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Agnes's Jacket: A Psychologist's Search for the
Meanings of Madness
Article in Contemporary psychoanalysis · April 2011
DOI: 10.1080/00107530.2011.10746456
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Agnes's Jacket: A Psychologist's
Search for the Meanings of
Madness
Jack Drescher M.D.
Published online: 31 Oct 2013.
To cite this article: Jack Drescher M.D. (2011) Agnes's Jacket: A Psychologist's Search
for the Meanings of Madness, Contemporary Psychoanalysis, 47:2, 268-272, DOI:
10.1080/00107530.2011.10746456
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268 BOOK REVIEWS
range of possibilities. His choice, clearly, would be for science and the
mainstream, but he points out that life at the margins is, after all, not
death. Many practices and professions have not only survived but man-
aged to thrive there.
It has become a tiresome cliche for reviewers to say a book is "indis-
pensable" or "should be required reading." I actually do feel that way
about this book, certainly in thinking of my colleagues who play roles in
guiding institutes and professional associations into the future. But I am
all too aware that-fractured, beleaguered, preoccupied, and entrenched
as they are-they may not want to know so much about the difficult
Downloaded by [New York University] at 22:17 23 June 2015
choices facing them. It might be more useful for me to say, simply, that
this book is chock full of fascinating facts and memorable stories. It will
engage and entertain, and certainly provide material to cite at social gath-
erings and faculty meetings. It will also provide much food for thought
along the way.
Kenneth Eisold, Ph.D., past president of the International Society for the
Psychoanalytic Studies of Organizations, as well as former director of the
Organizational Program at the White Institute, is a practicing psychoana-
lyst as well as organizational consultant. He has written extensively on
the organizational dimension of psychoanalysis.
353 Central Park West
New York, NY 10025
keneisold@[Link]
A review of Agnes'sjacket: A Psychologist's Search for the Meanings
ofMadness by Gail A. Hornstein New York: Rodale, 2009, 310 pp.
JACK DRESCHER, M.D.
A gnes Richter's hand-sewn jacket resides in a museum in Heidelberg.
.1"1J:t is covered with an "intricate text [that was] embroidered in five
colors over practically every inch of the garment," (p. ix) circa 1895. Why
BOOK REVIEWS 269
is it in a museum? It was collected by Heinz Prinzhorn, an art historian
who trained as a psychiatrist (but never practiced) who "had a special
interest in creativity and madness ... and was committed to understand-
ing the expressive impulse in its purest form" (p, x).
For Gail Hornstein, author of Agnes'sjacket: A Psychologist's Search for
the Meanings ofMadness, the jacket "precisely captures the fundamental
conundrum of madness, an experience rich with symbolic meanings that
are indecipherable by ordinary means" (p. xi).
Agnes's jacket, among other things, is an ethnographic study of self-
help groups for individuals who experience auditory hallucinations. It is
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written in the tradition of earlier psychiatrists like R. D. Laing and Thomas
Szasz who sought to find meaning in what is conventionally regarded as
meaningless insanity.
Hornstein positions herself as an opponent of pharmacological inter-
ventions for psychosis, asserting that "in the United States, psychiatry is
entirely controlled by doctors, who have a direct economic interest in
siding with the drug companies and preventing patients from treating
themselves" (p. 53). In Hornstein's view, there is no scientific evidence
demonstrating that any pharmacological interventions work.
As a result of her research, Hornstein believes hearing voices is often
adaptive, and therefore natural and normal for those who hallucinate.
She believes hearing voices is most likely caused by early trauma, and
that "lslexual abuse is, by far, the trauma most frequently found to pre-
cede voice hearing ... [which] occurred most often when the trauma
took place before the age of seven" (p. 41). Hornstein, who attended in-
numerable support groups both overseas and in the United States, sum-
marizes her ethnographic research:
It took three more years of attending these kinds of meetings, visiting sup-
port groups across England, and reading hundreds of pages of materials
produced by Hearing Voices Network (HVN) before I felt confident that I
understood how hearing voices groups work. ... The structure of local
HVN groups varies a great deal: Some have fixed membership, while oth-
ers operate as drop-ins. Some are facilitated by nurses, social workers or
occupational therapists; others are run entirely by voice-hearers them-
selves. HVN meetings are never as tightly structured as those of twelve-
step groups like Alcoholics Anonymous, where there's a fixed order and
everyone knows exactly what will happen. But all HVN meetings do share
certain general themes. Members give detailed descriptions of their indi-
270 BOOK REVIEWS
vidual experiences. They ask one another probing questions like these:
What do the voices say? What tone do they use? How many different voices
are there? Are they male or female? Have they changed over time? Are there
certain situations when they're most likely to appear? How do you feel
when they come? By encouraging this kind of detailed contextual analysis,
hearing voices groups help people make sense of experiences that have
often baffled or terrified them. . .. By reframing the problem itself-not
voice hearing per se, but the anxiety, guilt, or fear that often accompanies
it-support groups help people analyze the symbolic significance of the
voices.
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Hornstein repeatedly takes to task an authoritarian, biological psychia-
try that does not or will not listen to patients and the pharmaceutical in-
dustry. Together, she asserts, they have created made-up diagnoses (e.g.,
schizophrenia and bipolar disorder) in an effort to promote drug thera-
pies. She notes critically (albeit briefly in passing) that the parent body of
her own profession, the American Psychological Association, is actively
seeking prescribing privileges for its members as well. It is also not en-
tirely clear what Hornstein makes of psychiatrists who view psychotic
symptoms as meaningful communication, such as Harry Stack Sullivan
(who is not mentioned in the index) or Frieda Fromm-Reichmann, who
gets a brief mention. How do these influential leaders fit into her psychi-
atric cosmology?
Perhaps because the book is seeking a wider audience than mental-
health professionals, the narrative trope of Agnes's jacket is reminiscent
of Joseph Campbell's heroic journey. The heroes include herself (having
undergone a transformation from skeptic to believer), psychiatrists she
met along the way who do not subscribe to the conventional thinking
about psychosis, and psychiatric survivors (i.e., survivors of conventional
psychiatric treatment). The latter, having unsuccessfully undergone the
ministrations of the psychiatric-pharmaceutical complex, eventually found
alternative treatment approaches in self-help groups that were more person-
centered and respectful of their human subjectivity and individuality.
Hornstein notes,
Most firsthand accounts of emotional distress contradict doctors' trium-
phant stories of "conquering mental illness." For patients, madness isn't
about "scrambled electrical signals" or "new breakthroughs in the exciting
world of brain research." They write of captivity, insight and resilience.
Patient memoirs are filled with accounts of people struggling to escape
BOOK REVIEWS 271
their doctors' narrow thinking or having to cure themselves after everyone
else gave up on them. (p. xvii)
As a psychiatrist who has done intensive psychotherapy with psychotic
patients, I found the polemical tone of Agnes'sjacket's to be an unneces-
sary distraction. Hornstein, a professor of psychology at Mount Holyoke
College, infuses distracting polemics into what might otherwise have
been an interesting and well-written book about patient self-help groups
for individuals whose psychotic symptoms do not respond to conven-
tional psychiatric treatment. Instead, she speaks in pitched generaliza-
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tions. My own inner editorial voice repeatedly wondered whose voices
Hornstein was arguing with in her own head. Her tone brought to mind
James Cameron's recent film, Avatar: a tale of evil authoritarian techno-
crats who do not listen and who cannot see the natural beauty in front of
their eyes. Following the path of Avatars heroes, this reader is left with
the impression that Hornstein too has "gone native." In contrast with
T. M. Luhrmann's a/Two Minds: The Growing Disorder in American Psy-
chiatry, a book that takes up similar issues in a much more balanced
and thoughtful way, Hornstein completely identifies with her study's
participants.
I am entirely sympathetic to Hornstein's goals of improving patient-
centered care by getting doctors to listen. After all, history has shown that
psychiatric and medical resistance to change can be successfully chal-
lenged. Gay activists persuaded the American Psychiatric Association that
poor science informed the psychoanalytic theory of homosexuality as a
mental disorder, leading to the removal of homosexuality from the DSM
in 1973 (Bayer, 1981). Likewise, in the 1980s, American AIDS activists
successfully challenged existing protocols that made it difficult to bring
more quickly life-saving drugs to dying patients (Kramer, 1994). Starting
in the 1990s, the Intersex Society of North America successfully chal-
lenged established surgical and medical practices that sanctioned unnec-
essary and harmful surgeries performed on intersex children (Kessler,
1998). Each of those successful movements for changing medical and
psychiatric approaches began with demonization of the conventional
wisdom of physicians.
Hornstein critically contrasts care in the United States with European
countries that have single-payer systems. Certainly, there is much to fault
in the United States's current mental-health system. However, Hornstein
makes little note of the fact that the kind and quality of mental-health
272 BOOK REVIEWS
care Americans receive is directly related to wider social attitudes about
mental illness. Why single out psychiatrists, prescribing psychologists,
and the pharmaceutical industry, when taxpayers, policy makers, legisla-
tures, governors, and insurance companies do not want to pay for treat-
ment? Perhaps it is these attitudes, rather than the conspiracy to which
Hornstein alludes, that more accurately reflect how the United States'
social policies are Cdis)organized in delivering mental health care. Or, as
Pogo once put it, "We have met the enemy and he is us."
REFERENCES
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Bayer, R. (1981), Homosexuality and American Psychiatry: The Politics ofDiagnosis. New
York: Basic Books.
Kessler, S. J. (1998), Lessonsfrom the Intersexed. New Brunswick, N]: Rutgers University
Press.
Kramer, 1. (1994), Reportsfrom the Holocaust: The Story ofan AIDS Activist. New York: St.
Martin's Press.
Luhrmann, T. M. (2000), Of Two Minds: The Grounng Disorder in American Psychiatry.
New York: Knopf.
Jack Drescher, M.D., is Training and Supervising Analyst at the William
Alanson White Institute.
44 West 24th Street, #lA
New York, NY 10011
[Link]
CATCHING THE DRIFT: REMEMBER TO FORGET
A review of Psychotherapy without the Self: A Buddhist Perspective by
Mark Epstein 2007, New Haven: Yale University Press, 272 pp.
ROBERT LANGAN, Ph.D.
n the cover of the book is an empty chair and an empty psychoana-
O lytic couch. Who's not there? How can there be a psychotherapy
without the self? Opening the book reveals the development over the
past 20 years of Epstein's thinking about these matters. In this republica-
tion of scholarly papers too long languishing in dusty journals, he reflects,
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