost at least four shillings a week more than keeping someone in the workhouse (Scull 362), making poor law officials reluctant to send paupers to the asylum unless they became expensively inconvenient, which often meant not until the pauper was dying. Annual mortality in asylums was about 8%, and 10 to 18% for new admissions (Scull 276, 271). Up to 25% of new pauper admissions were simply senile (371), or, because of retardation, epilepsy, delirium tremens, palsies, or dementias (372), simply hard to care for in the workhouse.

Similar finances operated in America, where an 1873 inspection of Michigan workhouses found that "sane and insane" were indiscriminately housed together, and that "cells for the insane and idiotic were 'dark, damp, cold, and filthy beyond description'" (Rothman Discovery 288). These unfortunate people remained officially sane only so long as it was less expensive for them to be so. England's parliament tried various bookkeeping methods to encourage local officials to diagnose and commit lunatic paupers, including a weekly subsidy of 4 shillings per pauper asylum inmate, which made asylums less costly to local government than workhouses (Scull 368). With such subsidies, workhouse managers began to declare their charges insane on the slenderest of pretexts (Scull 362): the resulting rise in the numbers of pauper inmates led one critic to wonder if the subsidy would "gradually render extinct the race of sane paupers in England" (cited in Scull 370).

In 1921 and 1928 in England, two young women whose families turned them over to the state when they became pregnant were put in asylums because their county had no home for unwed mothers. The women did not get out of the asylum until 50 years later (Chesler 162). It seems that whenever poor people came under the control of the state social welfare apparatus, they were subject to being called insane and put in an asylum if they were troublesome (like Mary) or if that was the easiest way to deal with them.

Today, poor people continue to be called insane or not as economic expediency dictates. Poverty, inability to pay the rent, makes people lose their homes, yet for many people "homeless" has acquired the mandatory prefix "mentally ill." These poor people are called insane when their presence and actions render a business district unesthetic, but when debating whether to give the same people poverty relief, we decide that they are not sick and do not need us to buy them the baths, clothes, shelter, and food (or normalizing drugs) which would enable them to stop violating social norms.

Pauper inmates in Victorian asylums were lumped, "loosely diagnosed in such terms as mania or melancholia" (Showalter 322 original italics). In contrast, the detailed taxonomies of madness which existed at the time (Scull 207) were used to split the diagnoses of middle and upper class people, especially women. This was especially true of the lucrative middle class, largely female group of "nervous" outpatients--"neurotics, hysterics, anorexics," and neurastheniacs--who were "desperate to avoid the stigma" of being committed to an asylum (Scull 255-56). The more diagnoses available for such people, the more lucrative they became. The DSM, which today defines what insanities are covered by insurance, is a prime example of such lucrative splitting. It has grown from 106 diagnoses in the first edition (1952), to 374 ways to be insane or just "nervous" in the latest (1994) revision.

While they are diagnosed from the same book, the poor are still lumped, not split. Paula Caplan's They Say You're Crazy notes that schizophrenia, despite 70 years of research, and general consensus that its cause is in the physical brain, still suffers from "'a heterogeneity problem,' a polite way of saying that it [the label] is so variously applied that it is losing much of its meaning" (xvii). I suspect the label is "variously applied" in part because it is a default diagnosis for poor mad people. CMDT warns against confusing schizophrenia with "adolescent phases of growth and counterculture behaviors" (917).

Such women's insanities as "hysteria" are likewise heterogeneous, "wastebasket diagnoses" (Evans 229), but unlike "mania" or "melancholia," the madnesses of women have been elaborately codified and theorized. Middle class women's sexuality and reproductive biology were seen as so threatening to mental stability that it seemed a wonder to Victorian mad-doctors that so few women were insane (Showalter 322-23). Victorian taxonomies had "women only" madnesses like neurasthenia, nymphomania, and hysteria, while modern ones have self-defeating personality, PMS, and codependency: these also suffer from heterogeneity problems (Caplan passim). The core attitude has been that women are innately abnormal: women's insanity is simply an extreme of normal femininity. In short, "hysterics are more womanly than other women" (cited in Evans 30).

The most obvious result of defining women as innately abnormal has been a disproportionate number of supposed madwomen. In 1872, 54% of all certified lunatics in England were women (Showalter 316). Phyllis Chesler's Women and Madness notes that in 1968 America, excepting state mental hospitals (half men), 60% of all psychiatrically involved people were women, and the trend from '64 to '68 was toward higher percentages of women (306ff).

Much of this disparity is due to social definitions of gender. Men and women are seen as different and opposite, but normal healthy people are male, making women innately abnormal and unhealthy by default. Thus men are judged by different, often laxer rules of conduct. The violent, antisocial behavior of a typical action film hero (eg, Rambo) is seen as manly and admirable. When men's behavior is called disruptive, the men are more likely to be classed as criminal than insane. Chelser argues "the kinds of behaviors that are considered 'criminal' and 'mentally ill' are sex-typed, and each sex is conditioned accordingly" (57). Since he was taught, as a man, to be outwardly aggressive and active, John Salvy's delusions led him to kill abortion clinic receptionists. State mental hospitals, with an even sex ratio, tend to be reserved for those deemed "dangerous to others" (Warren 42), as well as for supposedly hopeless incurables and charity patients.

Material conditions of inmates

Wealth, followed by gender, was a deciding factor in how great a Victorian's peculiarities had to be for them to be stigmatized as insane. Impoverished people were declared insane at the discretion of workhouse managers. Working class and petty bourgeois families could ill afford to lose the income of a mad male relative, but could also ill afford to give home care to a nonworking lunatic. So long as the aberrant man was able to work, and no longer, a financially insecure family would put off committing him. While the same calculation applied to a woman's housework, her contribution to the family economy was less essential. Upper class and secure bourgeois families did not need the income or housework of a mad relative. They did need to keep their wealth from being dissipated by demented male heirs (Scull 358), and to save their reputation from being hurt by the presence or behavior of a lunatic, especially of a madwoman, whose actions were often shockingly unlike proper femininity (Showalter 320).

A similar division exists among children today (minors are the only modern group who, like adult Victorians, can be committed involuntarily without a legal hearing). Louise Armstrong's And They Call It Help: The Psychiatric Policing of America's Children unfortunately equates class with race, but one can see from her account that in general orphans and wards of the state become psychiatrically labeled at the whim of the state's child welfare apparatus. Working class children are labeled by teachers when they do not perform their jobs as students. Children of insured parents are labeled at their parents's request when they fail to measure up to the parents' standards of behavior.

The shame associated with having it known that a family member was insane caused many upper class Victorian families to hide their mad relatives at home, especially their madwomen (Scull 294): since sane women's actions were so restricted anyway, it was not all that different to lock up a madwoman (as in Jane Eyre). Respectability is still an issue for some families today. Noreen McCarrick, a therapist I know, told me of a patient of hers who had been locked in a walk-in closet by her husband for over ten years. The husband eventually packed up and left town, thoughtfully phoning his wife's sister to tell her that "your sister is locked up in the closet. You had better go and take care of her."

If home care was impractical or burdensome, affluent Victorian families preferred to ship their madmen abroad, or make use of one of a number of unlicensed, illegal and highly confidential madhouses, where inmates were subject to "often . . . appalling conditions" (Scull 294). Well off families who did send their mad to legal asylums usually paid over 100 pounds per year to place them in institutions of about 36 inmates (293). Public asylums held hundreds of inmates at a public expense of at most 11 shillings a week, or 29  a year (Scull 311). Parsimonious poor law officials usually pared costs to as little as 6 or 7 shillings a week (315). In contrast, prisoners cost 10 (312), and workhouse paupers about 3 shillings a week (Scull ??).

With their fees, private asylums provided a surfeit of diversions. The Crichton Royal Asylum, for example, offered a relatively modest program ranging from "bowls, billiards, summer ice, cards" and magic lantern shows, to "fishing, walks, concerts, the circus, outings to the theater" and the putting on of plays (Scull 296). One suspects upper class inmates were seldom asked to work. The cost paring economy of public asylums, however, meant that the poor insane had few activities other than work. The labor of more lucid lower class inmates was used to cut public asylums' costs by tilling the farms, sewing the clothes and bedding, and cleaning the buildings of the asylums (Rothman Discovery 146). In 1924, New York's Willard State Hospital reported that thanks to inmate cobblers, it had not had to purchase footwear for any of its inmates in over 25 years (Rothman Conscience 346). This cost-cutting exploitation of inmate labor was called "occupational therapy" (344).

Given fewer choices in work and play, women were in effect lower class inmates than men. Elaine Showalter's "Victorian Women and Insanity" notes that since asylums defined sanity according to bourgeois norms, madwomen had to conform "to the narrowest of Victorian sex stereotypes" (320). Colney Hatch asylum, on the theory that "physical exercise was essential to mental health," built a cricket ground for the men. Women inmates, seldom taken on walks or outings, were allowed to watch the men play cricket from a "specially fenced off enclosure" (321). Women's work was strongly sex-typed, "offered much less choice, took place indoors," and was often meaningless: while sewing, washing, and cooking were most common, in one asylum, women were asked to sort out different colored beads, which were dumped back together at the end of the day (320-21).

Work and play were unable to relieve the boredom of institutional life, however. Even with its leisure program, Crichton Royal Asylum reported in 1848 that "the effect of long continued discipline is to remove all salient parts of the character, all . . . peculiarities." "Enfeebled by monotony, by the absence of . . . new impressions," inmates acquire "a stolidity and torpor . . . superadded to their original malady" (cited in Scull 293). This iatrogenic, ingrained boredom was inextricable from what Crichton Royal Asylum's annual reports called an "impress of authority" which was "stamped on every transaction" in the asylum's regimented routine as a part of moral treatment's "curative discipline" (cited in Scull 171-72).

Despite the demise of moral treatment, work and regimented discipline have continued to the present day: they keep inmates passive (Scull 293) and help reduce costs. In 1966, in Mendota State Hospital, Mary was asked to type lab reports for 10 an hour. This exploitation was called "occupational rehabilitation." Refusal to work was and is treated as a sign of illness. George Ebert, an activist in Syracuse's Mental Patients' Liberation Alliance, told me that today such jobs are called "training programs" (the difference between training and work is a salary), or "work for pay," a name which implicitly acknowledges that being paid is unusual (phone interview).

Inmates who disrupted moral treatment's curative boredom, or who violated bourgeois norms, were disciplined. Padded rooms, straitjackets, and hot or cold baths were the most common punishments. At Colney Hatch, women inmates were punished by confinement to padded cells five times as often as men, and were more likely to be given steam baths (Showalter 321). Other punishments were more specific to public or private institutions. The huge inmate to staff ratio of public asylums encouraged the beating of inmates by asylum staff, which moral treatment reform had been unable to eradicate fully (Scull 292, see also Chesler). More legally, public asylums found it useful to keep inmates on a starvation diet, which made them docile and also pared costs (Scull 291). Women inmates were allowed fewer calories than men (Showalter 319). Private asylums, in contrast, could afford to use drugs to control outbursts. While sedatives were the most common punitive drugs, more dubious substances were also prescribed. Hyoscyamine caused "physical collapse and mental depression, confusion, and hallucinations of sight and touch." Inmates would understandably do much to avoid a second dose, so that the drug "created a 'moral effect lasting much longer'" than the physical one (Scull 291). Again, women inmates at Colney Hatch were more likely to be disciplined with sedative drugs (Showalter 321).

Today, the insured insane are disciplined into conformity with psychotropic drugs, while many uninsured insane, unable to work or pay the rent, are too hungry to disrupt commerce from their position on the street grate.

Neglectful vs. coercive control

The difference between the punishments of public and private Victorian asylums was more than one of costs. Hunger can enforce docility, but the fear of hyoscyamine can enforce arbitrary rules of conduct. If poor lunatics were starved because nobody much cared so long as they were not disruptive, rich ones were subject to fierce attempts to make them conform, docilely, to the norms of their class. Again, women were subject to higher standards than men. Institutions for the poor insane have defined their convenient custody and harsh control of inmates as medical therapy. But this "therapy" is seldom focused on relieving the inmate's distress, and sometimes instead exacerbated it.

The beating and bindings in madhouses, supposedly for reforming the souls of the mad, were a cheap way to keep many inmates in line with few staff. When moral treatment asylums, promising better results than madhouses (Scull 164), abandoned physical restraint, they found that madhouse bondage had in fact produced many of the wild ravings which supposedly made it necessary (Scull 289). The work and discipline of moral treatment, supposedly for producing conformity in the behavior of the mad, were a convenient way to reduce asylum costs and to control the insane. As noted above, asylum doctors saw that the boredom of discipline "superadded" new symptoms to the inmate's original madness.

While we can critique the effectiveness of the beatings in madhouses or the moral treatment in asylums, it is hard, without the separation of time, to see the current paradigm of psychotropic drug therapy used in mental hospitals in the same way. Attempting to achieve perspective through depth, I will focus on neuroleptic drugs, ubiquitously prescribed for schizophrenia and similar severe psychoses. (5)

Neuroleptics, ("major tranquilizers," "antipsychotics") are good at suppressing schizophrenia's "positive symptoms," like hallucinations, delusions, or variable moods, but are poor at stopping its "negative symptoms" like withdrawal or lassitude (CMDT 918). As with moral treatment, these drugs can impose an outer appearance of orderly behavior but do little for the person's inner distress. Note the value judgments: socially disruptive symptoms are "positive," important; mere internal misery is "negative," unimportant.

Neither The Merck manual nor CMDT mention neuroleptics' more visible effects as "major tranquilizers." They are profound sedatives which tend to suppress creativity, mental alertness and personal liveliness as they do "positive symptoms." As a former inmate told Louise Armstrong, "your mind turns to cotton candy. It's very hard to think. . . To function. I had no energy" (277). High enough doses can produce a zombie-like appearance ("flattened affect") that some associate with mental patients. Mary's husband once told her that after she took her medication, he could watch her mind and personality switch off. With them, Mary was (usually) not suicidal, enraged, or hearing voices; however, she wasn't as lively and interested in life either.

Neuroleptics also cause numerous unwanted effects, including Parkinson-like spasms, reduced sexual arousal (Merck manual 1639), constipation, and "extremely dry mouth. So that--my tongue would crack" (Armstrong 277). Prolonged use can cause a permanent impairment of fine muscle control (tardive dyskinesia). Neuroleptics are seldom prescribed alone, but with other drugs intended to treat these adverse effects (Merck manual 1639-42), which themselves have other adverse effects, so that even apart from her psychological state, a person taking neuroleptics will normally feel sick. However, with the exception of the highly visible spasms and dyskinesias, negative effects are a concern in The Merck Manual or CMDT only insofar as they threaten to reduce "patient compliance" to the prescribed regimen.

The Merck Manual recommends matching individual drugs and patients to help minimize harm and maximize "compliance" (1637). This advice is seldom followed. Clinics (and doctors) often simply prescribe the same drug to everyone, reducing costs and simplifying administration. The choice of drugs is strongly influenced, of course, by corporate advertising. As symptoms rise and ebb, a dose low enough to allow the person to mentally function is rarely able to eliminate all "positive" symptoms all the time. Both treatment manuals agree that neuroleptics are not able to help much with severe chronic insanity. Yet the recommended response is to prescribe more until all symptoms vanish: the "most common cause of failure in the treatment of acute psychosis is inadequate dosage" (CMDT 898). The result for the mad can be a sort of chemical lobotomy.

Neuroleptics are commonly used in mental hospitals, even for patients whose symptoms are not "psychotic" (Caplan 16-17). The zombie-like state the drugs produce is as useful as the ingrained boredom of moral treatment. Armstrong's informant said "I was on heavy doses because they wanted to use it for control. And it works. . . . It slows you right down" (277). With neuroleptics, inmates may be distressed and unhappy, but they are quiet about it and do not inconvenience the hospital staff or (as outpatients) their family with any obnoxious "morbid propensities." The first neuroleptic, chlorpromazine, was the least effective at suppressing positive symptoms. It was nonetheless popular for reasons that its nickname makes clear: patients called chlorpromazine "liquid handcuffs."

A "flattened and shallow" affect is both an effect of neuroleptics and a diagnostic criteria for schizophrenia (CMDT 916). But, as with the ravings of chained maniacs, or the ingrained boredom of asylum inmates, negative effects of drug "treatment" are ignored or called desirable. Armstrong notes, "that the [iatrogenic] behavior began only after the administration of . . . [the treatment] is not considered fact. What is considered fact is that the behavior is further evidence of the [supposed] disorder" (221).

Like underfeeding pauper asylum inmates, psychotropic drugs are a minimum effort, minimum expense, "go away and don't bother us" response to the disruptive behavior of mad people. True, the general level of control has increased, so that drug treatment once reserved for private patients is now ubiquitous. However, both underfeeding, and the usual cheap method of modern drug therapy (where all personal contact is with a therapist, and one very briefly sees an MD psychiatrist who barely knows them for a "med check" every few months), constitute a regime of neglect and minimal convenient control. Coercive enforcement of behavior norms tends to be reserved for women and the richer classes.

Even poor women who violated accepted gender roles were likely to be treated like New York's Lucy Ann Lobdell (1829-1912). Lobdell, who dressed as a man and supported herself and her wife by hunting, was discovered to be an "insane, foul, and unsexed" woman when she and her partner were jailed as paupers. Her "very poor" family published an obituary for her, and, diagnosed with "dementia and erotomania," she spent the last 32 years of her life in public asylums (Gamwell & Tomes, 164). In Madwives, Carol Warren discusses the 1957 case of "Peggy Sand," a working class housewife who voluntarily committed herself to escape from her abusive husband, then had an affair with a male patient; with her husband's consent, her transgression was seen as grounds to recommit her involuntarily (Warren 109-110). This enforcement of narrowly "proper" female roles only grew stricter with increasing social status.

Rich men who egregiously violated class boundaries were called insane. In 1858 in England, the relatives of a Rev. W. J. J. Leach tried to place him in an asylum when he announced his engagement to his housemaid. The doctor who signed his commitment papers was shocked that Leach "dined and took his meals with his servants and kissed them in the morning, and allowed them to sit on his knee," (6) and that after prayers, Leach would play "cards with them [the servants] until 3:00 in the morning, and between deals he read chapters out of the Bible to them" (McCandless 352). Notorious cases like Leach's led to formation of inmates' rights groups like the Alleged Lunatics Friends Society of Britain, which lobbied in 1859 for an end to the censorship of inmates' letters. But the group made an exception for ladies, who, they said, "needed to be protected [through censorship] from possibly indecorous self-revelation" (Showalter 319-20 original emphasis).

"Ladies" who were insane became unladylike. Victorian mad-doctors were shocked by, and interpreted as disease symptoms, women inmates' "rowdiness, restlessness, and use of obscene language," especially in "well nurtured" inmates. Male doctors expected and demanded women inmates to be "quiet, virtuous, and immobile" (Showalter 320). Girls' adolescence was called a "miniature insanity" when well-behaved children became "snappish, fretful" and "full of deceit and mischief" (324). Today, Caplan notes, the "range of acceptable feelings for women is [still] very narrow, from bland to nurturing" (163).

Quite mild class inappropriate behavior was grounds for putting women in the asylum. In 1687 Daniel Defoe wrote of the "vile practice now . . . In vogue among the better sort, as they are called, but the worst sort, in fact, namely the sending their wives to mad-houses at every whim or dislike" (cited in Chesler 163). If anything, moral treatment encouraged such actions. Many Victorian doctors, whose signature was all that was needed to place someone in an asylum, equated adherence to bourgeois social, moral, and sexual codes with sanity (McCandless 341). Thus in England, Edith Lanchester, a free-love socialist, was kidnapped by her father and brother and committed by a doctor who "believed her opposition to conventional matrimony made her unfit to take care of herself" (Showalter 325). Women of the Asylum (Jeffrey Geller & Maxine Harris) collects similar accounts from America. In 1860, Elizabeth Packard's husband kidnapped and imprisoned her, as she put it, in an asylum after she "defended some religious opinions which conflicted with" his Presbyterianism (Geller & Harris 58). Adriana Brinckle's father committed her in 1857 in order to avoid the family dishonor (and expense) of having his daughter sued for bad debts (108). Margaret Starr was committed in 1901 in order to take her inheritance away from her (214ff).

While habeas corpus laws now prevent adults from being committed without a hearing, such laws do not apply to children, who are still called mad because of inappropriate behavior. Recently, 16 year old Delia's divorced parents did not approve either of her choosing to live with a friend rather than one of them, or of her leaving school. So they committed her to a for-profit psychiatric hospital, where she was diagnosed with drug addiction and major depression based on their testimony. Delia's complaints that her patents were being paranoid and controlling, and her objections to having been kidnapped and incarcerated, were seen as symptoms of her supposed illness (Armstrong ch1).

Louise Armstrong shows that the "psychiatric policing" of the troublesome children of well off parents, like Delia, is characterized by systems of merits and demerits, called therapeutic, which are in fact applied in petty, tyrannical, and arbitrary ways by the staff to enforce bourgeois norms. Such systems have a long history. From the start, moral treatment segregated patients by social class and degree of outward conformity. This sorting evolved into grading systems like the 1930's ward poster defining the "way out" for schizophrenics (cited by Rothman). Grade A, "at home" was "able to act like normal people. Able and willing to work. Able to get along with family and friends." Grade B, "going home," was "working well," and so on. Grades E and F included being "lazy and shiftless," uncooperative, "mute, resistive," or "not working or playing" (conscience 343). Failing inmates were those with stereotypical lower class faults: to pass, they had to be "normal" in the eyes of the bourgeois doctors and staff who ranked them. Ostensibly a "new method of treating" inmates (Rothman Conscience 342), the system in practice was used to threaten inmates into behaving. During her hospitalization for agoraphobia (in the 1950's), Nancy Mairs was effectively told "do as I tell you, [and] you can get well. Otherwise, you will be here forever in that chronic ward I sent you to" (Mairs 209).

Coercive threats and controls are called therapeutic, resulting in an almost disingenuous double consciousness on the part of psychiatrists, in which obvious, deliberate cruelty is called proper and necessary. Hyoscyamine's severe negative effects, described above, were seen as having a "moral effect" on inmates.

One infamous example of such "therapeutic" torture is electroshock. Asylum doctors in France started giving women with "hysteria" painful shocks in the late 1800's out of a belief that the women were feigning (Evans 32). As French soldiers began coming down with "hysterical" symptoms (shell shock) during World War I, they were also viewed as "simulators and malingerers" and were treated by torpillage, "torpedoing" the soldier with "massive electric shocks" which enabled the doctors to send 90% of them back to the trenches, "cured" (Evans 75). After World War II, the procedure was given the more euphemistic name "electroshock" (111). Negative effects of this torture included risks of broken bones, including vertebrae (from the electrical convulsions), and memory loss ranging in degree from minor to profound and in duration from brief to permanent (Warren 129ff). Today, after years of disrepute, "electroconvulsive therapy" (ECT) is being touted as "the most effective . . . treatment of severe depression" whose use is hampered by "poor patient understanding" and a lack of public acceptance (CMDT 900). Two thirds of the people who receive ECT are women (Warren 129). Like ranking systems, the threat of ECT is used to make patients shut up and behave. My friend F complained during her January 1996 hospitalization that her antidepressants were giving her allergic reactions, and was told that ECT was "the alternative" (phone interview).

By itself, overt sexuality was a diagnostic criterion for many of the female insanities in Victorian taxonomies (Showalter 325). Violations of accepted sexual behavior, either seductiveness or mere obscene language, was called "nymphomania" (324). On the theory that women's madness was caused by the malfunction of their sexual organs or by masturbation, doctors tried to "cure" insanity through clitorodectomy and oophorectomy (removal of ovaries) as recently as 1924 and 1946, respectively (329).

Again, the claim was that this coercive, punitive, and damaging control method was good for the madwomen, a claim that seems less credible the more it is invoked. One of Mary's friends in Mendota, L, was put in an experimental "treatment" program after Mary left the hospital in 1966. Trying to reduce aggressive "schizophrenic" behavior, psychiatrists used what they called a "punishment program" of shocking women patients with a cattle prod whenever they "made accusations of being persecuted and abused" (the experiment or a similar one is cited in Chesler, 36). It seems unlikely that L derived benefit from her torture: within a few years she had drowned herself.

Torture and Stigma

How is it that psychiatrists can torture someone with a cattle prod and yet maintain that they have that person's health and well being at heart? The attitude which makes such doublethinking possible is exemplified by Mary's encounter in the late 1970's with a doctor at Buffalo's for-profit Bry-Lin psychiatric hospital. A psychiatrist on his way to something saw Mary, and without making eye contact, said "Hi! How are you today?" Mary said that she was feeling terrible, just awful. "That's great, have a nice day," he said, not stopping.

A virtually identical interchange is reported in the second half of D.L. Rosenhan's key article "On Being Sane In Insane Places." (7) Rosenhan's pseudopatients would politely ask, in the jargon of the ward, when they would be eligible to be moved up a grade in the hospital's ranking system.

The encounter frequently took the following bizarre form: (pseudopatient) "pardon me, Dr. X. Could you tell me when I am eligible for grounds privileges?" (Doctor) "Good morning, Dave. How are you today?" (Moves off without waiting for a response.) (255)

Rosenhan reports that even though individual staff members were asked such questions no more than once a day by the pseudopatients, the most common (71% of psychiatrists and 88% of other staff) response was silence or the briefest of answers, given with head averted and without stopping (255). Only 6% of psychiatrists and less than 3% of other staff paused to converse even briefly.

Rosenhan's data is suggestive of the authoritarian, one-way nature of treating the mad. Carol Warren found that none of the 17 working class 1950's housewives diagnosed with schizophrenia which she studied had received psychotherapy, although 10 received electroshock (128). Giving inmates individual psychological attention is expensive, but even in the context of the "med check," in which a doctor asks "how are you feeling," and writes a prescription, there is seldom any interest in hearing how the person is feeling. Mary was given over 20 different psychotropic drugs at different times during her first 16 years as a mental patient, but was never asked by any of the prescribing psychiatrists if any of them had seemed to help.

Medical philosophy

Paula Caplan repeatedly argues in They Say You're Crazy that if they told the truth to their clients, psychiatrists and therapists would say that "I have been able to help only some kinds of people with certain kinds of problems" and that "I am judging how much I have been able to help people in a very subjective and haphazard way" on the basis of anecdotal information (16). Instead of saying such things, and making psychiatric treatment a collaborative effort, psychiatrists tend to act as if they know exactly what is wrong with a mad person and exactly how to fix it. In 1976, Mary saw four different psychiatrists in 3 weeks in a public psychiatric ward (one for those unable to afford a personal psychiatrist), each of whom saw her briefly, gave her a new diagnosis, took her off her current drug, and put her on a new drug. This attitude of infallibility is part of the core philosophy of modern medicine, including psychiatry.

Scull traces the origin of psychiatry to the successful struggle of allopathic doctors to retain therapeutic power in the new asylums (ch4). Coulter covers the intellectual and institutional history of allopathic medicine. Aside from his infatuation with leeches, emetics, and purgatives, the allopathic doctor was characterized by a "confidence in his own medical theory" (Coulter 83), which allowed complete confidence in the rightness of the treatments he prescribed (86; 94-96). Allopaths also held a distrust of the natural "recuperative power of the organism" (83), instead seeing themselves as "masters of nature" and of the metabolic processes of the patient's body (84). This contempt toward the patient's body was extended to the patient: the causes of disease were simple, and only a few obvious symptoms were important, so doctors had to learn to ignore most of what patients told them (42). Medicine was an exact science (75), and it was only necessary to see a patient for a few minutes to divine the exact problem and remedy. Failures were due to patients who disobeyed directions (75).

Philosophy of Successes

To the contrary, the successes I am aware of are most often due to abandoning the allopathic philosophy. Before the system was overwhelmed by pauper patients, moral treatment was characterized by individual attention to the mental comfort and happiness of each inmate (Scull 102; also Walton 174-75). Early implementations of moral treatment combined such concern with a changed (country) environment, sufficient and nutritious food, and a comparatively restful but not idle routine (in comparison to the exhausting labor of the working classes and of most middle-class women). As a result, in its early years, the York Retreat discharged 45% of its total admissions as "recovered," double the rate at the end of the century (Scull 303). At first, the York Retreat's physicians only treated physical illnesses (188).

Traditional physicians are also notably absent from the field of treating environmental illness: environmental medicine's philosophy focuses on the extreme complexity of E.I. and on the active role of the patient in uncovering the "disguises" and solving the "mystery" of what substances are causing them to feel sick (Rogers 33). Van Flandern and "Joanna" (discussed in Not All In the Mind) recovered because their doctors were able to admit lack of knowledge.

Mary began to recover when her husband was hired to a tenure track university position and enrolled in the university's health plan. For the first time, Mary was able to afford a personal psychiatric psychotherapist, who asked her to try drugs and report back on whether they seemed to help or not. Mary enjoys nearly complete health today because of an unconventional drug therapy which is designed to promote mental alertness and focus (thus alleviating negative symptoms). "Unconventional" because the drug in question (Diamox, or acetazolimide, usually prescribed to treat glaucoma) is no longer protected by patent and its psychiatric use, discussed in a few journal articles, is not promoted by any advertising campaign. Unconventional also because the psychiatrist who introduced Mary to this drug, Hans Esser, does not prescribe any drug to his patients which he has not taken himself.

But these successes are the exceptions. It is very reassuring to a sick person to be treated by someone whose air of patriarchal authority proclaims that he knows what is wrong and how to fix it. The assumption that diseases are simple in cause means that psychiatrists seldom take into account the complex tangle of the causes of insanity's aberrant actions or its inner distress. That complex tangle, however, ensures that with virtually any treatment, some people will be helped. How many, and at what cost, in further harm to those who are not helped, or in the stain of cruelty on the therapist's conscience, is another matter.

Works Consulted

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Washington, DC: APA. 2nd Edition: 1968. 3rd Edition: 1980. 3rd Revised Edition: 1987. 4th Edition: 1994.

Armstrong, Louise. And They Call It Help: The Psychiatric Policing of America's Children. Reading, MA: Addison-Wesley Publishing Company, 1993.

Caplan, Paula J. They Say You're Crazy: How the World's Most Powerful Psychiatrists Decide Who's Normal. Reading, MA: Addison-Wesley Publishing Company, 1995.

Chesler, Phyllis. Women and Madness. Garden City: Doubleday, 1972.

Coulter, Harris Livermore. Political and Social Aspects of Nineteenth Century Medicine in the United States: The Formation of the American Medical Association and its Struggle with Homeopathic and Eclectic Physicians. Diss. Columbia U, 1969. Ann Arbor: UMI, 1970. 706955.

Current Medical Diagnosis and Treatment 1995. 34th Edition. Norwalk, CT: Appleton & Lange, 1995.

Davis, Lennard. Enforcing Normalcy: Disability, Deafness, and the Body. London: Verso, 1995.

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1 Foucault writes of madmen, even when his example is a woman. Although women comprise 60% of those called mad, he uses "he or she" only in discussing hysteria (12).
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2 I prefer the terms "lunatic" and "mad," which make clear insanity's cultural stigma.
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3 For additional information on "brain allergies," see Richard Mackarness, Not All In the Mind. Both books contributed to the following discussion.
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4 Both of these have been observed by Mary in her friends and husband, respectively.
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5 This discussion makes use of numerous interviews with Mary Pierce as well as the cited references.
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6 Class violation is so shocking that the servants are neutered and the sexual impropriety is effaced.
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7 "Pseudopatients" feigning to hear voices checked into mental hospitals, reported that the voices were gone, and behaved as they usually did, but keeping extensive journals, until released (after 19 days on average). The first, often cited, half of Rosenhan's essay shows that hospital staffs were unable to spot pseudopatients as fakers, and that all aspects of pseudopatient behavior were seen as symptomatic.
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