Get your head out of your hands!

If you tell an actor that his role is full of psychological action, tragic depths, he will immediately begin to contort himself, exaggerate his passion, “tear it to tatters”, dig around in his soul and do violence to his feelings. But if you give him some simple, physical problem to solve and wrap it up in interesting, affecting conditions, he will set about carrying it out without alarming himself or even thinking too deeply whether what he is doing will result in psychology, tragedy or drama. By approaching emotion in this way you avoid all violence and your result is natural, intuitive, and complete.

– Stanislavsky, An Actor Prepares

Ol’ Constantin clearly had his head screwed on right. This exactly reflects my experience of working with actors on pieces involving mental illness, and also of watching terrible (especially, but not exclusively) student fringe shows.

Apparently, all mad people constantly pull at their hair, rock back and forth, wear white put their hands to their foreheads, scream, shout, throw themselves about – such is the theatrical convention. (and indeed the ‘stock image’ convention, as @stfumisogynists’s blog post shows.)

I blame Ophelia for much of this – of which more soon.

In fact, as Stanislavsky makes clear here, even if this were the case (which it isn’t), this kind of melodrama is incredibly predictable for an audience. It also perpetuates a whole collection of other and more damaging stereotypes about mental illness (lack of control, tendency to lash out, physical threat etc.). So cut it out.

Review: The Effect (National Theatre and Headlong)

Lucy Prebble’s new play, The Effect (directed by Rupert Goold), is based around an existential question – if our perception of the world is predicated on the chemical composition of the brain, and if medical science can alter this composition, then how can we trust our experiences? Do psychoactive drugs, such as antidepressants, change “who we are”?

This question sets up for a play which engages the perennial question of psychiatry vs. anti-psychiatry, as well as exploring how ‘healthy’ psychology is characterized. Connie (Billie Piper) and Tristan  (Jonjo O’Neill), both apparently neurotypical, are taking part in the trial of a new antidepressant which acts specifically on dopamine levels. As clinical psychologist Lorna (Anastasia Hille) notes, dopamine, as well as being associated with depression, is also thought to be central to the experience of falling in love – which Connie and Tristan duly do.

The first half of the play establishes the question of how much psychiatry and neuroscience actually know about the etiology of mental illness, and depression in particular. Prebble shows skill in introducing the debate between a physical, psychopharmaceutical approach (championed by brash, wheeler-dealing psychiatrist Toby (Tom Goodman-Hill)) and Lorna’s more ‘humanist’ approach in a way which is both clear and theatrically engaging. I felt the distinction between the two positions was overly sharp, as Toby’s apparent inability to accept even the possibility of situational causes for depression seemed ludicrously extreme, promoting a popular anti-psychiatry which can be potentially harmful.

This simplistic picture is shattered in the second half. Both Lorna and Toby are shown to be motivated by personal romantic history as much as professional scientific conviction in their positions, while Connie and Tristan’s relationship spirals out of control due to Connie’s concern that, if one of them is on a placebo, their experience of love may be somehow false. It takes Tristan’s accidental overdose on the drug, a result of misunderstandings arising from a complex interaction of interpersonal relationships and scientific method, to reveal the play’s raw emotional core, raising it from an entertaining ‘issue play’ to a psychologically draining piece of theatre.

Anastasia Hille’s depiction of Lorna’s own depressive episode is almost frighteningly well-observed. In a grim parody of Toby’s monologue, which extols the virtues of medication and a purely empirical view of brain function, she uses a pickled brain as a puppet, ventriloquising the negative thoughts which characterize depression as she moves the two hemispheres of the brain like lips: “You should have done it years ago. You’ll never get the courage now,” “Even the people who love you, hate you, because you’re hurting the person they love.”

The comic absurdity of the stage picture amplifies the sheer bleakness of Lorna’s state of mind in a way which is both brutal and beautiful. Her comment “I’ll put pants on, and we’ll take it from there” rings particularly true for many who have suffered from depression, and the image of her lying foetal and motionless in bed provides a realist antidote to the more common hystericised images of mental illness which masquerade as naturalism.

The Effect gains its power from its eventual recognition both that the results of clinical antidepressant trials are inconclusive and often manipulated (the play’s microsite http://theeffectplay.com/ cites Ben Goldacre’s Bad Pharma as a source), and that, despite this lack of evidence, antidepressants do have positive effects for many who suffer depression. Whether this result is a placebo effect or not (Lorna notes that ‘the history of medicine is the history of the placebo effect, as we know now that very little of it works’), a blanket condemnation of medication, Prebble suggests, is as dangerous as the risk of overprescription.

‘Dark’ Batman tells us much about our attitudes to mental health

The Daily Star may win the award for ‘most predictable headline’ in the wake of the killings at the Dark Knight Rises premiere in Colorado – ‘Batman Psycho Kills 12’. Both the Mirror and the Sun referred to James Holmes as a ‘maniac’, as did the Scottish Daily Record. As with Anders Brevik and other mass shooters, the inability to find an explanation for their actions automatically renders them mentally ill in the eyes of the media. However, this ‘diagnosis’ does not remove responsibility in the traditional media narrative around mass killings. Indeed, one of the most interesting features of the Brevik trial has been that the prosecution, rather than the defence, has been pushing for him to be found insane – the defence are keener to demonstrate that he acted rationally as a result of the perceived threats of Islam and socialism.

The desire both to label and so understand shocking events like that in Colorado, and to see ‘proper’ justice done under the auspices of the law, rather than medicine, provides the basic ingredients for the conclusion of any ‘superhero’ story, and is especially prevalent in the Batman universe. Jonathan Jones asked, in the Guardian’s blog ‘On Art’, whether the Batman franchise inflicted a ‘sick universe’ on its fans, and although he clarified ‘I am absolutely not accusing the Batman comics or films of provoking this crime’, the very act of raising the question, and the term ‘inflict’ suggested that somehow the films were bleeding out into the psyches of fans. His conclusion, that the camp Adam West tv series represents the most ‘innocent’ and, by implication, ‘moral’ version of Batman, also implies that the modern iteration is somehow ‘guilty’. Of what, Jones does not say.

However, part of the reason for this change can be found in the more general development of attitudes towards mental illness. If mental health was though of at all in the earlier iterations of the franchise, it was either as an inappropriately medical approach to a failure of personal responsiblity, or as something which was not well understood, but which certainly shouldn’t be treated with inhumane institutionalisation and personality-sapping medication. Even Enoch ‘Rivers of Blood’ Powell supported the closure of asylums in Britain, and the process of deinstitutionalization in the United States occurred at the same time. Mental illness was not seen to be closely connected to criminality, and so the antagonists in series like Batman were ‘crooks’ or ‘villains’ – possibly psychologically ‘different’ to ‘ordinary Americans’, but not yet explicitly ‘mentally ill’.

This was all to change through the 1970s and 1980s (the period over which the Batman franchise became progressively darker). As the treatment of mental illness moved out of secluded hospitals which kept ‘the mad’ away from ‘normal people’, suddenly it became clear that sometimes people with a history of mental illness committed crimes. This led to the establishment in US law of the ‘guilty but mentally ill’ plea (in 12 states), which enables juries to find both criminal responsibility and the influence of a mental illness in the committing of a crime, ending the problems caused when a defendant found ‘not guilty for reasons of mental illness’ was free to go when discharged from hospital. The development of the ‘guilty but mentally ill’ plea occurred in 1975, only one year after the first appearance of ‘Arkham Asylum’ (then ‘Arkham Hospital’) in the Batman comics – even in the early days, the Batman franchise kept pace with, or anticipated, the issues raised by deinstitutionalization for criminal justice.

Arkham became more central to the Batman universe over the course of the 1970s and 80s, as well as closer to Gotham, featuring in a number of stand-alone comics and graphic novels in the late 80s and early 90s. The asylum is depicted as a stereotypical Victorian pile, full of long, narrow corridors, straitjackets and restraints, and is often the setting for exploring questions of how different Batman (troubled childhood, loner, costumed, above the law) is from the insane super-villains he is pitted against. This theme is especially strong in Arkham Asylum: A Serious House on a Serious Earth and Batman: The Last Arkham.

Image

These twin concerns again echo and reflect broader questions about conformity and mental illness, as well as partly suggesting a nostalgia for the days before deinstitutionalization, when ‘ordinary Americans’ could be sure that mentally ill offenders would find themselves in an institution with a recognizably penitential aspect – in Arkham, there is little evidence of treatments like occupational or art therapy. In addition the continuity of the Batman stories makes it clear that, for characters like the Joker, or Bane, rehabilitation is not even a distant possibility. Medical staff do discuss rehabilitation, but this marks them out as naïve, and possibly soon to become a villain, as in the cases of both Jonathan Crane (Scarecrow) and Dr. Harleen Quinzel (Harley Quinn).

Image

That this representation of Arkham has remained to the present, or at least the 2009 video game, suggests that attitudes towards mental illness have changed similarly little. If anything, the interest in Batman’s own psyche, emphasised in Nolan’s recent trilogy, suggests greater suspicion about possible mental illness even in those who seem to be ‘good’, such as the successful business man and philanthropist Bruce Wayne. While it is easy to blame mental illness, or the ‘sick’ influence of media for events like those in Colorado, it is more productive to realise that these influences do not go only one way – society is reflected in media far more strongly than media has the power the change society. We like to think that perpetrators of mass killings fit a nice narrative pattern, like Batman’s Joker, but the truth is that human beings are complex, and the line between ‘crook’ and ‘ordinary American’, between ‘nice guy’ and ‘psycho killer’ are so indistinct as to sometimes be invisible. Media can help us understand how our societies think, and influence some actions in combination with a plethora of other factors, but it can’t turn life into an easy narrative with superheroes and supervillains – a realisation the Batman franchise suggests may be dawning.

MSc Thesis: Mental Health in Scottish Theatre

Below is the abstract of my Edinburgh MSc thesis, and a link to a pdf of the full text.

I hope that this might be useful to people looking at Scottish Mental Health policy, as well as students studying Neilson’s plays, or just people interested in the range of activities that comprise ‘mental health in theatre’.

I’ll probably make some attempt to get some of this published, so any feedback is very, very welcome.

_________________________________________________________________

How Theatre NEMO and Anthony Neilson use drama to challenge perceptions of mental ill health in Scotland 2003-2010.

Abstract
Despite a continued interest in the study of power-relations and discourse following Michel Foucault’s work on psychiatric power in society, there has been little attempt to examine the representation of mental illness in literature and culture as anything other than an artistic trope. This thesis examines the specific ways that performances have engaged with mental health discourses in Scotland since the passing of the Mental Health (Care and Treatment) (Scotland) Act 2003. By reading Anthony Neilson’s The Wonderful World of Dissocia and Theatre NEMO’s Does Anyone Know in the light of Scottish policy discourse, the thesis draws attention to the potentials and limitations of performance as a medium for engaging with the issues facing mental health service-users. This includes the impact of physical presence in performance and the risks of falling into conventional, stereotyped views of madness. By doing this, the thesis exposes the extent to which the power-relations within the mental health system are related to mental distress, as well as the ways that transformational strategies in performance can have a positive impact in revealing and challenging these power-structures.

Full text [pdf] available here

Diagram of the House at Charenton

Below is a plan of Charenton, the setting of Peter Weiss’s Marat/Sade, as it was in 1836. Since the site was apparently redesigned in 1845, it seems likely that this plan represents the hospital as it was known to the historical de Sade and Coulmier.

I have also translated the key to the diagram, to make it clearer (and show how many ‘bathhouses’ there were). My French isn’t fantastic, so I’m sure some of this is inaccurate, and the major problem is the attempt to render Nineteenth century French terms for madness into idiomatic English for the Twenty-first. I’ve tried to get some sense of what these terms imply, but have provided the original in square brackets afterwards, so that people better at French than I am can come to their own conclusions, and tell me in the comments.

Many thanks to @miss_sobriety on twitter for bouncing ideas around about possible translations.

The hospital at Charenton

Plan of the house at Charenton [Charenton Hospital]

1. Main Gate

2. Porter’s lodge

3, 3, 3. Front courtyard.

3’. Passage from front courtyard to courtyard 10.

4’. Parlour above store rooms.

4. Four story building. On the ground floor, store rooms: on the first, a large hall, occupied by placid madwomen [aliénées tranquilles]: on the second, the director’s rooms, and a lounge for convalescents of both sexes: on the third, the bursar’s offices and some employees’ lodgings: the top floor is taken up with the big clock.

5. Four story building. On the ground floor, store rooms: on the first, the kitchens: on the second, the offices of the director, and those of the treasurer, and a room for the head doctor: on the third, the bursar’s lodgings (with a view of the gardens): on the fourth floor, lodgings for the employees.

6. Gallery which runs under the eaves of the third floor, connecting the director’s apartment to the dining room.

7. Stairs to the chapel.

8. Enclosed courtyard for the women, leading to garden 18.

9. Stairs by which one descends to courtyard 10.

10. Courtyard for madwomen who are scabrous, with a tendency to clamour [ordinairement agitées et galeuses].

11. Four story building. On the ground floor, a gallery which runs the whole length of the building, and onto which open the rooms occupied by agitated women: on the first floor, a corridor with rooms for women who are far out of their reason, yet calm [très déraisonnables, mais tranquilles].

12. On the first floor, a warm-room for agitated women: on the first floor, a warm-room which also serves as a work-room.

13. Courtyard for very disturbed women

13’. Courtyard related to the baths.

14. Isolation building for very disturbed women [très agitées].

15. Six dressing rooms [loges] and a gallery: above, a sick bay for suicidal patients [or attempted suicides – les suicides].

16. Bathhouse.

17. Dressing rooms [loges] for disturbed [agitées] women and a gallery overlooking the courtyard.

17’’. Warm-room.

18. Garden for placid madwomen [aliénées tranquilles].

19. Four story building. On the ground floor, a large hall for lunatics [les aliénées]: on the first and second floors, lodgings for the medical inspector, the chaplain, the warder, and some residents: on the third, a sick bay which, due to the uneven ground, is no more than one floor above the terrace: on the fourth floor, under the roof, is the women’s laundry.

20. The director’s personal garden.

21. Greenhouse.

22. Courtyard of the new building for placid madwomen [aliénées tranquilles].

23. Gallery.

24. Three story building. On the ground floor, a dining room, a meeting and work room, a dormitory: on the first floor, dormitories and bedrooms: on the second, two large dormitories.

25. Three stories, the ground floor with a gallery, divided into bedrooms: the same on the two higher floors.

26. Bathhouse, with a semi-circular dormitory above.

28. Terraces and gardens.

29. Courtyard used to store wood.

30. Four story building. On the ground floor, offices: on the first, the chapel: on the second, the dining room: on the third, a sick bay for placid madmen [aliénés tranquilles]: on the fourth, a dormitory.

31. Kitchen courtyard, separated from the garden by a terraced wall.

32. Bridge leading from the third floor of building 5 into the garden.

32. Billiards room at the height of the small bridge 32.

33. Bath courtyard.

[3]4. Four story building. On the ground floor, store rooms; on the first floor you find, at the same level as courtyard 33, a sick bay for lunatics, both those who are disturbed and those who are catatonic [les aliénés paralytiques et agitées]: on the second, a sick bay for those who are placid or only slightly disturbed [tranquilles ou peu agités]: on the third, rooms with one or two beds.

35 & 38. Buildings connected at right angles, with four stories. Along the middle of each floor, a corridor, on each side of which open rooms of one and two beds: heated meeting rooms.

36. Bathhouse.

37. Courtyard for maniacs/those in a frenzy [furieux].

39. Courtyard for those who are disturbed and incurable [agités et incurables].

40. Dovecote.

41. Building containing the pump which provides water for the whole house.

42, 42, 42, 42. Courtyard and promenade.

43. One story building: On the ground floor, dressing rooms and a gallery: on the floor above, corridor and bedrooms.

44. Heater for the first floor.

45. Heater for the ground floor.

47. One story building. On the ground floor, the bakery: on the first floor, which is at the same level as the courtyard no. 42, three dressing rooms for the most disturbed lunatics [les aliénés les plus agités].

48. Hayloft.

49. One story building. On the ground floor, the cowshed: on the first floor, a large sick bay.

50. One story building. On the ground floor, the pharmacy, and a room for four sick paupers who are not insane: on the first floor, the lodgings of the medical assistant, and the laundry.

51. Stairs connecting the medical assistant to the large sick bay [49].

52. Store rooms and workshops.

53. Farmyard.

54. Autopsy room.

55. Gardener’s lodge.

56. Sloping path leading from the front courtyard, under building no. 49, to garden 57.

57. Garden.

58. Lodgings for several employees.

59. A small pond.

P. Bridge crossing a branch of the Marne, leading to an island owned by the institution.

E. General sewer.

I. Island.

M. Isolated house belonging to the institution.

Figure 2 – New female quarters.

1. Gallery open to the country air.

2. Meeting room.

3. Two dormitories, each with a single row of beds.

4. Galleries.

5. Servery.

6. Room, furnace and apparatus for the baths.

7. Round pathway.

8. Corridor, onto which open the bedroom doors.

9. Bedrooms.

10. Lounge and dining-room.

11. Dormitory.

12. Lodgings for nurses, and passages.

In the middle of the courtyard, a fountain and a lamppost.

Source: Esquirol, Etienne. 1836. Des Maladies Mentales Considérées Sous Les Rapports Médical, Hygiénique Et Médico-légal, Volume 2, pp. 702-6.
Available here.

What’s in a name?

Terminology and Ideology in Mental Health Research

In a fairly random sample of articles discussing issues surrounding mental health and engagement, a dizzying number of different and conflicting terms draw attention to the deeply politicised nature of the area. Are we dealing with ‘service users’, as found in articles such as Liz Sayce’s ‘Stigma, discrimination and social exclusion’ (Sayce 1998)? ‘Clients’, as often found in official reports such as found in an analysis of submissions to a Scottish Executive suicide prevention framework (Ridley 2004)? Patients? Mentally ill people? Mad people? Indeed, many articles use some of this terminology interchangeably (and often critically), further highlighting the fact that the conceptual position of individuals within the mental health system is far from stable. In this post, I’m going to (briefly) examine the history and implications of each term.

Patient

This term was found to be the one most preferred by both mental health workers and individuals within the system in a 2000 survey in the US (Sharma, Whitney, and Kazarian 2000). One of the reasons for this is that, in its staunch medical association it legitimises the experience of the individual. In addition, it suggests an end-point to treatment, rather than an on-going and possibly interminable process.

However, there are problems with the term. Most objections focus on the implications of passivity and invalidity, and the wholesale embrace of the medical model bound up with the term. This is especially problematic for groups such as ‘Mad Pride’, as, with Thomas Szasz, many members of these groups believe that the medical paradigm is used to justify the coercive repression of deviance.

The term ‘mentally ill person’ shares many of the positive and negative features of ‘patient’.

Service User

The term ‘service user’ suggests an active involvement in the mental health system. Rather than being a ‘recipient of care’, the implication is that the individual is making an active choice to take advantage of available services. In this way, it is seen to be an improvement on ‘patient’, as it is linguistically empowering, and has paved the way for ‘user involvement’ initiatives, in which user representatives have been involved in discussions about changes in care and support structures, as well as the legal framework of mental health.

The idea of the service user can be criticised, however, on the basis that the sense of ‘empowerment’ provided by the term is often illusory. Not all individuals will be able to sit on official committees, and even those who do may face the dismissiveness afforded those considered to be representatives of ‘unreason’ (in Foucault’s terms). Many of those without the ability to represent themselves will remain legally compelled to remain in hospital or comply with regimes of medication – ‘service users’ only as a result of coercion. In addition, although a result of campaigning by groups of individuals both within and outside the mental health system, ‘service user’ contains the germ of marketisation, the idea that the only way to win rights within a system is by converting the system into a competitive commercial system in which ‘the customer is always right’.

More recent criticisms of the term, in the UK at least, have focussed on the impact of welfare and health budget cuts on the level of service provision available, arguing that it is offensive to define individuals by services which they may no longer be able to access as a result of central government cutbacks.

Client/Consumer

Both these terms represent a further evolution of the ‘consumer rights’ framework of mental health campaigning, already implied by ‘service user,’ and as such are subject to the same advantages and disadvantages. ‘Client’ offers a slightly more positive image of the relationship between individual and service, suggesting an active and collaborative process, but still one conceptualised primarily through contractual obligations rather than care and support.

Survivor/Mad person

These terms are generally employed by those people whose experience of the mental health system has been anything but positive. Rather than attempting to reframe the relationship between the system and the individual in terms which seem to offer a greater sense of collaboration, these terms engage critically and dialectally with the narrative of mental health services as part of the caring profession. This tactic aims to draw attention to perceived injustices and coercive structures within the system, as well as questioning the extent to which medical techniques are actually beneficial to those within the system.

These terms can be criticised, especially by those within the medical professions, as anti-evidence and anti-scientific. They have also been attacked by other individuals within the system who see their experiences as nothing to be proud of or celebrate. However, they, and direct action movements such as Mad Pride/Reclaim Bedlam, offer a totally different voice within the debate, and as such are worth of inclusion.

Conclusion

I am still unsure as to the terminology that I will use in my project, since there is no absolute ‘best term’. However, I do feel it important to note that the survivor/mad pride movement is the only voice which offers an internal (patient/user/survivor) perspective on the increasing medicalisation and commercialization of the field (evident in parallel between the increase in Pharmaceutical lobbying of governments and the growth of ‘client’-type terminology). Such perspectives are essential in any examination of public representations and performances of ‘mental illness’. Thomas Szasz offers another critical voice, but he would be more likely to support the terminology of the ‘client’, since he argues that only a contractual agreement between ‘practitioner’ and ‘client’ can prevent the coercive excesses of the ‘therapeutic machine’.

 

Ridley, Julie. 2004. National Framework for the Prevention of Suicide and Deliberate Self-harm in Scotland: Analysis of Written Submissions to Consultation (Central Research Unit Papers). Scottish Executive, October 4.

Sayce, L. 1998. “Stigma, discrimination and social exclusion: Whatʼs in a word?.” Journal of Mental Health 7 (4): 331–343.

Sharma, V, D Whitney, and SS Kazarian. 2000. “Preferred terms for users of mental health services among service providers and recipients.” … Services.

Madness and Theatre: Does Anyone Care?

Why, you ask, would anyone want to spend 3 years of their life researching how mental distress is represented in contemporary British drama? Surely there are more important issues, and, anyway, theatre has lost its position as lead source of entertainment, now only serving a minority of the middle-classes.

All of this may be true – there are certainly more important issues in the area of mental health research, and theatre audiences have indeed been dwindling. However, since theatre from Edward Bond to Sarah Daniels, Caryl Churchill to Mark Ravenhill has possessed (at least self-styled) ‘radical’ aesthetics, it is interesting to see how these authors treat the issues surrounding madness.

For Churchill and Daniels, madness is repeatedly invoked as a trope for the effect of patriarchy on women – marginalized and denied a voice, the characters in, for example, Daniels’ The Madness of Esme and Shaz manifest their oppression through madness, a trope drawn partly from half of the dichotomy presented by Gilbert and Guber in The Madwoman in the Attic. Bond and Ravenhill tie an interest in psychic distress with politico-economic themes in, for example, Lear and Shopping and Fucking respectively.

In fact, madness became more central to theatre in the so-called ‘In-Yer-Face’ movement of the 1990s, not least with the plays of Sarah Kane. When something which affects a large number of people for at least part of their lives is also being treated extensively on the stage, it is important to examine the reasons for this. As yet, very few reviewers or academics have treated these instances as actually having an impact on how people view ‘real’ mental-health service-users, preferring to see madness as it has always been – a literary trope with little connection to real-life experience.

This is clearly a problem. Feminist literary theorists have demonstrated how language shapes the way we conceive of sectors of society, and the representation of women as ‘types’ has been rightly identified as a symptom of the oppressive social discourse operating around them.  The same analysis must be applied to the representation of mad/mentally-ill people, especially when these representations occur in plays with an otherwise radical and inclusive agenda.

When plays focused on exclusion and discrimination use madness as only a trope, or a way to add dimensions to a character, or as a symptom of wider social disquiet, they diminish the impact of madness on the individual, as well as reenforcing the stereotypes which contribute to discrimination against mental health service users. On the other hand, representations which complicate or challenge these stereotypical views can contribute towards a more nuanced view of mad/mentally ill people, thereby combating the discrimination which causes social ostracism and exacerbates distress.