APY22110.1177/1039856213511276Australasian PsychiatryGarcia-Quiroga


The Arts

Australasian Psychiatry 2014, Vol 22(1) 44­–47 © The Royal Australian and New Zealand College of Psychiatrists 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1039856213511276 apy.sagepub.com

Two scripts of madness Juan Garcia-Quiroga   CAFMHS, Dunedin, New Zealand

Abstract Objective: The purpose of this article is to illustrate the concept of transient mental illness (TMI) as defined by Ian Hacking by way of two texts: Sybil by Flora Rhetta Schreiber and The Adventures of Don Quixote by Miguel de Cervantes. Conclusions: Psychiatric symptoms tend to follow, in varying degrees, a pre-determined script resulting from a collaborative effort between patient and therapist. They both work in a historical and cultural environment that supports and supplies the background and general lines of the script. Charcot’s hysterics and the multiple personality disorder epidemic provide good examples of this phenomenon. Most recently, the controversy around DSM5 suggests that there is growing concern that diagnostic manuals might be used as “scripts” that could lead to the creation of a string of new disorders. The concept of TMI helps explain the genesis and protean nature of psychiatric symptoms, while acknowledging the pain and disability of the sufferer. Keywords:  transient mental illness, MPD, Sybil, Don Quixote


acking1 describes transient mental illness (TMI) as “a psychiatric syndrome that arises, evolves and disappears according to very specific historical and local conditions”. In order to become apparent it requires an ecological niche. He refers to these symptoms as “idioms of distress”. He lists four requirements necessary for the appearance of a TMI: 1. The illness must be detectable as deviant behaviour. 2. The deviant behaviour must fit into a pre-existing taxonomy that allows it to be situated and recognised as an illness. 3. The illness must fit somewhere inside a cultural polarity that singles certain behaviours as positive and others as negative. 4. The illness must provide some release. Borch-Jacobsen2 suggests adding another requirement: 5. There must be a “clause of irresponsibility” that allows the ill person to lay the “fault” for their behaviour on something else. (Note that only when labelled a “true illness” it can provide the sufferer the release of responsibility).

Borch-Jacobsen argues that to refer to these conditions as socially constructed gives the impression that the patient is a passive recipient of the illness, rather than an active agent in its reality. A TMI, then, has a “legendary structure” as it conforms to some narrative or theory, to

expectations that precede and inform it. The illness is the patient’s idiom that he or she uses in order to communicate with the therapist. This idea had already been developed by Levi-Strauss:3 The shaman provides the sick woman with language, by means of which unexpressed, and otherwise inexpressible, psychic states can be immediately expressed. Borch-Jacobsen has expanded on this concept, emphasising the notion that, during the process of therapy, the subject’s production is the result of the conjoint work of analysand and analyst. The analysand is not just a passive receptor; he or she contributes in more or less degree to the construction of a view of reality that is shared by the dyad, and sometimes by people outside of it. Taking this notion to its logical conclusion we can then suggest that certain types of mental illness such as TMI cannot exist without the presence of an audience. In a dramatic representation actor and audience share a contract: they agree on a suspension of disbelief that will allow them to share a temporary reality. The performer and audience’s behaviour is also ruled by a fixed script. The actor has to stay “in character” and the audience must remain passive to the events happening on stage Correspondence: Juan Garcia-Quiroga, 2nd level, 9 Moray Place, Dunedin, 9016, New Zealand. Email: [email protected]

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without behaving as if they were real. Nevertheless, they are allowed to be moved by the events, to feel (but not behave) as if they were real. The concept of TMI considers the symptoms of the illness, which include a certain narrative as well, as bound to follow a prescribed and expected course. The symptoms are scripted, the playwright being the therapist (author) who is himself immersed in a culture that supplies the expectations of how the patient will behave during the course of the purported illness. The patient (protagonist/actor) contributes by adding his or her own personal stamp to the role, as an actor may occasionally ad lib or make contributions to the play that may eventually become part of the expected performance. This paper aims to explore the concept of TMI as a shared creation using two literary texts that, though dissimilar in context and artistic value, offer a good illustration of the subject: the first is The Adventures of the Ingenious Hidalgo Don Quixote de la Mancha by Miguel de Cervantes Saavedra.4 The plot is well known: Don Quixote is Alfonso Quijano, an impoverished Spanish hidalgo whose mind becomes deranged after reading too many romances of chivalry. He decides to revive the tradition of knight errantry and takes off accompanied by a village rustic as his squire to seek adventures to gain renown for his lady, whom he calls Dulcinea. All sorts of misadventures take place caused by the Don’s inability to differentiate between the prosaic realities he encounters and the romantic version provided by his readings. Cervantes suggests that the Don can actually perceive things the way other people see them, but that he must choose to see things according to what his readings have prescribed. He is following a script and the script does not allow variations outside of the prescribed texts rules. When things don’t go his way he has an iron-clad excuse: an evil enchanter has cast a spell that doesn’t allow others to see things as they are. On the other hand he is aware that he plays a part on this change. For example, he tells Sancho that he is aware that Dulcinea exists mostly in his imagination: “I am content to imagine that what I say is so and that she is neither more nor less than I picture her and would have her be…” The transmutation of reality from the one described by Sancho to the one he chooses to believe is very clear in the description Sancho gives of his encounter with Dulcinea whom, by the way, he has never met. The dialogue goes: - Surely you must have found her stringing pearls or embroidering some device in gold thread for this, her captive knight. - I found her winnowing two fanegas of wheat… - Well then make it that the grains of that wheat were grains of pearls, touched by her hands. And if you were able to see that wheat, friend, was it white or brown?

- It was red. - Well I assure you that, winnowed by her hands, it made the finest of white bread. The need to follow the prescribed rules makes Sancho describe Dulcinea’s hair as golden, her skin like alabaster, and her eyes like pearls. The Don takes exception to that last comparison and sets him straight: …you said that she had eyes of pearls, and eyes that look like pearls are more becoming to a bream than to a lady; and I believe that Dulcinea’s eyes must be made of green emeralds, with two heavenly arcs that serve as her eyebrows; so take those pearls out of her eyes and pass them on to her teeth, as no doubt you erred, Sancho, mistaking her teeth for her eyes. The plot becomes more complex during the second book of the novel: Don Quixote will now encounter people who have read about him on that first book. This creates a situation in which some of the actors become audience with particular expectations about the way they expect him to act. The Don, in turn becomes more inclined (and bound) to act and think as he has done during the first part of the book. There are also people who, having read about him and aware of his particular type of madness, create elaborate stages and situations in order to see him act as himself (in character) and laugh at his expense. In summary, both Sancho and the Don share a personal reality that is based on a script that is not shared by, but is intelligible to, most of the people they encounter, so they are able to anticipate the way that the two protagonists will react and think. They have no choice but to continue behaving as people expect them to do. To give up on their personal view of reality would mean having to accept a much grimmer, prosaic one: “I am an impoverished, unimportant old man and you are a village rustic.” The next text was fundamental in setting the canon by which multiple personality disorder (MPD) came to be understood, enacted and experienced. The book is called Sybil and was written by Flora Rheta Schreiber.5 It was published in 1973 and was advertised as the “true story of the treatment of a girl who suffered from multiple personalities”. The background for this disorder was scant, with most reports of double personalities (but not multiple) coming from the French schools of Psychiatry between 1870 and 1890. The French clinicians had described several cases of male and female patients who presented two personalities and considered this phenomenon to be a symptom of hysteria. The possibility that the “splitting” had occurred following a trauma of sorts had been considered, especially by the Nancy School. The condition had never been associated with child abuse.

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Australasian Psychiatry 22(1)

A literary precursor was the book entitled The Three Faces of Eve.6 It told the story of a woman who presented in therapy with three distinct personalities and how these personalities were finally resolved after she was able to remember a traumatic event during her analysis. The event was somewhat banal: as a child she had been made to kiss her grandmother while she lay dead in her coffin. It was made into a successful movie starring Joanne Woodward, who won an Academy Award for her role as Eve. In spite of the movie’s success, it failed to make a deep popular impression, probably because the traumatic event did not resonate much with the public. Sybil was a phenomenal publishing success: it sold more than 11 million copies and was twice made into a movie. It became the canon of how people with MPD behaved and presented. It also introduced for the first time the notion that MPD was the result of childhood sexual abuse, in this particular case inflicted to Sybil by her psychotic mother. This was in keeping with the psychoanalytic vogue at the time, which considered that most childhood psycho-pathology originated from a distorted mother/child relationship. Eventually the primary source of the sexual abuse would switch to male relatives, causing the same symptoms. Similar presentations are interpreted differently depending on their ecological niche. Briefly told, Sybil’s story as portrayed in the book is that she developed severe symptoms of what was diagnosed as hysteria by the time she left home to study at University. She was seen in therapy by Dr Cornelia Wilbur, who became aware that Sybil was presenting different personalities. Dr Wilbur counted up to 16. During the course of analysis Dr Wilbur was able to reconstruct Sybil’s history: she had been born to very religious and conservative parents, and all through her childhood her psychotic mother had subjected her to sadistic torture, some of it of sexual nature, inserting things into her anus, vagina, etc., developing severe malnutrition as a result. Her father was weak and chose not to interfere with his wife. After approximately 10 years of analysis Dr Wilbur was finally able to reunite all personalities into one, and Sybil went on to have a successful career as an art therapist. The book became a classic text, similar to Freud’s papers on Dora and Anna O; several psychiatric programmes recommended their registrars to read the book as a true portrayal of MPD and how it could be treated successfully through analysis. Thanks to the research done by of Borch-Jacobsen7 and the subsequent exposé by Debbie Nathan,8 we now know that the story of Sybil, whose real name was Shirley Mason, was somewhat different. She was born in Dodge Center, Minnesota, in 1923. Her parents were elderly. Her mother was not schizophrenic and most probably never subjected her to the ordeals described in the book. She was never diagnosed as undernourished, and most of the people who knew her as a teenager remember her as shy but not unusual.

She left home at 17 to study at Teacher’s College in Mankato. She developed anxiety attacks. These became more frequent, and she was referred to the Mayo Clinic where she was diagnosed as suffering from hysterical neurosis and treated with Luminal. She may have also had a trial of sleep cure. She left college in 1943 and was treated briefly by Dr Cornelia Wilbur, who had just finished her medical degree, was training in Psychiatry and was very interested in the subject of MPD. In 1954 Shirley moved to New York to begin a Masters program in Art Education. She met Dr Wilbur and started therapy with her. Wilbur had been working on memory retrieval techniques using pentothal. Within a few weeks Shirley started acting as if she had multiple personalities. In 1955 Dr Wilbur offered to treat her for free and told her they could write a book about her case. She treated her with large doses of psychotropics, paid her rent and gave her odd jobs around her house and office. She also suggested that Shirley should become an analyst, which meant going to medical school. This, of course, required for her personalities to fuse into one. Shirley needed to produce material and get better. In 1958 Shirley wrote a letter to Dr Wilbur telling her she didn’t think she had multiple personalities: I don’t have any multiple personalities… I do not even have a ‘double’ to help me out… I am all of them. I have essentially been lying in my pretence of them, I know. Also later: The things I told you about her (the extreme things, that is) were not true… I did not exactly ‘make them up’ ahead of time nor plan to say them… they just sort of rolled out from somewhere and once I had started and found you were interested, I continued…under pentothal I am much more original than otherwise, so I said more… it made a good story and it accounted for some of the fake symptoms I displayed. This was interpreted as a “major defensive manoeuvre” and attributed to an “intruder alter”. In 1962 Wilbur met Flora Schreiber and together with Shirley they decided to write a book about Shirley’s case. Schreiber stipulated that the book had to have a happy ending and came up with the idea of linking the symptoms to early abuse: What do we say, by way of selling the idea, that establishes uniqueness, that makes a publisher feel that this is sufficiently different from Eve to justify his interest?… One (factor) I think of, of course, is the linkage with the battered child syndrome.7 In October 1965 Dr Wilbur separated from her second husband and decided to move to a new a job at a hospital

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in Weston, West Virginia. Shirley’s symptoms disappeared after 11 years (2354 sessions) of therapy. After a few months Shirley moved to a position as an occupational therapist at a hospital near Weston and, with her part of the royalties, paid Dr Wilbur for her analysis and eventually moved to a house in Lexington a few blocks away from her. MPD was officially recognised as a psychiatric disorder in 1980.

General considerations In view of the most recent findings, it seems clear that the story of Sybil should be read as a work of fiction created by three people: Dr Wilbur, Shirley Mason and Flora Schreiber. Each of them made different contributions to create the story of Sybil. The story was devised to resonate within a particular cultural and historical moment and was quickly accepted as fact. Just as Don Quixote needed to continue acting a role consistent with being a knight errant, Shirley Mason was bound to the role of experiencing multiple personalities. Both were creating their realities as they acted. Cervantes writes a book about a gentleman who, swayed by a steady diet of chivalry books, decides to play a particular role: that of a knight errant in pursuit of fantastic adventures. By following a demanding script Alonso Quijano becomes Don Quixote and his new perception of reality results in a series of adventures, a new identity and a new life. His actions become determined by a script he has helped create. Just as Quixote, Shirley became a prisoner of a literary creation that she was partly responsible for. When everyday reality intruded into his world the Don could claim that the distortion was the work of an evil enchanter trying to deceive him. In Shirley’s case, any attempt to act out of character was attributed to “intruder alters”. As a consequence of his choice Quijano loses money and the respect of his friends, puts his life in danger, is beaten

up and mocked. Shirley spent more than 10 years of her life as a virtual invalid. The concept of TMI does not consider the patient’s symptoms and personal narrative necessarily as historical fact, but as a way of expressing and explaining distress. This particular way will be a conjoint creation of the therapist, patient and their particular historical and social circumstance. In one of his more accessible texts, The Function and Field of Speech and Language, Lacan9 writes: In psychoanalytic anamnesis, it is not a question of reality, but of truth, because the effect of full speech is to reorder past contingencies by conferring on them the sense of necessities to come. I interpret this as meaning that in order for the patients to be true to their script, they may need to reorder or recreate their past in order to accommodate or explain the present. The story may not be real, but becomes “true” to the script. Disclosure The author reports no conflict of interest. The author alone is responsible for the content and writing of the paper.

References 1. Hacking I. Mad Travelers: Reflections on the Reality of Transient Mental Illnesses. Charlottesville: University of Virginia Press, 1998. 2. Borch-Jacobsen M. What Made Albert Run? In: Making Minds and Madness. Cambridge: Cambridge University Press, 2009, pp.105-106. 3. Levi-Strauss C. Magic and Religion. In: Structural Anthropology. New York: Basic Books, 1963, p.198. 4. Cervantes Saavedra M de. The Adventures of Don Quixote. Tr. Samuel Putnam. New York: Modern Library, 1998. 5. Schreiber FR. Sybil. 2nd ed. New York: Warner Books, 1974. 6. Thigpen C and Cleckley H. The Three Faces of Eve. New York: McGraw-Hill, 1957. 7. Borch-Jacobsen M. A Black Box named “Sybil”. In: Making Minds and Madness. Cambridge: Cambridge University Press, 2009, p.83. 8. Nathan D. Sybil Exposed. New York: Free Press, 2011. 9. Lacan J. Ecrits, A Selection. The Function and Field of Speech and Language. New York: WW Norton & Co, 1977, p.48.

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Two scripts of madness.

The purpose of this article is to illustrate the concept of transient mental illness (TMI) as defined by Ian Hacking by way of two texts: Sybil by Flo...
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