What is madness? Throughout the recorded history of Western civilization many a theorist has been concerned with this very question. However, across this vast expanse of time, madness, and its contemporary corollary, mental illness, has lacked any measure of conceptual consistency. Today, the question as to whether mental illness may be a culture-bound phenomenon further complicates any understanding of this rather nebulous construct. Consider the following examples: a small percentage of Chinese men have been found to suffer from a condition known as koro, a profound and intense fear that the penis is shrinking and will eventually disappear into the abdomen. In parts of Southeast Asia, Siberia, and Hokkaido there is documentation of a condition known as latah, which usually occurs in women and consists of brief periods of hypersuggestibility and automatic obedience, precipitated by the individuals' being startled in some way (Eaton, 1986). While these "disorders" might seem odd or even ridiculous to Europeans and North Americans, the Western world is also rife with conceptions of mental illness that grow out of the value and belief systems that dictate those behaviours which are considered "normal", as well as those which are considered "abnormal". Given that cultural diversity is a reality, how might psychologists, along with philosophers, physicians and lay-people, come to better understand a construct which is so intimately tied to the socially-imposed parameters that dictate which behaviours are acceptable and those which are not?
This paper is an exploration of mental illness as a culture-bound phenomena in Western societies. Specifically, it will address the ways in which conceptions of mental illness are in many ways tied to Western conceptions of "woman". To do so, a number of avenues of inquiry must be investigated. I will begin with a brief explication of the basic premises of a cultural psychological approach and how these differ from general psychology. This will be followed by an examination of the apparent connections between the constructs madness and woman that have occurred throughout history, with particular emphasis on the European witchhunts which took place from the mid- to late-Middle Ages through to the beginning of the Renaissance. Next I will consider common uses of language and how relationships between certain words may illustrate the connection between women and mental illness. The remainder of the paper will address contemporary conceptions of mental illness within the psychiatric community, exemplifying several categories of mental disorders which are overwhelmingly reserved for women.
Although cultural psychology differs from other paradigms also concerned with human behaviour and psychological functioning, general psychology is the approach from which it strays the furthest. According to Schweder (1990), general psychology adheres to a basic Platonic assumption sometimes referred to as the principle of "psychic unity". This principle consists of the belief that all mental functioning can be attributed to a "presupposed...processing mechanism inherent...in human beings, which enables them to think..., experience..., act..., and learn" (p. 4). It is assumed that this mechanism, although hidden to the naked eye, exists deep within each individual and is fixed and universal across individuals. The aim of general psychology is to describe and understand this central processing mechanism of mental life, untainted by content and context. The particulars of individual lives and the cultural milieu in which they live are considered irrelevant, as these are external to the general processing mechanism. In fact, it is assumed that attention to these "external" variables may interfere with the task at hand, which is to identify the mechanisms inherent to the properties of the universal psyche. Thus, the experimental laboratory is assumed to be the "transcendental realm where the effects of context, content, and meaning can be eliminated, standardized, or kept under control, and the central processor observed in the raw" (Shweder, 1990, pp. 7-8). The implications of this approach as it is applied to mental illness will be explored later in the paper.
How is cultural psychology different from general psychology? Cultural psychology, like the latter, is concerned with the study of human behaviour and psychological functioning. However, unlike general psychology, cultural psychology focuses on these phenomena as they are embedded in particular cultural contexts; it is the "study of the way cultural traditions and social practices regulate, express, transform, and permute the human psyche, resulting less in psychic unity for humankind than in ethnic divergences in mind, self, and emotion" (Shweder, 1990, p. 1). Its aim is to imaginatively conceive of subject-dependent objects (intentional worlds) and object-dependent subjects (intentional persons). The cultural psychologist assumes that no socio-cultural environment can exist independently of the way human beings seize meanings and resources from it, and every human being has his or her subjectivity of mental life altered through the process of seizing those meanings and resources from some socio-cultural environment and using them. From this perspective, it is the synthesis of psyche and culture that is of interest, as it is assumed that the two are, and always will be, intimately linked to one another. Shweder sums up this relationship nicely in his claim: "you can't take the stuff out of the psyche and you can't take the psyche out of the stuff" (1990, p. 22).
Cultural psychology is an interpretative discipline. According to Shweder (1990), in order to interpret intentional worlds and intentional persons one must engage in a process of "thinking through others", which entails a number of strategies. First, one can think by means of the other. This involves recognizing the other as a specialist or expert on some aspect of human experience. The second strategy consists of getting the other straight, or providing a systematic account of the internal logic of the intentional world constructed by the other. Third, is necessary to recognize oneself as the perspectival observer, or situated witness, while there, in the context of one's engagement with the other; here it is important to remember that the act of representing the other includes the process of portraying one's self, itself, as part of the process of representing the other. Finally, one can deconstruct and go beyond the other; here the aim is to pass through or intellectually transform the other into something else by revealing what the intentional world has dogmatically hidden, specifically its partiality and incompleteness. It is this final strategy which is most relevant to the task at hand, as it is the aim of this paper to deconstruct aspects of Western culture, at present and throughout history, in an attempt to reveal how its patriarchal and realist assumptions have influenced how conceptions of mental illness and those of women have evolved together in particular ways.
From the mid-to late-Middle ages up to the Renaissance in Europe, it is estimated that as many as nine million people were put to death for their heretical beliefs; an overwhelming majority of these individuals were women. These women were tortured, mutilated, incarcerated and killed, apparently for forming an unbreachable bond with the devil. Further, certain groups of women were especially vulnerable to the Christian Inquisition: old women, unmarried women, midwives, and herbalists in particular (Penelope, 1990). In 1847 Pope Innocent VIII commissioned the publication of the Malleus Malificarum (the Witches' Hammer), a "guide" to be used by judges, clerics and scholars in identifying witches for persecution. This book, which became the "bible" of the Inquisition, further legitimized the "licentious speculation about the behavior of all women" (Ussher, 1991, p. 44).
Many have offered speculations as to why women were far more likely to be accused of witchcraft than men. With the emergence of psychiatry as a distinct medical discipline during the 19th century came psychological interpretations of many historical events. The witchhunts were one of the more popular historical occurrences that engendered such attention. Unfortunately, many theorists did not see this event as being indicative of widespread hatred of women, but, instead interpreted the "burning times" as a gross misunderstanding of mental illness. As Spanos (1978) notes, three popular interpretations have been argued by historians of psychiatry: that a great upsurge in mental disorder occurred in the 15th century; that the mentally ill were considered to be witches; that witches were obviously disturbed because they confessed to bizarre and impossible things. According to Szasz (1967), some of the best known and most eloquent medical and psychiatric authors of the 20th century have endorsed the medical theory of witchcraft, which asserts that the medieval women who were accused of witchcraft "really" suffered from what come to be known a hysteria.
However "empathetic" and insightful these posthoc analyses may seem, Porter (1987) notes that in the 18th and 19th centuries, "madness, hysteria and insanity came to replace the catchall description of 'witch' as a label applied to women who were in some way deviant, in some way different: women who did not fit" (p. 113). By seeing the "witch" as the misunderstood, but nonetheless mentally ill, individual, these theorists failed to account for the socio-political factors which greatly influenced and legitimized the extermination of great numbers of women. In patriarchal societies, where women are defined and represented as Other; witches were doubly guilty, for being both women, and wicked (Ussher, 1991). While many women did confess to being witches or to having sexual intercourse with the devil, they did so only under sustained torture, on the false promise that if they confessed, their lives would be spared (Spanos, 1978). However, these factors have been neglected by those who choose to posthumously diagnose witches as hysterics. Perhaps the most striking omission from these theorists' analyses is that, despite their willingness to interpret charges of witchcraft as misunderstood mental illness, they fail to address the fact that it was mainly women who were falling "ill" with such conditions. Is it possible that in a time of "great upsurge in mental disorder", men could be so much less vulnerable? It is clear that 18th and 19th century interpretations of the witchhunts and the mental state of the witch do not represent better of more accurate interpretations of mental illness as is applies to women; they are just different interpretations based on the social norms and mores of the time--equally misogynist, equally destructive.
The cultural norms of the time of the "hysteric" created a composite image of the "lady"--the ideally feminized woman, who, in order to ensure her protection from the "evils" of the public sphere was delegated to the domestic duties of the home. Although this ideal was realistic for only the upper and middle classes, as working class women could not afford the "luxury" of remaining in the home, it was an ideal nonetheless. The male dominated medical community warned that a woman who trespassed beyond the private realm would surely be vulnerable to psychiatric collapse (Porter, 1987). Szasz (1967) claims that psychiatrists of the late-19th and early-20th centuries were no closer to a thorough understanding of mental illness than were the inquisitors during the "burning times"; in fact, he notes that some of Freud's opinions about women, were not unlike those of Sprenger and Kraemer, authors of the Malleus Malificarum. He further states the even today, the notion of mental illness is used to obscure and "explain away" problems in personal and social relationships, in much the same way that witchcraft was used as a scapegoat from the Middle Ages to the Renaissance.
How is this relevant to a cultural psychological approach to the study of women and mental illness? As has been demonstrated, conceptions of mental illness have not been static across time in Western culture. Indeed, culture has not been static across time. What was evil possession by the devil, became physiological manifestations of wish fulfillment, and is, presently, a complex and vast spectrum of disorders with a variety of characteristics. That is, in different "intentional worlds", "abnormal" or "deviant" behaviours are interpreted in different ways and are given different labels by "intentional persons" existing in those worlds. It is important to note that this is not conspiracy theory. It is likely that the majority of people living in Europe and the Americas did, at one time, believe that the devil could possess and transform a person; it is equally likely that many 18th and 19th century psychiatrists believed that their patients were truly suffering from hysteria as it was understood. Further, those subjected to the labels may have been equally susceptible to commonly held notions of "evil", "hysteria" and "mental illness". However, in order to understand why women have been particularly vulnerable to such labels, one must recognize popular conceptions of what is woman according to patriarchal ideology. Women have been variously considered evil, or at least more vulnerable to "evil" influences; emotionally weak; irrational; and perhaps most importantly, powerless. Some of the connections between conceptions of mental illness become clear with an analysis of popular uses of language.
Much of the work done by Thomas Szasz has been concerned with linguistic interpretations of the notion of mental illness. He has offered countless critiques regarding causation of mental illness, and the growing emphasis on its supposedly physiological roots. According to Szasz (1982), the term mental illness is a metaphor, and "Bodily illness stands in the same relation to mental illness as a defective television set stands to a bad television programme" (cited in Champlin, 1989, p. 24). That is, physical illness and mental illness are two totally separate kinds of phenomena, linked only by metaphor. Yet, mental illnesses are often treated as physiological ailments of the brain. Szasz (1975) claims that this is due to the fact that, unlike in the Middle Ages, when the lives and languages of people were rife with the imagery of God and permeated by the ideology of Christianity, today, they are suffused with the imagery of nature and permeated by the ideology of medicine. Accordingly, psychiatrists committed to biological causes of mental illness adhere to an ancient Roman philosophy that assumes that the main goal of man (sic) is to have a healthy body and a healthy mind. Here the "mind" is treated as simply another part of the human organism (Szasz, 1967).
However, as Szasz (1975) notes, if mental illness was indeed considered to be a specific form of physical illness, then the term "mentally ill" would not have come into being, as "ill" would be sufficient to describe it. Here, Szasz points to conceptual confusions inherent to the notion of mental illness. Although an implicit connection between physical and mental illness is assumed, and "sick" and "ill" are often used interchangeably, the latter implies more permanence than the former; we tend to use "sick" to describe states, and mentally "sick" or "ill" to describe characteristics, which are often considered to be longlasting. Whereas one might say: "I was sick yesterday. I came down with a cold", it would indeed be considered odd for one to say: "I was mentally ill yesterday. I came down with schizophrenia". According to Szasz, "permanence has always been the very essence of madness" (1975, p. 861).
In her book, Speaking Freely (1990), Julia Penelope offers a thorough interrogation of the English language, revealing its patriarchal roots. Penelope investigates the ways in which English (and many other languages), throughout its development has been male-defined and embedded in male conceptions of reality. She further notes that English is asymmetrical in terms of gender. That is, certain pairs of words seemingly distinguished only by gender (e.g., spinster/bachelor; witch/warlock; mistress/master), in fact carry different connotations; femaleness is semantically derogated, while maleness is semantically celebrated. While the spinster's chances of attaining marital bliss are bleak, the bachelor's are promising. The witch who casts her evil spells is shrouded in villainy; the warlock, by contrast, exudes mystique. The mistress is the one either wrecking or keeping the "happy home", while the master is consistantly the controller of that domain.
When taken together, what do these separate linguistic analyses mean? I believe the answer lies in notions of deviance. According to Berger and Luckman (1967), symbolic universes (or intentional worlds) require constant maintenance, and the "legitimation [sic] of the institutional order is faced with the ongoing necessity of keeping chaos at bay...All societies are constructions in the face of chaos" (cited in Eaton, 1986, p. 6). Acts are not deviant until someone defines them as such, and in patriarchal symbolic universes it is men who define both reality and what behaviours may be considered "appropriate" and "inappropriate" in that reality. As Rosen (1968) notes, the behaviour of those considered to be mentally ill has been historically "regarded as more than merely perplexing or perverse. They were regarded as deranged because their behaviour, and, inferentially, their orientation to reality were considered excessively divergent from socially accepted norms" (cited in Gorder, 1992, p. 22).
According to Broverman (1970), women are faced with a double standard with regards to mental health. She cites several studies that indicate that the ideal personality for the North American adult is that of the male; the "normal" female model is characterized by less than positive features such as: submissiveness; less independence, influencability, less aggressiveness, less competitiveness, excitability in minor crises, more emotionality, more conceit, and less objectivity (cited in Cockerham, 1989). Thus, women are deviant either way--if they act like the "normal" women, they do not fit the personality ideal of the "normal" adult; if their behaviour is consistent with that of the "normal" adult, they are exuding masculine traits, which deviate from the behaviour that is expected of them as women. According to Chesler, deviancy is readily equated with mental illness (cited in Synder, 1974). Perhaps some women labeled with mental disorders are not "sick", but are, instead, breaching the boundaries of socially sanctioned rules of conduct and must be controlled by any means; describing these cases of mental "illness" in terms of mental "sickness" legitimizes this control, yet the metaphor is left unrecognized.
Before providing a few examples of categories of mental illness which are disproportionately imposed on women, it may be prudent to first briefly comment on contemporary conceptions of mental illness within the psychiatric community. According to Busfield (1986), "positivist science rescued 18th century physicians from the mire, and has continued to be the 'lynchpin of psychiatric practice'" (cited in Ussher, 1991, p. 142). The psychiatric community's adherence to positivism, with its assumption of a fixed, objective, and universal reality, has aided in perpetuating the assumption that behaviour can be classified and categorized in the same way scientists have classified and categorized atoms and particles; this has led to the legitimization of the classification of mental disorders, and the taxonomic approach to madness (Ussher, 1991). To couch this in Shweder's terms, psychiatry, like general psychology, assumes that mental disorder (read: deviations from accepted prescriptions for behavioural conduct) results from the malfunctioning of an inherent central processing mechanism assumed to be responsible for all mental functioning. Yet, evidence suggests that this assumption provides only a thin veneer from which the psychiatric community can justify its power, as reliability and validity are poor across diagnostic categories (Busfield, 1986; cited in Ussher, 1991). However, it would be foolish to underestimate the power of the DSM-III-R (and its successor, DSM-IV), psychiatry's "bible", as "its diagnoses are generally recognized by the courts, hospitals, and insurance companies" (Leo, 1985; cited in Caplan, 1988, p. 187). The mechanisms for social control are intimately linked.
Although many have noted that a close relationship between women and mental illness (or deviance) has existed throughout Western history, not all categories of mental disorders are disproportionately reserved for women, as the behaviour of some men may also deviate from established rules of conduct. However, it is interesting to examine those diagnoses of mental illness which are more frequently imposed on women in order to reveal certain stereotypes regarding what is woman in our culture. Three examples will be given here: depression; battered wives syndrome; masochistic personality disorder.
First, studies have indicated that women are 2-6 times as likely to be diagnosed with depression as men (Penfold & Walker, 1983). There has been a growing emphasis on endogenous causes of depression; that is, depression that is characteristic of prominent "hypothalamic symptoms, and no "clear" precipitating factor (Wilson, O'Leary, & Nathan, 1992). According to the DSM-III, the essential feature of a major depressive episode is either dysphoric mood--characterized by symptoms such as the following: "depressed, sad, blue, hopeless, low, down in the dumps, irritable"--or loss of interest in all or almost all usual activities or pastimes (p. 213). This must be accompanied by four symptoms from a list of eight (e.g., poor appetite or increased appetite, weight gain or weight loss, insomnia or hypersomnia, loss of energy), for a period of at least two weeks. These criteria are vague and ambiguous at best, and are laden with problematic descriptors such as: "blue", "irritable", and "inappropriate sexual drive". However, the symptoms themselves are not the worst problem, as depression can be tremendously debilitating, and those so diagnosed often feel these symptoms. The major flaw with the classification of depression is that despite its apparently overwhelming prevalence in women, there is little attempt to locate any part of its etiology in the social position allocated to women in contemporary society. Instead, the psychiatric community generally views depression as the cause rather than an effect of women's problems (Penfold & Walker, 1983).
A second "disorder" reserved for women is battered wives syndrome. Although it is not formally listed as a disorder in the DSM-IV, the mere formulation of such a label may reveal some common conceptions regarding women in Western society. Specifically, it demonstrates the commonly held belief that women must be the gate-keepers of men's passions. It is woman who is defined as Other, thus it is she who becomes responsible for deviant behaviour, even that of others. Further, this label masks the abuser (men) and, in my opinion, this cannot be coincidental, for it is he who holds the power. This is but a simple example of the ways in which the psychiatric community legitimizes and perpetuates oppressive social relationships.
Finally, Caplan (1988) notes that "masochistic personality disorder" is a label often given to women by mental health care professionals. This "disorder" reflects the myth of women's masochism, the belief that women take pleasure in pain and are prone to seek out suffering. There are two tributaries to the myth: (1) women's anatomically-based pain (e.g., menstrual cramps, labour pains) reflects their enjoyment of pain; (2) mislabeling as masochism much of women's learned behaviour, especially being nurturing and self-denying (Caplan, 1988). As a result of adherence to this myth, many health professionals are quick to blame an unhappy woman for her own misery. The fact that labels such as these gain legitimacy within psychiatry tells us something about certain conceptions of women that prevail in our culture; women are considered vulnerable to evil, they are scapegoated for the "ills" of society, and they have only themselves to blame.
At the outset of this paper I posed the questions: What is Madness? I can only hope that I have illustrated that madness (and its contemporary correlate, mental illness) is a culture-bound phenomena, its meaning dependent on the dominant beliefs, values, and ideology of the cultures in which it exists. In patriarchal societies women are defined as opposite to the norm, which is male. In many respects women's very being is devalued and disdained. If mental illness can indeed be considered a category of deviance, then it is not surprising that women, seen as deviant in male-defined realities, are vulnerable to being labeled with a mental illness. By examining Western history, language, and contemporary conceptions of mental illness we can shed some light on this special relationship. Perhaps employing a cultural psychological approach such as this will help to broaden our definitions and increase our understanding of mental illness as a whole.
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