Literature and Psychiatry: The Case for a Close Liaison

INTRODUCTION

Literature is acquiring status in medical education and academia. Literature is presently taught in over a third of medical schools in the USA. ² In Australian medical curricula, the medical humanities (comprising the history of medicine, ethics, philosophy and literature) are starting to be appreciated and examined. ³ The University of Sydney's new medical course uses literature to illuminate issues surrounding old age, death and dying. ⁴ There are currently full academic chairs of Literature and Medicine in the USA. An international journal called Literature and Medicine ⁵ is in its twenty-first year and articles on literature and medicine are being published in major medical journals.e.g.6

The affinity between literature and medicine is not new. In Ancient Greece, Apollo was the God of Literature and Medicine; the seven strings of his lyre had mystical significance and were used for medicinal purposes. ⁷ Modern interest in the marriage of medicine and literature has a more practical basis. There appears to be increasing recognition that we as health professionals have much to learn from literature and that literature has the capacity to influence its readership - to impart knowledge, shape attitudes and to be a healing experience. The flip side is that literature may have the capacity to harm. Our paper aims to examine the relevance of literature for psychiatrists and to make a case for psychiatrists taking a keen interest in this art form.

THERE IS MUCH TO LEARN

Literature is a forum for the depiction of human suffering, both physical and psychological. In literature, psychiatrists and trainees will find the panorama of experience from well-being, developmental psychology, distress, symptom through to psychiatric disorder

Descriptions of what would now be classified as ‘psychiatric disorders’ have existed in literature long before they were reified in psychiatric nosological systems. In his diary account of the Great Fire of London, Samuel Pepys ⁸ records the re-experiencing of symptoms, emotional numbing, anxiety, hyperarousal and avoidance behaviour. The ‘Great Fire of London Syndrome’ became, in another age, ‘Shellshock’ and, most recently, ‘Post Traumatic Stress Disorder’. Russian literature in particular is replete with diagnoses and has been a recent focus for study. ⁶ In Dostoyevsky's The Idiot, ⁹ we find authentic descriptions of the various psychiatric states associated with temporal lobe epilepsy. In Tale of Vanka, ¹⁰ Chekov depicts profound depression in a nine year-old boy and in Black Monk ¹¹ he describes the classic manic psychosis.

Literature also serves as a window on the history of psychiatry, allowing us to appreciate not only enduring phenomena but also changes in the presentation and recognition of disorders over time. For example, in children's literature there seems to be a dramatic shift in how children are perceived as suffering psychologically. Consider the writings of Hans Christen Andersen - so many of his child subjects are emotionally or physically deprived and abused, yet these children seldom show unhappy emotion. The Little Match Girl ¹² is barefoot in the snow, starving and afraid to go home lest she be beaten by her father. She freezes to death on a New Year's Eve not in a state of depression, but in an ecstasy of fantasy about ‘the warm fire, the warm food and the great glorious Christmas tree’. The passers-by who find her the next day wonder at ‘her red cheeks and smiling mouth’. From early this century, hard on the heels of Freud, the children of literature are conspicuous for being in wheelchairs. These children include Colin in The Secret Garden ¹³ and Clara in Heidi. ¹⁴ The common theme and sequence is early maternal loss ? remaining parent lost in grief ? child suffers a conversion disorder ? (emotional nurturance) ? the child gets up and walks. Nowadays there is very little either covert or converted about psychological distress in the older children of literature. They are more likely to be depicted teetering on the edge of a cliff, balcony or railway platform. ¹⁵ Their suffering is very much ‘in your face’. In the climax of Dear Miffy ¹⁶ by John Marsden, we read:

Our appreciation of ‘adolescence’ as a developmental stage has been heightened by the literary account. While the modern teenager may have been benchmarked this century in JD Salinger's The Catcher in the Rye, ¹⁷ he or she has been sighted and described in earlier literature. In Romeo and Juliet and Much Ado About Nothing, the world of the adolescent is illuminated. Herein are the familiar ingredients of adolescent crisis. Did Elizabethan England know a ‘teenager’ or did Shakespeare, as Barrett suggests, ‘like a sensitive seismometer feel the first rumblings of a modern adolescence some century or so before it emerged and exploded onto the late classical/early modern landscape’? (Barratt R: unpubl. data, 2000). The literature of eighteenth and early nineteenth century England seems to document the emergence of social space between childhood and adulthood, one which flowed from the Industrial Revolution and which was contingent on social class. Avery and Kinnell trace references to this potential adoles-cence. ¹⁸ In 1741 Lord Chesterfield had written to his son that, at age 9, ‘childish toys and playthings must be thrown aside and your mind directed to serious objects’. But by 1761, in The Parent's and Guardian's Directory and the Youth's Guide to Choice of Profession or Trade, the youth seeking a job has already had his education and is aged about 14 before being apprenticed, some five years after the age at which Lord Chesterfield's son was told to act like a man. The romantic and literary rescue of the child of industrial England - rescue from the harsh reality of child abuse, slave labour and deliverance into the safe, potential adolescent space, is portrayed in Charles Dickens' Oliver Twist. ¹⁹

Unlike the medical textbook which focuses largely on patients and their pathology, literature is inclusive of the other players in the drama of human suffering. It captures the experience of carers, families, doctors and society with respect to mental illness. In literature, family members of persons with mental illness find a voice. Goodnight Mister Tom, a children's novel by Michelle Magorian, ²⁰ is such a book. ‘She must be orf ‘er nut’ a character says of William Beech's mother. Reading between the lines, the mother has a chronic psychotic illness culminating in her suicide. However, it is through the eyes of William that the story unfolds. He is an abused, latency age boy, whose final trauma is to be imprisoned by his deranged mother under the stairs where he is eventually found, ‘a thin, emaciated boy with matted hair and skin like parchment … tied to a length of copper piping …’. Tell Me I'm Here by Anne Deveson ²¹ was the 1991 winner of the Human Rights Non-Fiction Award. It is the personal story of her son's journey into madness ‘leading us all into the brambles and the boglands’. It is the poignant account of the ‘us all’ - the family, the carers of the mentally ill - which is the eye opener.

In her introduction to the 1998 edition, Deveson recounts the social impact of her work:

Literature can facilitate self-reflection. Works such as Camus' The Plague ²² and Chekov's Ward No 6 ²³ delve into the personal, professional and political lives of the doctor and psychiatrist.

Posen ²⁴ gathers images of ‘the impaired doctor’ in his review of the portrayal of the doctor in non-medical literature. Behind the social facade is the deranged child molester, the alcoholic or opiate addict, the stubborn, the ignorant, the careless and the incompetent.

In Francis Webb's collection of poems titled Electric, ²⁵ the vicissitudes of our professional endeavour are assembled. Webb goes behind the textbook account of Bini and Cerletti's discovery of electroconvulsive therapy to portray the quandary and trepidation these mental health professionals may have experienced in the decade of animal experimentation culminating in trials on humans. Initially they had hesitated and argued ‘outside the black doorway of the convulsion’, then they had dared to see ‘the black doorway, As being perhaps a mercy when life, the invader, aggressor, … threatens the private jealous living atom’. And all this passion and risk against the backdrop of a Europe bridling towards war ‘a world with no time to waste on such grotesque things’.

Literature has this capacity to hold a mirror to psychiatry. We see reflected the image society has of its mental health professionals, its institutions, its sufferers and mental illness per se. From this we may access society's knowledge base and attitude, our perceived integrity as a profession and changes that need to be made to correct the gulf between the image we see and the image we would like to have. In Harry, ²⁵ a poem about an intellectually retarded man and fellow inmate of the mental hospital, Webb captures society's stigmatising of the disabled. He reasons:

and in The Homosexual ²⁵ Webb records psychiatry's and society's abuse of psychiatric diagnosis:

Abhorrence of the mental health institution and its workers is part of the legacy of Michael Dransfeld's poetry. This prolific and popular Australian poet died on Good Friday, 1973, aged 24. He had a heroin addiction. His poems, The Second Month ²⁶ were:

Dransfield's hostility is overt in Tuesday Night. He threatens: ²⁶

The images are difficult and disturbing but contemporary psychiatry cannot ignore them.

WE MAY LEARN EVEN BETTER

From literature we can undoubtedly learn - about psychopathology, developmental psychology, sufferers, carers, mental health professionals, psychiatric treatments and institutions, and social attitudes. But the argument goes further: perhaps we can learn even better than from other sources. The argument is that the Shakespeares and Tolstoys of this world can articulate better than textbook, tutor or perhaps even patient, the experience of suffering. By mobilising the imagination and fantasy, literary works engage the reader more fully. With the freedom of metaphor, portrayals of suffering go beyond what is allowed by the careful terminology of nosological classification. In Darkness Visible: A Memoir of Madness, ²⁷ William Styron rejects the very term ‘depression’ as hopelessly inadequate given the intensity of the disease it describes. It is ‘a true wimp of a word for such a major illness’. His metaphors are of drowning and suffocation. Similarly, Australia's poet laureate, Les Murray, communicates the horror of his major depressive episode through metaphor, ²⁸ which is very removed from DSM descriptors:

Another reason why we may ‘learn even better’ from literature is that literature creates the accessible and safe zone of the fictional patient. At the clinical coalface there are barriers to achieving full understanding and empathy with our patients. These barriers include constraints of time and staffing levels, personal pressures, ethical and medico-legal imperatives and transference/counter transference issues. For the fictional patient, however, these barriers are nonexistent, or much diminished. Within the world of Tolstoy's novel Anna Karenina, ²⁹ few mental health professionals would have difficulty empathising with the heroine's honest human dilemma, cumulative trauma and great suffering. However, in the real-world psychiatric unit, there would be many impediments to treating this beautiful, needy, conflicted and suicidal socialite who abandoned her son and left an international trail of failed relationships! This concept of the fictional character as ‘safe’ and ‘accessible’ is articulated in the theory of narrative therapy. For example, the rationale behind the use of fairy tales in child therapy is that it indirectly facilitates discussion about a child's predicament, introduces themes to therapy in a non-threatening way and allows the child to escape into the safety of the story. This capacity of the child to confront even his or her most shameful problem through narrative is demonstrated in the clinical use of the modern day fairy tale, Sneaky Poo. ³⁰

Mental health professionals can learn not only from the subject matter of literature, but also from literature's methods. In the narrative style of therapy, patients are allowed to tell their own story. Using words and gestures, patients relate a complex, multi-layered story to recount the events and sensation of illness. They may be hesitant or chaotic story tellers, but it is the narrative art to fill in the blanks, identify meaning, main plots, sub-plots and irrelevancies and so follow the story to its end. In this model, evaluating patients requires the skills exercised by the careful reader, such as the skills of respecting language, adopting alien viewpoints and integrating many pieces of information. This contrasts with the directive and reductionistic medical model where the valued dominant craft is to extract symptoms and signs, identify syndromes, establish causes, make diagnoses, and treat. In Australia, the value of the narrative style of assessment has been recognised in various settings including Aboriginal health care. Eades ³¹ explains that: ‘In Aboriginal society the passing of information doesn't result from a direct query … it is the result of normal two-way interactions between people’. A successful doctor may begin by relating a little of their own story then sit back, tune in and listen to the patient's story - a story which is likely to focus not just on the well-being of the individual but the social, cultural and emotional well-being of the whole community. ³²

TO INFORM, HEAL OR HARM

That literature has the capacity to influence people by informing, healing or harming, is the second reason why it is relevant to contemporary psychiatry. The mass media has been shown to be the public's single most important source of information about mental illness. ³³ Well-studied forms of mass media include television, ³⁴ movies, ³⁵ newspapers ³⁶ and cartoons. ³⁷

In these studies, the depiction of psychiatry has generally been negative. In a recent study of depictions of mental illness in prime time TV drama, ³⁴ of twenty characters depicted in fourteen episodes, the majority of sufferers were aggressive (75%) simple/childlike (70%), unpredictable (60%), and failures (60%); almost half were loners (45%) and vulnerable (45%). Mass media, by reinforcing a negative image, foments stigma and this stigma is worn not only by the patients but by their doctors as well. ³⁸ The stereotype of the mad psychiatrist has been propagated in the movies, cartoons and contemporary idiom. ³⁹ In his study of the depiction of psychiatry in recent Australian and New Zealand fiction, Dudley finds the predominant images of psychiatry are negative or markedly ambivalent. ⁴⁰ While it is difficult to measure the specific effect of these negative portrayals on societal attitudes, it is reasonable to assume that there is an impact on society's understanding of psychiatric illness, readiness to seek help from mental health professionals, acceptance of psychiatric illness within the family and community, readiness by young people to embark on a career in mental health, political prominence given to the plight of the mentally ill, attitudes of health insurers and employers and responses of police and security forces to the behaviourally disturbed, mentally ill. ³⁹ The capacity of mass media to inform public knowledge and attitude exceeds by far that of the novel or poem. Nevertheless, literature remains an original storehouse of material, the initial point at which authors comment on society. Behind the movie Cosi is the play by Louis Nowra ⁴¹ and behind the 1999 prime time ABC TV serial Queen Kat, Carmel and St Jude is the 1997 Children's Book Council award winning teenage novel by Maureen McCarthy. ⁴² Even works of poetry may reach a mass audience: Margaret Throsby's ABC radio interview with Les Murray which covered his Subhuman Redneck Poems, life story and major depressive episode, was repeated by popular demand. ⁴³ This broadcast was conspicuous for its destigmatisation of mental illness and the positive message conveyed about psychiatrists and psychiatry.

The capacity of literature to either uplift or bring low is common knowledge. We readily recommend ‘a good book’ as an antidote to being down in the dumps and caution against a book which is ‘so depressing’. Perhaps this effect can be enduring, as occurred with the Tolkien devotee whose lifetime capacity for fantasy and idealism seems to have been indelibly altered by the famous trilogy. ⁴⁴ Or perhaps the effect is fleeting. Wheatley's 1995 collection of short stories, The Night Tolkien Died, ⁴⁵ discloses tenuous opportunity for fantasy and idealism in our realism-ridden social landscape. Can Tolkien be reduced to nothing more than an LSD-induced visual hallucination ‘the face of Sauron of Mordor on the kitchen wall’? ⁴⁵

As a specific mode of psychotherapy, the reading, writing and telling of literature has long been promoted. This goes as far back as Aristotle's observation on literature's powers of catharsis. ⁴⁶ In Samuel Taylor Coleridge's The Ryme of the Ancient Mariner, ⁴⁷ the actual telling and retelling of the tale is the pivotal healing experience. But with shades of obsessive compulsive disorder, the release and expiation from the telling are only temporary: ⁴⁷

Les Murray is adamant his recent volume of poems ²⁸ has been a healing experience. By working out his life crises at the point of a pen, he believes he has achieved catharsis of an original hurt. Finally ridding himself of his neurosis, which he dubs ‘the Head Spider’, he proclaims ‘I've written a new body that only needs a reader's touch’. ²⁸ Craig Powell identifies, in Francis Webb's poetry, ‘a vital striving towards self-healing on the part of the poet’. ⁴⁸ It is as though the poetry wins him reprieve from a breathtaking pain: ‘… my thought is pain, pain, till Chanticleer will carol truce again’.

The therapeutic value of narrative is central to the practice of narrative therapy. Providing clients with a text of their life enables them to view their life as a story. ‘Restorying’ their lives becomes the intervention. ‘Our lives are multistoried’, says White, ⁴⁹ ‘the role of therapy is to bring the alternate stories out of the shadows’. By externalising their problems into narrative, patients are empowered to control and change the text.

A more straightforward application of literature to therapy is the ‘bibliotherapy’ movement which arose in the USA in the 1970s. This is largely seen as pathology-driven publishing, providing, for example, series specifically written for certain groups addressing specific problems. This movement is alive and well in Australia today. The Linking-Up Bookshop publishes a list of books ‘To help parents help their children’. Books such as Gentle Willow - A Story for Children about Dying ⁵⁰ and Sammy's Mummy has Cancer ⁵¹ address themes of grief and loss. Cat's got your Tongue? ⁵² explores elective mutism and Russell is Extra Special ⁵³ is a book about autism for children.

If literature has an ability to uplift and heal, it may also have the potential to harm. The ‘copy cat suicide’ or ‘Werther Effect’ is the most studied harmful outcome. The name derives from Goethe's novel The Sorrows of Young Werther. ⁵⁴ This 1774 novel is hailed as the first great tragic novel of European literature. It was controversial and banned in some areas because it seemed to recommend suicide and was, indeed, blamed for a number of suicides among the book's cult following. Greater judgement and caution is now sometimes exercised by the media in the way real or fictitious violence, especially suicide, is depicted on screen or reported in newspapers. This trend flows from studies ⁵⁵ , ⁵⁸ which demonstrate that suicides increase immediately after a suicide story has been published in the media. One of the most famous media suicides of the 1990s, that of Kurt Cobain, lead singer of the pop group, ‘Nirvana’, was followed by a significant increase in suicide crisis calls in the Seattle area. It is testimony to the power of pop culture that an effect continues: a Kurt Cobain, now of mythical proportions, finds his way into Shoovy Jed, a 1997 Australian teenage novel by Maureen Stewart. ⁵⁹ Jed Barnes is fifteen years old. The book is an account of his suicidal thoughts, plans and actions. Jed writes:

Anecdotally, the evidence accrues of a relationship between media accounts and suicidal behaviours. An Australian example is the copycat suicidal behaviour which followed the suicide of the sixteen year old lead singer of the pop group ‘Silver Chair’. ⁶⁰ Preoccupation with death by suicide is integral to the Silver Chair song Suicidal Dream. The alluring lyrics go: ⁶¹

More recently still, in the wake of the Denver, Colorado High School massacre, there has been widespread civil and political protest against the violence of big screen computer games and contemporary song. The speculation is that the teenage gunmen were enacting the texts of songs by the controversial Marilyn Manson.

Compared to newspaper, television, movies and pop music, the individual work of literature would seem to have less potency when it comes to harm. After all, the great tragic works of Ancient Greece vividly depict some of the most horrible, bloody and violent scenarios, yet these works are regularly and without controversy included in high school syllabi. A case for qualitative difference between the literary and the visual media form of a work with respect to harmful capacity can be fashioned around Shakespeare's Romeo and Juliet. As a piece of literature, it has long and safely been read and enacted in the school context. Yet when it is translated to the big screen, given the fresh trappings of contemporary adolescence and with the idolised Leonardo de Caprio as its lead, schools and health authorities express anxiety about the potential for copycat suicide and stories of suicide pacts hit the headlines. Why this relative safety of the literary form? Perhaps it is because the work of literature is usually experienced as an individual rather than collective experience, because the act of reading necessarily takes time (i.e. is interspersed with and titrated against real life) and because the individual reader is less vulnerable, and less valuable, to the cultivations of a promotional industry whose vested interest lies in creating cult followings and intense identifications with their stars. Nevertheless, the issue of potential harm remains at the heart of controversy in the contemporary Australian adolescent literary scene. ¹⁵

‘Harm’ in this setting is considered not only in terms of the large events such as suicide and violence, but in the influence of the book on social values, individual behaviour and world view. Indeed whole debates have hung on the subject of the ‘hope’ content of teenage books, whether there is too much or too little and the effect on the teenage reader.

CONCLUSION

Sir Aubrey Lewis' belief in the value of literature to psychiatry appears to be congruent with the prevailing view of RANZCP Fellows. A poll conducted during a session of the 2000 Congress in Adelaide found that the vast majority of those present (163 out of 174, 94%) agreed with the proposition that ‘the humanities are as important as the sciences in the proper practice of psychiatry’. This outcome is consonant, too, with recent debate over what constitutes the essence of psychiatry. The imagery, metaphor and icon spawned in this debate encourage the psychiatrist to be sensitive to and informed by literature and indeed all the liberal arts. Leaving behind the hackneyed polemics of Rat versus Couch and Mind versus Brain, the debate projects an image of Doctor as Renaissance Man - a Leonardo in white coat. ⁶² Bloch ⁶³ has the psychiatrist perched upon a sturdy three legged stool - the legs representing the Science, the Art and the Ethics of psychiatry. Miller ⁶² depicts the psychiatrist in a cosmic straddle - spanning the two ends of the Art-Science spectrum: ‘one foot planted in the physical world, electronic impulses and the muck of the human brain; the other is planted in the subjective and experiential world of consciousness and conduct’. Putting fine imagery, mysticism and Renaissance fantasies aside, we suggest that literature, with its capacity to teach and heal, is a tool that should be considered in the daily practice of psychiatry.

ACKNOWLEDGEMENT

We thank Louise Newman for her comments on an earlier draft of this paper.