Father Knows Best

I just finished reading Michael E. Staub's Madness Is Civilization: When the Diagnosis Was Social, 1948-1980 (Chicago, 2011), which is an interesting account of the clash between the medical model of mental illness and the "social diagnosis" model in the United States during the decades right after World War II.

It just occurred to me that there's a parallel with the essentialist / social constructionist debates going on here, though Staub doesn't refer to that terminology. At times Staub seems to believe that the antipsychiatry movement of the Fifties and Sixties, exemplified by R. D. Laing and Thomas Szasz, held that there was no such thing as mental illness, though he also shows and seems to recognize that this is, at best, only partially true. There has been a lot of confusion about that question, though, as shown by a declaration Staub quotes from the Icarus Project, a "mad pride" collective: "Are we delusional and dysfunctional, or is it the culture we live in?" (192) As Staub documents throughout the book, this is a familiar idea: it weaves back and forth between denying that the concepts of madness and sanity/normality have any meaning at all, and declaring that I'm not sick, you are! -- which seems to concede the reality of "mental illness", but tosses it back and forth like a hot potato.

That's why I've always been ambivalent about this idea. I've read a fair amount of literature which holds that in an insane society, it's sane to be insane. (That's the premise of Doris Lessing's 1971 novel Briefing for a Descent Into Hell, for example, though it's also a theme in much of her fiction.) I'm inclined to think that sanity and normality may be relative to the situation, like Darwinian fitness: a trait that's adaptive in one environment may be maladaptive in another. But it also seemed to me that if the "mad" are really, as some have suggested (the questions are often more rhetorical than serious), gifted and superior beings, they should be able to function more successfully in an "insane" society than those of us who are putatively normal. Or maybe not: the real problem is that sanity and insanity are not very well-defined concepts, and even professionals are far too quick to label others as insane or mad or crazy -- not a whole lot better than laypeople. (As Staub also shows, "schizophrenia" is an ill-defined, hard-to-diagnose condition to this day, despite the ongoing claims that it's a medical, biological illness with a genetic base. I've long suspected that it will ultimately be defined circularly, as whatever condition responds well to a given treatment, and other conditions that don't, but which would have been confidently labeled schizoid in the past, will be defined as something else.)

Anyway, there's a lot of useful information in Madness Is Civilization, with a whole chapter largely devoted to the feminist revolt against the psychiatric/psychoanalytic establishment.

With disarming candor the psychoanalyst Theodore Reik – who had been trained by Sigmund Freud and who founded the National Psychological Association for Psychoanalysis in New York – repeatedly revealed that his female patients were unwilling to accept his insights into their states of mind. “When you listen to me a long time without saying anything, I often have the impression that what I say is silly woman’s stuff and without value,” one patient told Reik. “It is as if you do not consider it worth your while to speak to me.” Reik recollected how another female patient responded more sharply to his interpretations: “Goddam, I don’t know why I am here. Fuck yourself!” And a third female patient had this exchange with Reik: “When I told a patient in her forties that she had wanted to be a boy like her brother, she began to curse and abuse me, saying ‘Fuck you!’ and ‘Go to hell!’ and other unladylike expressions.” But these challenges to his authority did not cause Reik to doubt his own judgment. At no point did Reik allow for the possibility that outbursts from female patients reflected the legitimacy of their frustrations with him. (It was left to radical feminist Shulamith Firestone to point out that Reik’s commentaries read “like a Freudian jokebook.”) Yet by the early 1970s even the densest of analysts and other MDs could see that an extraordinary number of women were increasingly uncomfortable with their treatment.

Women in therapy were reportedly becoming so uncooperative that a proposal in 1971 sought to introduce a new diagnostic phenomenon. Called “the angry woman syndrome,” it described patients who took “fiendish delight in deriding their husbands” and who exhibited a “baleful disregard to decency.” These women were superficially well adjusted and successful in their lives, but they nonetheless “strike out blindly, frightened by any threat to their not being the sole center of attention.” In short, their behavior revealed patterns that “at times border on psychotic with paranoid and aggressive overtones.” In 1972 there was a second proposal for another new category of client called “the intractable female patient.” These were women who initially presented “exactly the kind of patient with whom the young resident in particular hopes to work.” But looks could be deceiving. In reality these women were supreme manipulators who used their feminine wiles to turn psychotherapy “into a quagmire from which escape is ever more difficult.” The psychiatric solution for the intractable female patient was for therapists to “set a firm discharge date reasonably early” and to insist that the husband “assume a posture of strength and resolution – especially toward his wife.” This was because the intractable female patient most desired to be dominated by men, the essay concluded, and though she might repeatedly test the resolve of men to dominate her, “she really hopes that she will not win” [144-45].

Here are some good examples of what I wrote earlier. Women who were angry at being confined by the narrow strictures of 1950s American femininity were not just labeled as sick, they were borderline psychotic. And you know it had to be true, because this was a scientific medical diagnosis, by the intellectual heirs of the Enlightenment and its values! Only an irrationalist would reject the authority of these men of science! In much the same way as today's evolutionary psychologists are embarrassed by and try to dissociate themselves from the racist and sexist eugenics of the earlier twentieth century, today's scientific psychiatrists probably prefer to forget this period in their field. The question for the layperson, though, remains what it was sixty years ago: how am I to tell whether today's practitioner really has a sound basis for his or her diagnosis -- or will it look just as embarrassing a few decades from now as "the intractable woman"? It's like asking a theist why I should believe in his or her god, but not in someone else's.

I'm not rejecting the medical model of mental illness out of hand, you understand. It may well be useful in some cases. But the burden of proof lies on the person who advocates the medical model, and a sharp, informed skepticism toward such a person's claims is not just appropriate, it's obligatory.