Mad, Bad and Sad, By Lisa Appignanesi

The interplay between 'mad' women and their shrinks is endlessly fascinating

Psychoanalysis was founded upon a collaboration between listening male doctor and talking female patient. The couch joined men and women, and separated them too. What do women want? Freud famously asked. Modern women may answer tartly: pretty much the same as men. Work, love, a sense of life being meaningful.

Now Lisa Appignanesi suggests that what both men and women may want is a revised and enriched history of the relationships between the female patients and their male mind-doctors. Accordingly, she gives us accounts not only of famous patients, such as Alice James, Zelda Fitzgerald, Marilyn Monroe and Virginia Woolf, but also of famous patient-doctor collaborations, such as those between Freud and "Dora", Jung and Sabina Spielrein, R D Laing and Mary Barnes, Lacan and "Aimée".

Earlier accounts by pioneering feminists often stressed the misogynistic and coercive aspects of diagnoses and treatments. Appignanesi balances the picture, emphasising the complexities of the reciprocal and collusive therapeutic relationship, the gamut of emotions experienced by both sides, and the benevolence of many male doctors. She suggests that patients had their own subtle methods of gaining power inside imperfect set-ups, and offers an account of the shifting cultural and scientific backgrounds of different epochs that shaped attitudes inside asylums, hospitals and consulting rooms.

Why concentrate on female patients, though? Isn't that to repeat worn-out perceptions of women as frailer vessels? Surely just as many men as women feel severe distress, seek help, may be labelled mad. Appignanesi offers several answers. Contemporary statistics emphasise women's greater propensity to suffer from the "sadness" end of madness.

In terms of the historical account of the female malady – oppressed women struggling to articulate their anger being written off as neurotic or worse – Appignanesi wants to discover whether women's rise in the therapeutic professions has changed the status of women patients for the better. Most compelling for her, though, is the fact that there are "simply so many riveting cases" of women patients. Here, Appignanesi's novelist self (she is well known as a writer of fiction) pops up, and helps her to create a narrative method mixing historical description with illuminating biographical anecdotes, and happily wandering between America and Europe.

She begins with the 18th-century writer Mary Lamb, the co-author, with her brother Charles, of the children's classic Tales from Shakespeare. When Mary took a knife to their mother, stabbing her fatally, Charles saved her from a murder charge and death on the gallows. As soon as he found his mother dead, and a blood-spattered Mary still with the knife in her hand, he put his sister into an Islington madhouse, thus making it clear to the coroner and jury who promptly arrived to ascertain the facts that his sister should be classified as a lunatic rather than a criminal. He guaranteed that either he would care for her or that she would be cared for in a private madhouse. Given a private room and affectionate treatment by her nurses, Mary quickly returned to the self all her friends knew and loved. Her brother then took over the responsibility for looking after her. Her own version of the talking cure was the writing cure: pseudonymous stories in the collection Mrs Leicester's School, which explored her anguished childhood.

Her gender was not particularly an issue for her guardians, in terms of her diagnosis, as it was not with other contemporary inhabitants of asylums. These places, in fact, in her day, sheltered more men than women. Female inmates were, however, vulnerable to rape and assault. Sometimes the assault entailed forcefeeding, if the woman refused to eat. Two centuries later, as psychiatry textbooks proliferate with specifically labelled conditions, we have split off that symptom from mania and named it anorexia, a fullblown disease in its own right.

Simple containment, plus the trust in time away from the pressures of daily life, gave way to the rigorous classification of kinds of illness as the profession of the "alienists" gradually became established, alongside the use of statistics, carefully recorded observation and the belief in the power of expert diagnosis. If doctors began to make careers treating those they labelled insane, patients could also develop careers as doctors' compliant partners. At the Salpetrière in 19th-century Paris, Charcot paraded his "hysteric" patients in front of audiences. Demonstration, drama and spectacle were heightened by recourse to the new technology of photography, useful for keeping patient records. A celebrated patient such as "Augustine" might act out her own fantasies but crucially refract these via her doctors' expectations. Similarly, the practice of hypnosis might replicate the roles of theatre director and actress.

Gradually the doctors abandoned these techniques. The dance between expert and patient shifted first to a linguistic stage, as Freud investigated childhood seduction and fantasies of childhood seduction, and subsequently to a chemical one. Ending her survey with a sensitive discussion of drug use and abuse, of women as self-medicators, Appignanesi also nods towards the role played by hormonal changes during the great physical turning points in women's lives, from puberty to menopause. Her conclusion is cautious: "It is clear that symptoms and diagnoses play into each other and cluster to create cultural fashions in illness and cure. Whatever the sophistication of the diagnosis, however, and its attendant treatment, this may not alter the recurrent or chronic nature of an individual's suffering."

Now the stage is set with technological props. We image our minds as computers, image ourselves as machines suffering stress or faulty design, in need of new parts, place our faith in techno-wizards tinkering with genetics and plastic surgery. We consume the babble of self-help books promising quick fixes via simple willpower. Our fantasy lives are increasingly acted out via email, chatrooms, video games, porn sites. Virtual therapists will presumably soon be commonplace everywhere. The NHS is being urged by government to turn away from psychotherapy to the brisker, short-term, cognitive therapies, designed to get workers back into production. In the frenzied world of the global market, perhaps therapists and patients of both genders need each other more than ever.