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Lauren Slater and the Experts:
Malingering, Masquerade, and the Disciplinary Control of Diagnosis
Abstract

The work of psychologist and author Lauren Slater has elicited strong reactions from both medical professionals and disability studies theorists, ranging from criticism to high praise. Attending to these responses, I argue that her work, in perhaps perverse fashion, can provide a narrative touch point for attempts from both fields to complicate the outdated binary division of the medical and social models. I illustrate the need for this collaboration through the example of malingering, suggesting that reading Slater’s work through the lens of Tobin Siebers’s theory of “masquerade” can open progressive conversations about “illness deception,” which is an issue of central importance in disability rights, psychiatry, and political conversations. By using Slater’s work and research on malingering as a test case, I point to potentially productive convergences among academic, medical, and social fields.

Keywords

masquerade, malingering, disability, stigma, diagnosis

Sickness demands compassion, but even so, one can be forgiven for wanting to throttle the narrator of Lauren Slater’s latest book.

—Rebecca Mead, The New York Times

Slater portrays herself as the innocent victim of a vigilante mob of angry academics. In fact, the true victims are Slater’s readers.

—Scott Lilienfeld, Robert Spitzer, and Michael Miller, The Journal of Nervous and Mental Disease

The comments above, from 2000 and 2005 respectively, highlight the passionate criticisms that have been leveled at psychologist and author Lauren Slater. Reactions to her work in the popular press, the medical field, and the academic disability studies community range from such criticisms to high praise as she willfully confuses the objective and subjective in her memoirs of mental illness.1 The variety of parties disavowing and defending Slater suggests that she has hit a raw nerve in American culture, signaling that she operates within fraught territory, highlighting complex debates in both medicine and disability studies. By interrogating these debates in connection with Slater’s work, I present a case study for the merits and possibilities of a more interdisciplinary approach to representations of illness as scientific fields reckon with the limits of data-driven studies, and humanities fields increasingly develop a framework that moves beyond a simple social model to account for material conditions, as has been the case in recent work in disability studies. When medical experts reject criticism that falls outside the traditional peer-review model, [End Page 23] and when scholars of disability neglect to account for the physicality of mental disability, they reveal disciplinary limitations that preclude cross-disciplinary approaches to problematic issues in health and disability. The wealth of critiques of such stances in each discipline shows that each field is engaged in a nuanced and generative conversation. Disability studies in particular is marked by careful, thoughtful growth as it has developed from a pure social model to one that accounts for lived experience, as in recent work by Tobin Siebers, Anna Mollow, Elizabeth Donaldson, and others.2 However, the power differential in healthcare today is very much weighted toward the seemingly objective medical sciences, and these nuanced conversations too rarely cross the borderland between the medical and humanities communities. Such disciplinary borders must be acknowledged and troubled in order to move toward progressive interdisciplinary research and conversations about mental disability, diagnosis, and neuroethics—the types of conversations, I argue, that Slater is trying to initiate with her texts, and which ought to be continued around complex issues like the concept of illness deception, or malingering.

I begin this paper by examining the most conservative reactions to Slater’s work from the fields of medicine and the humanities: in 2005, responding to Slater’s essay “On Being Sane in Insane Places” from her book Opening Skinner’s Box, psychiatrist Robert Spitzer castigates her work, while in the field of disability studies G. Thomas Couser included a chapter headed “What’s Wrong With Lying” in his book Signifying Bodies, which concludes that the memoir is unethical and stigmatizing. After presenting these approaches, I introduce more nuanced positions from each side. In this way, I hope to unwind the tangle of concerns brought to the surface by Slater’s work and the concerns expressed about it by experts. Throughout, I keep in mind Rosemarie Garland-Thomson’s reminder that feminist disability theory “should illuminate and explain, not become ideological policing or set orthodoxy.”3 By following Garland-Thomson’s lead and emphasizing illumination and conversation rather than authoritative declarations, I work to move beyond judgment of Slater, instead focusing on the contexts which frame the judgments to which her work has been subjected. Her work, in perhaps perverse fashion, can provide a narrative touch point for attempts from both camps to complicate the outdated binary division of the medical and social models.

To this end, I will offer an account of Slater’s most controversial works, Lying: A Metaphorical Memoir (2000) and “On Being Sane in Insane Places” (2004) and the tensions they reveal about complex interactions [End Page 24] between diagnosis and identity, pathology and religious impulse, neuroscience and free will, and physical disability and mental disorder.4 After establishing the feminist roots of Slater’s disruptive narratives, I will discuss how this orientation triggers the two specific reactions mentioned above: first, a series of articles by Spitzer and his co-authors in The Journal of Nervous and Mental Disease that challenge conclusions she drew in “On Being Sane,” and, second, Couser’s disability theory critique of epilepsy as metaphor in Lying. These responses represent the strongest disciplinary and boundary-policing impulses exhibited by some of those working in both medicine and disability theory in reaction to Slater’s attempts to complicate the diagnostic process.5 Responses to these conservative stances from those in each discipline reveal more progressive and flexible possibilities—those in science to account for social phenomena and narrative within science, and those in disability studies to add materialist, and sometimes even medical, elements to understandings of disability. To extend such approaches and provide a concrete example of how narratives can soften disciplinary boundaries, I will focus on the role of “malingering” in these responses, using it as a test case for how medical and social theorists can work across disciplines to foster conversations about stigma in the doctor-patient relationship. Illness deception is a highly charged issue in disability rights, as people with invisible disabilities must fight for accommodation, both in the field of psychiatry, where practitioners work to detect it, and on the social stage, where charges of malingering are leveled against those receiving disability benefits as part of a political agenda. Slater’s texts, I argue, can be read profitably through the lens of disability theorist Siebers’s concept of the masquerade, a strategic performance in which an actual impairment is exaggerated in order to confront inaccessibility and cultural attitudes that emerge from ignoring the lived experience of disability. The conversation about illness deception and malingering emphasizes the problems with an evidence-based scientific approach that fails to fully account for social, economic, and psychological factors since those that push back against dominant narratives about willful abuse of social safety nets are vastly outnumbered by those providing supposedly objective evidence of systemic abuses. In this environment, the increasingly nuanced integration of material and medical elements into disability theory provides the basis for a strong bridge to the sciences—one that will hopefully be traversed in both directions to provide more traffic between departments of the humanities and the medical sciences, the latter of which could be drastically improved by the careful and self-critical theorizing that takes place in the former. [End Page 25]

“Slippery, Playful, Impish, Exasperating”: Lauren Slater’s Antidisciplinary Project

Only a touch over fifty, Slater has written, among other things, six memoirs and a book of nonfiction essays, Opening Skinner’s Box (2004).6 Her first memoir, Welcome to My Country (1996), is a series of essays about her work as a therapist for the mentally ill. In the book’s final essay, she reveals that she herself spent time as a patient in several psychiatric wards. In her next, and probably most well-known work, the 1998 memoir Prozac Diary, Slater recounts her experience as one of the first patients on Prozac, detailing both the functionality that the drug gave her, and the side effects (loss of creativity, decrease in sexual desire) that plagued her. Her next memoir was not so straightforward. Titled Lying: A Metaphorical Memoir, it begins with Slater’s description of the onset of epilepsy in her adolescence. However, the first chapter of the text consists of only two words, “I exaggerate,” and she soon declares that she may be using epilepsy as a metaphor for other types of illness, suggesting that, rather than epilepsy, she may have actually had Munchausen Syndrome, a psychiatric disorder in which patients feign or cause disease symptoms to garner medical attention. She explains, “Perhaps I was, and still am, a pretender, a person who creates illnesses because she needs time, attention, touch, because she knows no other way of telling her life’s tale. Munchausen’s is a fascinating psychiatric disorder, its sufferers makers of myths that are still somehow true, the illness a conduit to convey real pain” (88). Later, she compounds this complication by pointing out that Munchausen’s may be yet another metaphor to describe what she sees as a “fitful” life of mental illness. Slater’s admission that she may have falsified her medical history in Lying invites readers into the confused space that she says she has occupied throughout a life of illness. Slater’s ultimate claim is that whether or not she truly is epileptic is irrelevant, and that speaking metaphorically about one’s experiences can convey the “truth” of the matter as well as or better than speaking only about diagnostic “facts.”

The essay “On Being Sane in Insane Places,” which disability scholar Elizabeth Donaldson has previously and fruitfully read in conjunction with Lying, continues Slater’s disruption of diagnosis as an objective science.7 Opening Skinner’s Box is composed of ten chapters in which Slater explores famous psychology experiments and the lives of the scientists who led them. Of these essays, the response to “On Being Sane” was most intense, spawning four articles in a peer-reviewed [End Page 26] scientific journal. In the essay, Slater revisits David Rosenhan’s 1973 study in which he and several friends presented to psychiatrists as patients with a single, fictional auditory symptom: hearing the word “thud.” Each of the study members was subsequently committed to a mental hospital (all but one given a diagnosis of schizophrenia), at which point they began to act normally. The average length of commitment was nineteen days, with one pseudopatient held for fifty-two days. Slater presents this study as a tense moment in the history of psychiatry—many researchers, Spitzer most significantly, contested Rosen-han’s work as dangerous and inaccurate, but ultimately, Slater claims, “psychiatry hung its head” (76). Rosenhan’s study came among a wave of critiques of the disease model of psychiatry, including the work of Thomas Szasz and Erving Goffman, and it was in this atmosphere that Spitzer, a biological psychiatrist, was given control of the revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM).8 So, Spitzer led the creation of the DSM-III, which claimed to include objectively measurable, rather than subjective, symptoms, and did so by composing his task force entirely of those with similar psychiatric ideologies.9 Bradley Lewis has gone so far as to claim that DSM-III was the single most formative work in modern psychiatry and that, through it, “the new scientific psychiatry solidified its position as the premier paradigm for psychiatry.”10

In the essay, Slater interviews Spitzer, who claims that under the new criteria psychiatrists now would refuse to diagnose the pseudopatients with such limited information. Doubtful, Slater responds by recreating the experiment. She goes to several psychiatric emergency rooms with the same auditory symptom, and though she is never committed, she writes that doctors diagnosed psychotic depression almost every time and prescribed her “a total of twenty-five antipsychotics and sixty antidepressants” (87). She concludes that, “In Rosenhan’s day it was preexisting psychoanalytic schema that determined what was wrong; in our day, it’s the preexisting pharmacological schema, the pill” (86). In her account, she reaffirms Rosenhan’s critique of diagnostic procedures, suggesting that even in its revised form the system is deeply flawed.

Slater’s use of metaphor in Lying reinforces her attack on the objectivity of diagnosis. In the afterword, she acknowledges that the reader wants “the truth.” Yet after pointing out that she may have made up accounts of having surgery, or going to a Catholic school for epileptics in Kansas, Slater addresses her own complicated interaction with diagnosis: [End Page 27]

All I can give you is this. I take anticonvulsant medication daily. I have had auras all my life. I have had several symptoms that doctors have diagnosed as consistent with temporal lobe epilepsy. However, diagnosis itself is a narrative phenomenon, because the same symptoms that doctors saw as epilepsy in one era of my life, they saw as borderline personality disorder in another era of my life, and then as posttraumatic stress disorder in yet another era, and as bipolar, and as Munchausen’s, and as OCD, and as depression and, once, even, as autism. Autism! All I know for sure is this. I have been ill much of my life. … All I can tell you is this. Illness, medicine itself, is the ultimate narrative; there is no truth there, as diagnoses come in and out of vogue as fast as yearly fashions.

(220)

The nature of diagnosis, she claims, is such that in attempting to communicate experience, a metaphor is no less authentic than a diagnostic label. If medicine and illness are the “ultimate narratives,” this means her autobiographical projects have as much veracity as medical explanations of her condition—perhaps more, since she acknowledges the narrative elements of her texts, rather than claiming them as objectively true.

Using metaphor as a tool for troubling rigid psychiatric nosologies aligns well with strategies proposed by some in the disability studies community. Jay Dolmage has suggested that novel metaphorical language can alter our perceptions, writing that the “metaphorical nature of writing does not make it less real or less true. It does make it potentially revolutionary.”11 He also encourages an examination of the power dynamics of metaphorical language, pointing out that medical language about disability is often metaphorical, but is used and repeated as though it were presenting objective truths (113). Both Dolmage and Amy Vidali have claimed that metaphor can create new knowledge, and it is in this way, as a challenge to the monolithic narratives of medicine, that I read Slater’s use of illness as a metaphor in Lying. Vidali advocates an approach that both “encourages transgression from the disability community” and “invites creative and historical reinterpretations of metaphor.”12 Slater’s work, I argue, attempts to do both of those things.13

Disability critics working on mental illness have recognized the transgressive potential of Slater’s work. Elizabeth Donaldson writes, “reading Lying ultimately forces us to examine the multiple ways in which our experiences and ideas are pathologized and categorized, the ways in which we are complicit in that process, and the limited [End Page 28] terms of our possible rebellion.”14 Slater’s anecdotal study in “On Being Sane” invites the reader to draw the same conclusion. By drawing attention to the slipperiness of diagnostic claims, Slater taps into intense cultural anxiety about the meaning of such labels. In Mad at School, Margaret Price calls Slater’s strategy “counter-diagnosis.”15 She explains, “In counter-diagnosis, the autobiographical narrator uses language … to subvert the diagnostic urge to ‘explain’ an irrational mind. … The counter-diagnostic story does not merely parallel or replace the conventional diagnostic story: it ruins it altogether, attacks its foundations, queers it.”16 Although Price acknowledges the risks of using a stigmatized condition as a metaphor, she concludes that “perhaps in its very shamelessness lies its value. With this flamboyant gesture of untruth, the narrator of Lying refuses to become the exposed, confessing narrator of conventional disability autobiography. … Instead, the narrator of Lying invents her own diagnosis to unnerve the normative gaze” (183). Lisa Diedrich also praises the work for revealing the “historically and geographically contingent character of all diagnoses,” and points in particular to the liberating potential of metaphor: “it isn’t so much that metaphor is truth, but that metaphor reveals the difficulty of telling a truth of the self.”17 In A Condition of Doubt, Catherine Belling writes, “defined by the absence of [quantifiable objectively observable evidence], hypochondria asks medicine to take into account the subjective and ambiguous, and to question and complicate the sources of its own knowledge.”18 Though Belling is careful to distinguish between hypochondria, in which patients read experiences of their body as symptoms of an undiscovered pathology, and malingering, Slater’s narrative can still be read productively as encouraging the need to account for the subjective patient experience, a fact suggested by Belling’s inclusion of Slater’s work in a chapter on unreliable narrators of illness. Belling writes that “rather than needing to know from hypochondriacs whether they are ‘really sick,’ we might ask how they experience and understand their bodies, how they imagine what’s inside and what could be wrong there” (21). Slater’s book seems like an exercise in pushing for this revised conversation. Reacting to a world in which diagnostic categories proliferate at a remarkable speed, Slater’s book sets forth one complicated question: what does it mean to have a diagnosis? In both Lying and “On Being Sane,” the answer suggested is “not as much as you might think.”

Slater’s narratives, dealing with complicated issues of identity, free will, and truth, access unstable theoretical ground, asking questions without providing authoritative answers. Reading her work through [End Page 29] the lens of the feminist disability theory articulated by Garland-Thomson demonstrates the value of such an approach. One important aspect of this theory is that it takes up feminism’s ability to embrace paradoxes—it “asks difficult questions but accepts provisional answers. This method recognizes the power of identity at the same time that it reveals identity as fiction. … This method both writes new stories and recovers traditional ones.”19 As I have noted, Slater’s attempt to write a story reclaiming the subject position of the mentally ill narrator engages with difficult questions—how does diagnosis inflect liability? where does “normal” behavior end and “pathological” behavior begin? how do doctors reach diagnostic decisions, especially about problems of self-perception and self-representation?—without authoritatively claiming a model of understanding. This framework helps to move beyond individual problematic moments in Slater’s texts, such as her troubling claim in Lying that “alcoholism can stand in for epilepsy, the same way epilepsy can stand in for depression, for disintegration, for self-hatred, for the unspeakable dirt between a mother and a daughter,” to consider the troublesome context in which she and her critics live and write (203-4). By encouraging dialogue and interrogation rather than ethical judgment and assertion, Slater’s texts operate, alongside feminist disability studies, to break down the types of disciplinary border policing seen in the more conservative medical and social science responses to her work.

“A Response to a Nonresponse to Criticisms of a Nonstudy”: Spitzer and Slater

The exposure of the limitations of the diagnostic process common to both Lying and “On Being Sane,” triggered, I believe, the vehement reactions against Slater. Perhaps the most openly violent and disciplinary reaction to her work was Robert Spitzer’s.20 Responding to Slater’s claim in “On Being Sane” that “the zeal to prescribe drives diagnosis in our day, much like the zeal to pathologize drove diagnosis in Rosenhan’s day, but either way, it does seem to be more a product of fashion, or fad” (89), Spitzer went so far as to initiate and publish a study in The Journal of Nervous and Mental Disease to disprove her conclusion. The editors of the journal rallied with Spitzer, and although they allowed Slater to respond, they also published a review article from a member of the editorial board who supported Spitzer as well as a rebuttal to Slater’s response by the authors of the [End Page 30] Spitzer study (with the unlikely title “A Response to a Nonresponse to Criticisms of a Nonstudy”) that ended on the most dismissive note possible: “Never mind.”21 In an editorial note to the Spitzer article, the editors introduced Slater, who holds a graduate degree in psychology from Harvard and has years of experience as a practicing psychologist, as “presented on her book’s cover as a psychologist,” while Spitzer was “Robert P. Spitzer, MD, a leading architect of the contemporary psychiatric diagnostic system.”22 The allegiances in the case are clear: Slater’s attempt to challenge the status quo of the psychiatric system is utterly dismissed, and the scientific community of the journal has reaffirmed its boundaries by expelling a rogue member.

Spitzer, who was lifted into the high ranks of psychiatry as a result of his work on the DSM—work meant to override criticisms coming from critics like Rosenhan—reacted strongly against Slater’s reinforcement of Rosenhan’s counter-diagnostic project by defending his own version of medical authority. For the study, Spitzer and his co-authors issued a questionnaire based on Slater’s account to a group of psychiatrists, concluding that very few of them would have diagnosed or medicated her as she claims. Essentially, he suggests that she lied, and that through his diligence he has protected the good name of science, and the safety of potential mental health care consumers.23

Significantly, this reassertion of authority comes through a study of the self-reported practices of physicians, not of patient accounts. Of course, I cannot say whether or not Slater accurately reported her experiences, and I do not rule out the possibility that Spitzer is correct in his claim that Slater exaggerated the diagnoses and medications she was given, especially since Lying proves that she understands the narrative power of altering literal histories. My intention here is not to back up Slater’s claims, but rather to illuminate the tactics the researchers use to disqualify her from participating in a conversation about mental health. Whether or not Slater’s story is true, it remains undeniable that our psychiatric system needs to engage with charges of overmedication and the pathologization of personality.

Throughout the article, the authors point out that Slater’s work is popular, and by aligning popularity with an uncritical approach, suggest that this is what makes it so problematic: it is “widely acclaimed” and “likely to be read widely by the lay public as well as by undergraduate and graduate psychology students” (734). They launch similar complaints about the Rosenhan study, writing that “some recent and widely used psychology textbooks continue to cite the study uncritically despite extensive critiques of the study” (735). In a literature review, [End Page 31] the authors find 750 citations of the Rosenhan study, while critiques of the study were much less popular, and Spitzer’s own 1976 article is cited only 36 times. Catering to an audience accustomed to small readerships, Spitzer’s team portrays Slater’s popularity, like Rosenhan’s, as dangerous: since the work was “undoubtedly read by thousands of individuals in the general public, it is probably more likely to shape the laypersons’ impressions of diagnostic and prescription practices of psychiatrists than are peer-reviewed publications. Mental health researchers ignore popular perceptions of psychology at their peril … and must remain vigilant about correcting potential distortions and misrepresentations of scientific findings that are promulgated to the general public” (738). Using terms like “vigilant” and “peril,” the authors suggest that popularity itself is dangerous. Because the general public is unqualified to view scientific information critically, they imply, it is the duty of the scientific community to protect them, “correcting” any claims that go against academic ideology. The authors make disagreement sound dangerous, writing that Slater and Rosenhan’s work could lead the public to think that diagnosis is insignificant, harming the quality of life of people diagnosed with psychiatric conditions (734). They have thus positioned the exclusive group of researchers as the defenders of the public.

By focusing on Slater’s outsider status and the danger of popular media, Spitzer et al. establish scientific study as the only appropriate response to psychology, and they write that their findings “underscore the hazards of uncritically accepting and disseminating findings that have not undergone peer review,” pointing out that Slater hasn’t followed protocol in revealing documentation, which is “traditionally regarded as a prerequisite for placing trust in published scientific findings” (738). These comments suggest to the journal’s readers that Slater has somehow fraudulently snuck an un-peer-reviewed study into a peer-reviewed or otherwise scholarly journal. Considering that the “findings” that Slater is “disseminating” take the form of a creative nonfiction essay, it seems as though the authors of the study are not attacking Slater’s scientific ethics, but rather the act of publishing anything critical to psychiatry in the popular press. Apparently, they believe that people shouldn’t write books about science unless these are peer-reviewed documents. Significantly, Spitzer et al. take the opportunity to frame Rosenhan’s initial work as an outsider text as well; they write that Rosenhan’s study “was like a sword plunged into the heart of psychiatry” (735). This is not presented as a suicidal endeavor—Spitzer has thrown Rosenhan out of the role of psychiatrist, [End Page 32] and has cast him instead as a murderer. In this way, the authors of the study maintain that, for the good of the public at large, only academic insiders should comment on scientific issues.

This is not to say that psychiatry as a discipline is uniformly supportive of medicalizing and boundary-policing approaches. For example, a recent volume edited by Joel Paris and James Phillips, both of whom are based in psychiatry departments, examines the politics of the DSM and includes critiques of the psychiatric status quo as manifested in the DSM. Further, Marie Crowe, a researcher in nursing and psychiatric issues, published “Constructing Normality: A Discourse Analysis of the DSM-IV” in the Journal of Psychiatric and Mental Health Nursing, explicitly challenging the notion that mental disorders are located in the individual rather than in social factors. The article serves to correct what she sees as a troublesome uncritical adoption of the disease model of mental illness into nursing care, and she writes that the politics of the production of texts like the DSM must “be openly acknowledged rather than be veiled in a cloak of scientific objectivity” (72). Critiques of psychiatric infrastructure from within the field provide a valuable perspective—a perspective that I believe could be strengthened and extended by an engagement with researchers working within the humanities, or by an infusion of disability studies theory into other disciplines. The 2013 and 2014 annual conferences for the Society for Disability Studies provide a strong basis for this kind of work by featuring a robust strand, funded by the National Institutes of Health, on “Translational Research in Disability Studies and the Health Sciences” that showed the possibilities for applications of disability studies approaches into social and health science research—the kind of work that ought to become more typical in the sciences.24

“Infuriating as an Epileptic”: Mental Illness, Epilepsy, and Stigma

Disability studies responses to Slater’s work, positive and negative, get at the conceptual problems raised by mental illness within disability studies. Anna Mollow writes that “cognitive and psychiatric impairments, although they are gaining more attention, nonetheless remain marginalized, both within disability studies and in the broader culture,”25 and Elizabeth Donaldson has pointed out that the long-reigning impairment/disability divide assumes a “transcendent civil identity that exists above and beyond the body”26—an assumption troubled by mental and cognitive disabilities. Couser’s critique of [End Page 33] Slater’s work in his Signifying Bodies showcases the marginalization of mental disability within disability studies. He claims that Slater’s work is unethical and works against the goals of the disability community because it perpetuates stereotypes of epilepsy, already a highly stigmatized disease. This is a valid and important concern. Rebecca Mead’s New York Times review validates the possibility of this stigmatized reading, as she writes that Lying “wants to be as charismatic and infuriating as an epileptic, which is a risky strategy, because when it does this most successfully, it is also at its most alienating,” evidence that epilepsy can be and is seen as associated with such negative traits even in a modern arena.27

Couser refers to Slater’s play with diagnosis as “glib” and presents her stigmatizing choices as little more than an attempt not to offend her family so that she can eventually restore ties with them.28 In many ways, this misses the point, as part of what Slater communicates in Lying is that she has received many diagnoses and that none of these provides a satisfying narrative. More significantly, she suggests that the complex of psychiatric and neurological symptoms she has experienced over the course of her life has left her as confused about her medical situation as we are. It is not as if she knows her own “accurate” diagnosis, and then engages in postmodern play at the reader’s expense. In a speech delivered at an Alcoholics Anonymous meeting in the text, she says, “I hid through lies, but at the same time, every tale I told expressed a truth. It has been very confusing for me.”29 In other words, we might read Slater’s work as authentically questioning rather than “glib.”

I am not interested in determining whether Slater did or did not cross an ethical line, but rather why associating epilepsy with mental illness is especially egregious. If Slater’s troublesome act is associating epilepsy with symptoms attributed elsewhere to psychiatric disorders, perhaps we ought to interrogate why both diagnoses are so stigmatized. I believe Couser is right to be wary of metaphors that can be seen as moralizing or essentializing but, to me, the larger issue in his response to Slater’s questioned ethics is the desperate attempt to distance epilepsy from mental illness. Couser explains his concerns, saying that, “as historians of epilepsy are at pains to point out, epilepsy has been a particularly and peculiarly stigmatic condition throughout history,” partly because it “has been susceptible to so many mystifying constructions over the centuries,” of which he claims Slater’s memoir is one (125–26). One of the “three detrimental myths” about epilepsy is that “it is, or can lead to, a form of psychopathology” (156). Thus, [End Page 34] he asserts, associating epilepsy with mental illness will stigmatize the former condition. However, this is only the case because mental illness carries the ultimate stigma. Similarly, while Couser writes that Slater “trades heavily in the notion of an epileptic personality,” calling this strategy “insidious” (126), I, as previously discussed, see this as a strategy that lampoons the notion that pathology and pathological labels structure identity.

Couser’s chapter on Slater arises from the very real concern of damaging, appropriative texts about disability. I share several of Couser’s concerns. He writes, “The ethical crux of Lying is not that Slater may be lying about having epilepsy, but that in exercising prose license she commits herself to an essentializing and mystifying characterization of a still stigmatic disability” (112). I agree that, read straight, Slater is guilty of this infraction; it was my suspiciousness of her text that led me to write about it in the first place. However, I differ with Couser in reading the book as a memoir of epilepsy.30 In my view, Slater so straightforwardly acknowledges that we are talking about a history of mental illness rather than one of epilepsy that I simply cannot read it as a book that asks its readers to form any opinions on epilepsy or whether she actually has it.

The history of epilepsy is in some ways bound up with that of mental illness. For many years, epileptics were housed in the same asylums as people with mental illnesses, addictions, and cognitive disabilities, and the attempt to distance one from the others illustrates the creation of a hierarchy.31 Often, marginalized groups will rhetorically position themselves as opposed to some group that truly deserves to be stigmatized, thus gaining enfranchisement at the expense of the newly devalued group. David Mitchell and Sharon Snyder write, “From the segregation of special education classrooms to the systematic murder of people with cognitive disabilities in Nazi Germany, the fate of people with physical disabilities has often depended on their ability to distance themselves from their cognitively disabled peers.”32 In this way, being grouped together with people who have mental disabilities was the ultimate indignity—clearly, those with epilepsy did not fit with those who “really did belong” in such wards. Catherine Prendergast writes that as a field, “disability studies, with its emphasis on the body and not the mind, creates fissures through which attention to the mentally disabled easily falls,” and concludes that, “to be disabled mentally is to be disabled rhetorically.”33 Couser’s concern with destigmatizing epilepsy, itself an important goal, identifies one of these “fissures,” as claiming a neutral value for epilepsy relies on distancing it from [End Page 35] mental illness. Thus, reading Lying solely as a record of malingering forecloses reading for the stigma of mental illness, the lack of clarity in psychiatric diagnosis, and the impact of diagnosis on personhood.

Further, I argue, Slater’s use of epilepsy does not disregard the condition’s historical stigma, but rather is conscious of it, putting it to use to advance her claims. For instance, she herself acknowledges the historical uncertainty surrounding epilepsy, asking, “Is epilepsy mental or is it physical? A long time ago, when van Gogh was alive, people with epilepsy were put in insane asylums, where I’m sure, with their froth, they fit right in.”34 Couser critiques Slater’s use of quotations from a 1854 medical textbook, The Text Book of Grand and Petite [sic] Mal Seizures in Childhood, claiming that it is evidence of “how little concerned she is with contemporary developments in understanding and treating this condition” (124). To the contrary, I read her use of this antiquated text as yet another attempt to showcase medical diagnosis as a malleable social phenomenon, and to engage with illness as a historical, but still material, reality.

There are multiple convergences between historical mappings of hysteria and Slater’s symptoms in Lying. Donaldson mentions that the memoir seems like a “hysterical conversion,” but there are other diagnostic markers as well.35 For instance, Jean-Martin Charcot (1825–1893), a neurologist who researched hysteria at the Salpêtrière in the nineteenth century, saw seizures as the most essential sign of hysteria, outlining “four [seizure] states: a premonitory period in which there might be visual disturbances or the classic globus hystericus; involuntary movements, building to backbending athletic acrobatics; stagy poses, which Charcot called attitudes passionnelles and suggestively titled ‘summons,’ ‘amorous supplication,’ ‘mockery,’ ‘menace,’ ‘eroticism,’ and ‘ecstacy’; and resolution.”36 In Lying, Slater breaks the book into four sections—not perfectly aligned with Charcot’s but bearing a definite resemblance: “Onset,” “Rigid Stage,” “Convulsive Stage,” and “Resolution.” The connection between epilepsy and hysteria has long been a site of doctors’ anxiety, and it was often difficult for doctors at the Salpêtrière to distinguish between cases of hysteria and epilepsy.37 Thus, by writing of seizures, Slater calls up not only contemporary epilepsy but also Charcot’s hysteria, and in so doing blurs the line between physical and mental distress.

Recent work by disability studies theorists on mental disability has progressed past the problematic social model to a paradigm that seriously accounts for material conditions. Mollow, for instance, complicates the anti-psychiatry model through her reading of Meri [End Page 36] Nana-Ama Danquah’s Willow Weep For Me, a memoir of depression that is inextricably bound up in the author’s lived experience of race, class, and suffering. Mollow uses Danquah’s book to argue for an acknowledgement that the social model blots out accounts of pain such as Danquah’s. Developing “complex embodiment,” which “theorizes the body and its representations as mutually transformative,” Tobin Siebers notes that the social model unfairly suggests that a subject can gain emancipation from oppression through “intellectual and emotional resources.”38 Elizabeth Donaldson writes, “A feminist disability studies theory of mental illness that includes the body, one that theorizes bodies as ‘material-semiotic generative nodes’ and mental illnesses as physical impairments, would be a timely and productive way of developing the discussion of madness/mental illness within women’s studies scholarship,” and argues for contextualized theories of embodiment.39 By complicating the divide between agency and compulsion and mental and physical, Slater’s texts help theorize this move beyond a pure social model.

Slater’s conflation of physical and mental symptoms in Lying—she writes that “the lying hurt, physically” (91) and refers to herself after her first intentionally initiated seizure as “arsonist of the flesh” (85)—helpfully illustrates the physicality of mental distress. She uses this historical confusion of physical and mental symptoms to disrupt the idea of diagnoses as intrinsically physical or mental. She writes dismissively of those who suggested she could will herself out of having seizures—a line of critique important for people with mental illnesses, who are often popularly diagnosed with something more like a lack of will or agency than with a disabling condition (as will be seen later in discussions of illness deception). Slater acknowledges the importance of evolving historical contexts, and explains, “Epilepsy today is definitely a physical thing, but two hundred years ago it was definitely a demon. You can be cured, today, with drugs, but long ago the same cure came through stork’s dung, the liver of a she-goat, an amulet of stones taken from the stomach of a swallow at the waxing moon.”40 Though the “glibness” Couser identified comes through in this passage, Slater earnestly engages with the hazy intersection of mental and physical symptoms, and encourages her readers to linger there, as her complex of symptoms takes precedence over a diagnosis that would allow the reader to classify them neatly as physical or mental. As expressed by Professor Hayward Krieger, the fusty academic persona Slater takes on to write the book’s introduction, Lying asks us to enter “the truth of the liminal, the not-knowing, the truth of confusion, [End Page 37] which, if we can only learn to tolerate, yields us greater wisdom in the long run than packaged and parceled facts” (x).

Faking It: Slater and Illness Deception

The issues raised above—science’s overwhelming emphasis on its own traditional methodologies and the conceptual problems of mental disability in disability theory—can converge in important social conversations, such as the one surrounding malingering. A quick search of PubMed reveals a vast proliferation of studies attempting to draw lines between real and malingered symptoms, and it becomes clear that detecting patient deception is a significant concern. Drob et al. found more than 1200 peer-reviewed articles on the topic from 1989 to 2009 (1217). If medical science can converge with disability theories that increasingly leave space for medical understandings of illness, we could move past this impulse to quantify the incidence of illness deception, and instead have productive conversations about meeting the needs of those who struggle in non-stigmatizing ways.41

Cultural nervousness about illness deception has long played out in popular and literary culture. In the nineteenth century, people were endlessly curious about the role of performance in famous cases of hysteria, to the extent that Charcot’s patient Blanche was asked whether she was faking her symptoms even in her dying moments.42 More recently, illness deception has been brought into debates about social security and disability payments, and thus into questions of political economy and the quality of life of those who rely on such services. Conservative political commentator Jonah Goldberg, for example, suggests that the number of citizens receiving disability benefits in America might fall drastically if each was submitted to a “thorough examination,” and NPR’s Chana Joffe-Walt has coined the term “disability industrial complex” to refer to the legal business that has cropped up as the number of people seeking disability payments has increased in the face of the recession.

This anxiety arises from the impossibility of determining disability from outward appearance, and from medicine’s reliance on an evidence-based diagnosis that cannot adequately deal with many conditions and impairments. Mollow addresses the struggle that comes with having an “invisible disability”: “Mainstream Western medicine does not recognize as legitimate impairments that cannot be diagnosed with conventional medical tests. People who have [environmental illness] [End Page 38] (or similarly ‘controversial’ impairments, such as fibromyalgia, chronic fatigue syndrome, or chronic pain) are therefore often regarded as malingerers or hypochondriacs. … For most people with impairments that manifest neither visible differences nor abnormal test results, it is an ongoing struggle to obtain disability benefits, access employment accommodations, or persuade family members and friends that they really are disabled.”43 Spitzer and his co-authors exhibit an opposing anxiety, and their article claims, “Only three [psychiatrists given Slater’s narrative] noted the correct diagnosis of malingering as a diagnosis to be ruled out. This finding may indicate that most emergency room psychiatrists are insufficiently cognizant of the possibility of deliberate faking of psychological symptoms” (737). Ours is a culture that watches for and condemns any trace of malingering, and both Lying and “On Being Sane” spark concern about its prevalence. This is a prime example of a politically salient issue that would benefit from a disability studies approach to more dominant models that insist on statistical data. Many of the 1200-plus articles found by Drob focus on new, more specific metrics for detecting deception. Perspectives from scholars such as Mollow, who worry about the potential overstatement of malingering and the negative impact of this overstatement on those who can’t point to a set of lab results to validate their symptoms, could be a valuable corrective to this poorly theorized proliferation of data points.44

The concern with illness deception is widespread. The dominant cultural and medical narrative suggests that many claims of disability or chronic illness are fabricated: a 1999 report showed that employers won 94 percent of federal ADA cases because the court ruled that the plaintiff was not really disabled.45 Further, a British survey showed “54 per cent of respondents wanted the government to stop fraud more than facilitate those people entitled to claim benefits.”46 One could argue that Lying reinforces these ideas—by acknowledging that she is lying or has lied about her medical condition, Slater gives credence to fears about deception. However, her narrative also rejects the idea that the deceptive behavior accompanying her mental illness ought to be stigmatized. It is certainly not the story of a “well” woman shamming illness for personal gain, and instead it works to humanize a set of symptoms that are deeply prone to stigma.

On the other hand, some work in psychology is invested in moving illness deception out of the medical realm and even further into the moral one. This argument relies on the notion that disability claims have risen in the past several decades simply because “more [End Page 39] generous benefits have become more widely available” (a view that I imagine would be strongly contested by those receiving such compensation).47 Halligan et al. point out that the claims that have risen most significantly are those that rely on subjective personal accounts, but rather than understanding this as a shift in what people feel willing to claim, or can finally get more support for, they read it as evidence that people are increasingly engaging in illness deception in the same way that they would go about tax fraud or theft. To solve this problem, they propose that we consider illness deception not as a psychiatric problem, but as an exercise of free will: “This pervasive and deep-seated notion of free will and individual responsibility remains central to all democratic and legal conceptions of human nature, and provides a reasonable framework from which to explain and discuss illness behaviour not produced by disease, injury, or psychopathology” (5). Ultimately, this claim leaves no space for impairments that cannot be medically explained, and insists that those who engage in illness deception “simply lack the moral faculties that we assume most in society take for granted” (13). They posit that illness deception is far more common than we have previously assumed, suggesting that we are not concerned enough with it—this even though some studies have suggested that it occurs in up to 60 percent of cases.48

Like Spitzer, who worries that malingering goes unnoticed, Halligan and his team also stress the hypervigilance needed for doctors to differentiate between real symptoms, fake symptoms, and symptoms of psychopathology, and this sense extends beyond the medical field. In an Internet message board for the website Coping with Epilepsy, one thread, “Munchausen by Internet,” encourages members of the website to be wary of possible cases of members posting about their struggles with an illness they do not really have. The responses in this thread include anecdotes about how members previously “found out” people faking symptoms in various forums and one poster’s assertion that, “It is a sickness of the very core of that person.”49 Further, Halligan et al. write that the American Psychiatric System’s most popular course in 1995 taught how to detect malingering (17). The question of Munchausen’s is thus closely linked with the idea of monitoring—people are comforted when they can evaluate properly signs of health or illness, so when health “passes” as illness, as in Munchausen Syndrome and malingering, it is experienced as a frightening transgression. The response of people, especially doctors, to this fear is to seek to exercise their powers of delineation and make judgments: who is really sick, who is not, and how do we know? [End Page 40]

As noted earlier, only seven percent of disability suits are found in favor of the plaintiff; the idea that medicalization has allowed people to get away with disability fraud is poorly founded. Halligan et al. write, “Sensitivity to issues surrounding the nature of illness deception continues to be a major feature of modern medicine and social security policy in most Western democracies, all of which has contributed to the paucity of published research on this subject” (22). Thus, they claim that it is medicine’s laxity with patients claiming unverifiable conditions that is a problem, though, in opposition, disability studies literature has shown that dismissiveness is a larger problem for people with impairments. Further, as Drob et al. have thoroughly shown, there is hardly a “paucity” of research on malingering. Ultimately, this reveals a distinct problem in the medical field—their commitment to monitoring and diagnosing without challenge leads to an overestimation of the problems posed by patient accounts. In this scheme, the story of the patient is not just a story, but a document to be fact-checked with a critical eye. Many disability theorists, such as Susan Wendell, have contested this process, but the medical community’s tendency to claim authority limits the possibility for an interdisciplinary discussion of a key issue in the politics of the doctor-patient encounter: whose job is it to tell or decipher the illness narrative?

Replacing the notion of malingering with Siebers’s concept of the “masquerade” suggests a way that Slater’s performance of her mental disability could spark productive conversation about patients’ narrative rights. Siebers writes about increasing his post-polio syndrome limp when it is time to board planes so that he doesn’t get questions about why he should get to board early, “despite the fact that it fills me with a sense of anxiety and bad faith, emotions that resonate with previous experiences in which doctors and nurses have accused me of false complaints, oversensitivity, and malingering” (97). His argument is that this kind of masquerade can be a political strategy. It can be problematic, as is the case for what Siebers calls “disability drag,” which he says “represses disability and affirms the ideology of ability” (114). An example of this would be an able-bodied person who plays a disabled one in a film. Couser’s criticism of Lying is based on reading it as this type of work. After all, Slater never had a corpus callosotomy, and she acknowledges that much of her account of illness is not factually true. Thus, she seems like an able-bodied person claiming a disability identity for entertainment purposes. Still, considering Lying as a memoir of mental illness, one that pushes its readers to blur and reconsider hard lines between mental and physical [End Page 41] distress, it begins to sound more like Siebers’s powerful masquerade than disability drag. Siebers writes, “The masquerade counteracts passing, claiming disability rather than concealing it. Exaggerating or performing difference, when that difference is a stigma, marks one as a target, but it also exposes and resists the prejudices of society. The masquerade fulfills the desire to tell a story steeped in disability, often the very story that society does not want to hear, by refusing to obey the ideology of ability” (118). Reading Slater’s work as exaggerating or performing her mental disability rather than exploiting epilepsy results in a text that transgressively displays its refusal to follow the rules in a society that values ability, and which reads physical impairment as more “legitimate” than mental. In her discussion of the problems facing those with invisible disabilities, Mollow asserts that for such people, even claiming a diagnosis is a politically powerful act (11). By foregrounding her illness, Slater makes a strong statement about the need to confront, rather than ignore, stories of mental disability, and to claim individual experience without bowing to medicalization. Margaret Price has also argued for this reading, and writes that Slater confronts us with “the diagnostic urge, the desire to figure out what is really wrong with Lauren,” which she claims “is precisely the counter-diagnostic strategy of Lying: it dangles an illusory promise of truth before its reader, and calls our attention once again to the appetite for diagnosis.”50 In this vein, when Slater narrativizes the difficulty faced when atypical experience interacts with the medical establishment, she pushes her readers to question their reactions: how do their opinions of her change with the relocation from epilepsy to Munchausen’s to a habit of deception to a cloud of nebulous somatic and mental symptoms with no simple name?

If they reject, rather than genuinely respond to, confrontations of diagnostic authority and insistence on patients’ narrative power, medical professionals miss an opportunity to rethink their practices in socially beneficial ways, such as in the debates over illness deception. If disability studies scholars continue to develop critiques of theory that is overly focused on physical disability and the social model, they will help shape a field even riper for interdisciplinary work. Perhaps then we will see the types of research in the Society for Disability Studies’ translational research panels become more prominent in more traditional health science venues. [End Page 42]

Conclusion

The August 2012 edition of Science included an article by an interdisciplinary team: a cognitive psychologist, a philosopher, and a law professor. The researchers set out to study the effect of diagnosis on legal sentencing, and they passed out hypothetical cases to several judges. What they discovered was this: when the judges were told that the offender in an aggravated assault case was a psychopath, the average sentencing time was 13.93 years, compared to the 9-year average for those without a diagnosis. However, given the same case and diagnosis, but adding “expert testimony from a neurobiologist who presented an explanation of the biomechanism contributing to the development of psychopathology (here, low MAOA activity, atypical amygdala function, and other neurodevelopmental factors),” sentencing time on average was cut by just over a year to 12.83 years.51

Another group of researchers, this time for the American Psychiatric Association, has reworked the DSM once again, and the DSM-5, released in 2013, takes up questions of diagnostic criteria, attempting to redraw the lines around what is and is not pathological behavior. According to the APA, some of these changes include the elimination of schizophrenia’s subtypes, the creation of the diagnosis “disruptive mood dysregulation disorder,” which is meant for children under eighteen who may previously have been diagnosed with bipolar disorder, and also the addition of hoarding and skin picking disorders.52 In the preface to Making the DSM-5, Joel Paris notes that the APA’s original intention was to make a “paradigm shift, in which psychiatric diagnosis would be in greater harmony with neuroscience,” a goal abandoned because it couldn’t be backed up with current findings.53 He also claims that the revised manual works to place diagnoses more on a continuum with normality. Bradley Lewis’s critique points out, though, that while the authors have revised the work to keep up with changing perceptions of science, they “have not been open to robust ‘rhetorical’ critique that seriously questions the core rhetorical frames of the manual” (105).

Both of these examples emphasize an ongoing cultural concern with dividing behavior into categorized pathologies. Our increased understanding (or at least our increased sense of understanding) of the biomechanics of mental illness does, as the sentencing study suggests, affect the way that we make sense of and respond to the behavior of others. The changes to the DSM point to particular anxieties about diagnosis: do our children have ADHD, or are they bored? Are we [End Page 43] depressed, or are we grieving? Am I stressed, or do I have Generalized Anxiety Disorder? The fact that the manual has been rewritten again suggests that medical authorities believe the answers are out there—as a society, we simply have to rework the criteria until we are experts in detecting them. Increasingly scientific explanations of behavior alter our perception of liability and morality (this has of course long been the case, though brain scans and chemistry panels have replaced phrenology).54

Lauren Slater’s refusal to simplify such concerns irritates many of her readers. Robert Spitzer’s attack on her essay (and the Rosenhan study on which it was based) is a case study in medical science’s resistance to incorporating challenges that would call for radically rethinking the field, while Couser’s critique of Lying suggests how difficult it can be to challenge hierarchies even in a field invested in dismantling them. The bright side to all of this is that those criticisms spurred a defense of Slater; despite their limitations, both fields have shown deep concern with the ethics of diagnosis, and are charting the possibilities for more integrated theory that accounts for a mutually constitutive relationship between body and environment theorized in Siebers’s “complex embodiment.” It is to be hoped that increased interdisciplinarity will translate into our broader culture, where science is often viewed as more valuable than narrative, and mental disability as even more disqualifying than physical.55

With this goal, we are left with a need to increase cross-disciplinary conversation and research. The three-field convergence of the sentencing study is a step in this direction. I would hope to see, too, an increased use of humanities-based critiques like Price’s and Lewis’s in pre-med degree programs as well as graduate and professional schools in health sciences, and for disability studies theorists to think about how they can strategically engage in debates in the sciences in order to gain influence outside the relatively limited scope of science and disability studies in the academy. I will conclude this paper with a passage from the British Psychological Society’s response to the development of the DSM-5 that also responds to the fear of stigmatizing illness. I do not intend to put their view on a pedestal—the question of diagnostic ethics is, of course, too complicated to be “solved” in a single statement—but rather to point to a place where social and medical approaches have begun to work together:

The Society is concerned that clients and the general public are negatively affected by the continued and continuous medicalisation [End Page 44] of their natural and normal responses to their experiences; responses which undoubtedly have distressing consequences which demand helping responses, but which do not reflect illnesses so much as normal individual variation. … The Society recommends a revision of the way mental distress is thought about, starting with recognition of the overwhelming evidence that it is on a spectrum with “normal” experience, and that psychosocial factors such as poverty, unemployment and trauma are the most strongly-evidenced causal factors. … We therefore believe that alternatives to diagnostic frameworks exist, should be preferred, and should be developed with as much investment of resource and effort as has been expended on revising DSM-IV. The Society would be happy to help in such an exercise.56

The response draws on both peer-reviewed scientific studies and social theory in order to critique not just the revision of the DSM, but diagnostic processes as a whole. Such an endorsement of rethinking the field by a professional psychological association bodes well for the project with which Slater is engaged—her attempts to question approaching psychiatric distress solely through the medical model without disavowing the aid she has been granted, and has granted to others, through psychological and psychiatric practices.

Lindsey Grubbs

Lindsey Grubbs is a doctoral student in English at Emory University, where she is also pursuing a certificate in bioethics. She holds an MA in English and gender studies from the University of Wyoming. Her research focuses on nineteenth- and twentieth-century American literature, bioethics, disability studies, and the rhetoric of “authentic” illness. She is an editorial intern for American Journal of Bioethics: Neuroscience, and is completing a bioethics practicum at the Centers for Disease Control.

NOTES

I would like to extend thanks to many people for this essay. To Michelle Jarman, Nicole Quackenbush, Jason Baskin, and Benjamin Reiss for their conversation and energy from earliest conception to final revision, and to the journal’s editors and reviewers, who contributed new sources and insights, and who pushed me to approach this topic with more nuance and fuller context. The essay in its current form emerged from the careful reading and close attention of these and others, and I am deeply indebted to each.

1. The terminology surrounding what is commonly called “mental illness” is fraught, and I use the term because of its popular clarity, not for a particular rhetorical effect. In this essay, I alternate between several quasi-synonyms—mental illness, mental disability, and psychiatric disability—though find each in some ways insufficient.

4. Subsequent references to these editions will be cited parenthetically in the text.

5. It is worth noting at this point that although I look at disciplinary boundary policing in both the medical field and the humanities, the power differential between the two is surely skewed in favor of the former, as medical authority is often situated as unquestionable in matters of health. [End Page 45]

6. She was also the editor of the 2006 edition of The Best American Essays and the 2003 Complete Guide to Mental Health for Women, and she contributes to Elle Magazine, Harper’s Magazine, and The New York Times Magazine. Her Amazon author page states that she has won “a 2004 National Endowment for the Arts Award, multiple inclusions in Best American Volumes, and a Knight Science Journalism Fellowship at The Massachusetts Institute for Technology.” She has also written a book of revised fairytales, Blue Beyond Blue (Norton, 2005). All this is to say that even if Slater is not a bestselling author, her work has a wide audience, and she is read in upscale literary publications as well as in women’s fashion magazines.

7. Donaldson’s “Lauren Slater’s Lying carefully unpacks the rhetorical stakes of the controversy in the Journal of Nervous and Mental Disease and considers the diagnostic implications of Lying. She sees Slater’s obfuscatory style as appropriately matching the complicated history of women, mental illness, and diagnosis, and she touches on Couser’s critique of the work from a disability studies perspective and on Price’s “counter-diagnosis.” She writes, “Slater’s project in Lying … is more than simply an exercise in pushing the boundaries of the memoir genre, and her work in general raises issues that are central to the study of medical humanities, disability studies, and feminist critiques of psychiatry” (n.p.). In what follows, I extend Donaldson’s reading to focus on the expulsionary schemes set up by various critics that seek to eliminate the threat of the complicated history of diagnosis as they see it manifested in Slater. Because Donaldson has so beautifully illustrated several of these themes, I will try to set up some of these implications without dwelling on them.

10. Ibid., 98.

13. See also Kate Cantrell’s “Lying in All Honesty.” Although she does not frame her essay with a disability studies perspective, she cites both Donaldson and Price while exploring the ethics of using metaphor to express figurative truth in Lying and considers the role of metaphor for the female confessant in memoir more broadly.

16. Ibid.

20. Again, Donaldson also summarizes this debate, but I include my own brief summary in this paragraph and the next to assist in setting up the argument to come.

22. Spitzer et al., 738; emphasis mine.

23. Ibid., 734.

24. For example, the 2014 Society for Disability Studies conference included six panels fusing quantitative and qualitative research with disability theory perspectives in its translational strand. In one panel, Marsha Saxton presented community outreach work on disability, sport, and fitness in the Bay Area; Elaine Gerber presented anthropological work on food deserts and access to grocery stores for the disabled; Gerald Jordan and his co-authors presented on disability theory’s lessons for psychiatric research on first episode psychosis; and Eloise Tyler discussed stuttering in African-American populations.

25. Mollow, 70. [End Page 46]

27. Diedrich’s article provides an insightful analysis of Rebecca Mead’s review of Lying; see especially 139–40. The essay also helpfully argues for the significance of epilepsy, specifically, as Slater’s “metaphor” of choice.

28. Couser, 113. Subsequent references will be cited parenthetically in the text.

30. Donaldson, too, challenges this characterization. She writes, “Lying cannot be reduced to a mental illness memoir dressed up as an epilepsy memoir: Slater’s story is a complex hysterical conversion that translates the experiences of her childhood in indirect ways” (“Lauren Slater,” n.p.).

35. “Lauren Slater,” n.p.

37. Hustvedt, 173. Ian Hacking’s Mad Travelers includes an extended conversation about the politics of assigning a diagnosis of “hysteria” as opposed to one of “epilepsy” in Charcot’s era. Diedrich notes that dividing the narrative into these four stages suggests “the interrelationship between a particular biological experience—seizure—and its depiction in a historical medical narrative, as well as in her own contemporary narrative of self” (140).

41. Donaldson expresses this possibility eloquently in “Revisiting the Corpus”: “It is possible to begin with the premise that mental illness is a neurobiological disorder and still remain committed to a feminist and a disability studies agenda—an agenda that fights discrimination, advocates for the rights of women and people with disabilities, seeks to dismantle ideologies of oppression, critiques medical discourses of mental illness, and demands equal access to social services and medical treatment—and it is important that feminists and disability scholars begin to think about mental illness in these medical and physical terms” (106).

44. Interestingly, the role of trust in the doctor-patient relationship is often cited as deeply important, but the literature is significantly one-sided. Many people work to see how we can encourage patient trust in the doctor (for example, studies examine such phenomena as patient trust related to doctor body mass index, to the rural or urban location of clinics, etc.), but instead of studies about how to increase doctors’ trust in patients, we see a convergence of interests on better detecting how patients lie.

47. Ibid., 3.

48. See Chafetz and Underhill. As one might expect, such claims have been critiqued not only from science critics in the humanities but also by fellow psychiatrists. Drob, Meehan, and Waxman’s article “Clinical and Conceptual Problems in the Attribution of Malingering in Forensic Evaluations” gives an excellent overview of problems in malingering studies.

49. User “Birdbomb,” November 12, 2007, comment on “Munchausen by Internet.”

50. Price, 190. Although she doesn’t explicitly use Siebers’s term “masquerade” here, Price’s argument is clearly shaped by the concept—she cites his article when talking about “closeting” (see Mad at School, 179). [End Page 47]

54. See bioethicist Paul Root Wolpe’s “Treatment, Enhancement, and the Ethics of Neurotherapeutics,” which begins by briefly tracing ways that studying the brain has “promised more than just the cure of disease” (387). He mentions phrenology, criminology, craniometry, and lobotomy as morally charged brain sciences, and claims that “Neuroscience today is also built on a series of fundamental assumptions about human nature and worth” (387). Additionally, literary scholar Justine S. Murison’s “‘The Paradise of Non-Experts’” helpfully reads the current fascination with neuroscience alongside the popularity of the “science” of mesmerism in the 1840s.

55. On the divide between attitudes to physical and mental disability, see Donaldson, “Corpus of the Madwoman”; Prendergast; and Mollow. The bias toward the sciences takes many forms. Monetarily speaking, compare the 2013–2014 median salaries for full professors in engineering ($123,103), the biological sciences ($99,598), and the health professions ($103,501) with those for history ($86,636), philosophy and religious studies ($90,607), and English ($85,404) (“Tenured/Tenure-Track Faculty Salaries”). Voices from the humanities have responded to departmental cuts and rhetoric devaluing the field, as in 2010 opinion pieces by Robert Watson and Stanley Fish, and work from many disciplines has tracked the way that neuroim-aging and technical explanations for behavior increase the receptivity of a listener or viewer. For instance, see Caulfield, Rachul, and Zarzeczny on “neurohype”; Ali, Lifshitz, and Raz on “neuroenchantment”; McCabe and Castel; and Weisberg et al. For a historical approach to the origin and ascendance of scientific objectivity, see Lorraine Daston and Peter Galison’s Objectivity (2010).

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