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Literature as an exploration of the phenomenology of schizophrenia: disorder and recovery in Denis Johnson's Jesus’ Son
  1. Jay A Hamm1,
  2. Bethany L Leonhardt2,
  3. Rebecca L Fogley2,
  4. Paul H Lysaker3,4
  1. 1Midtown Community Mental Health Center, Eskenazi Health, Indianapolis, Indiana, USA
  2. 2School of Psychological Sciences, University of Indianapolis, Indianapolis, Indiana, USA
  3. 3Richard L Roudebush VA Medical Center, Indianapolis, Indiana, USA
  4. 4Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana, USA
  1. Correspondence to Dr Jay A Hamm, Wishard Health Services, Midtown Community Mental Health Center, 1700 N Illinois St, Indianapolis, IN 46202, USA; jay.a.hamm{at}gmail.com

Abstract

When read as a fictional psychosis narrative, Jesus’ Son, a collection of short stories by Denis Johnson, reveals important elements of the phenomenology of schizophrenia and recovery. It is possible that Jesus’ Son, as a work of fiction, may be able to uniquely add depth and nuance to an understanding of the phenomenology of schizophrenia involving a state of psychological fragmentation, an ever-changing interpersonal field and a loss of personal agency. In addition, by following the protagonist in Jesus’ Son as he begins to resolve some of his difficulties, the book also offers an individualised account of recovery. The authors detail how the book reveals these insights about schizophrenia and recovery and suggest that these elements are intertwined in such a manner that leads to a profound disruption of self-experience, characterised by a collapse of metacognitive processes. Jesus’ Son may add depth to our understanding of the subjective experience of schizophrenia and recovery, and also may serve as one example in which the study of humanities offers an opportunity to explore the human elements in the most profound forms of suffering.

Keywords
  • schizophrenia
  • recovery
  • phenomenology
  • psychosis
  • metacognition

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Keywords

Introduction

The role of narratives, including fictional and non-fictional narratives, in the study of illness has received increased attention across a number of disciplines in recent years.1 In mental illness, the reading of fictional narratives has been suggested for a range of purposes, including increased understanding of psychopathology, enhanced empathy and the development of skills in ethical reflection.2 ,3 Fiction, as well as other forms of creative art, has also been used to enhance an understanding of the experience of the most severe forms of psychiatric disorders.4 ,5

Jesus’ Son is a collection of short stories by American writer Denis Johnson.6 Although manifestly a tale of drug addiction, the book can also be read as an account of psychosis and recovery. Understood in this manner, Jesus’ Son offers the reader insight into schizophrenia and recovery by providing a window into the phenomenology of prolonged psychosis. In this paper we will detail how Jesus’ Son adds depth to our understanding of the phenomenology of schizophrenia and also offers insight into what recovery from schizophrenia might look like.

Although it is possible to glean from the text evidence of the symptoms that serve as the formal diagnostic criteria for schizophrenia, the intention here is not to read Jesus’ Son as a fictional diagnostic case study. Rather, the value of Jesus’ Son as a fictional schizophrenia narrative appears to be in its ability to enhance a phenomenological understanding of core processes at play in schizophrenia. As a fictional account, Jesus’ Son may avoid certain identified dangers inherent in the study of biographical or autobiographical narratives, including concerns about establishing the ‘truth-value’ of the account,7 while still offering a rich, nuanced first-person view into schizophrenia that is not accessible through quantitative research. This is consistent with suggestions that the use of fiction might uniquely offer insights into schizophrenia that might not be available through traditional avenues of study.8 This manner of analysis may be one strategy for exploring and understanding the humanity within schizophrenia and is thus consistent with the broader aims of the medical humanities, such as the development of an ethic which emphasises the importance of subjectivity and self-experience within medical conditions and the promotion of reflective and humane medical care.9 ,10 The importance of these aims may be further underscored when applied to the most profound forms of suffering.3 ,11

To address this possibility, following a brief synopsis of the book, we will explore a number of inter-related phenomena revealed in Jesus’ Son. More specifically, we will describe three elements found in the book that offer the reader a deeper understanding of the phenomenology of schizophrenia. These elements include a view of a subjective state characterised by pronounced fragmentation, a state in which the subjective interpersonal field is amorphous and bereft of stable others and a state in which a person no longer possesses agency. We will then offer a conceptualisation of a profound disruption of self-experience stemming from these intertwined elements. After this, we will discuss how these difficulties appear to begin to be resolved as the book's protagonist progresses toward a state of increased organisation and improved functioning, illustrating a view of recovery as more than a matter of symptom relief and or dissipation of pain. Finally, we will consider how these insights align with current research interested in the experiences of people with schizophrenia and offer implications for clinical practice.

A brief synopsis of Jesus’ Son

Jesus’ Son is written as a collection of short stories, although the stories are linked thematically and through ostensible continuity of a single unnamed narrator-protagonist. Taken as a single work, Jesus’ Son offers a fragmented narrative of a troubled man. The chronology of the book is not entirely linear, although it is clear that the final stories take place at some point after the earlier stories. The protagonist's exploits occur in various geographical locations and introduce a number of fleeting and unpredictable interpersonal connections. The protagonist chronicles a series of graphic and occasionally violent episodes involving car crashes, criminal activity, loss and a number of surreal experiences that tend to be characterised by the protagonist's repeated failures to adaptively navigate life's challenges. The tone begins to shift in the final two stories, though, which find the protagonist having entered and been discharged from an inpatient treatment unit, working part-time and establishing new relationships.

Fragmentation in schizophrenia

From the opening passages and extending through the first nine of 11 stories, the reader of Jesus’ Son is directly exposed to fragmentation, a core element of the phenomenology of schizophrenia. Jesus’ Son is able uniquely to offer a first-hand account of psychotic fragmentation through two distinct mechanisms. First, there is an element of fragmentation in the structure of the book, as the text comprises disjointed short stories rather than a single, coherent narrative. Second, the stories offer a view of fragmented experience in which elements of the protagonist's view of himself in the world do not appear to fit together, and there also does not appear to be any attempt by the protagonist to make sense of them. In general, the protagonist's difficulties in organising a coherent consciousness become gradually more severe during the first two-thirds of the book, before changing direction in the final stories as he begins to improve. Especially early on, the fragmentation forces the reader to sort through disordered narratives in order to form an image of the action or to develop complex representations of the characters therein: A salesman who shared his liquor and steered while sleeping…A Cherokee filled with bourbon…A VW no more than a bubble of hashish fumes, captained by a college student… And a family from Marshalltown who headonned and killed forever a man driving west out of Bethany, Missouri… (p.3, Car Crash While Hitchhiking) (ellipses original)

This fragmentation seems to disclose a core element of the phenomenology of schizophrenia and may be related to an underlying process involving an unbinding of associations that leads to a collapse of higher order understanding of oneself and others, a central feature of schizophrenia posited by Bleuler nearly 100 years ago.12 Theoretical accounts from both psychoanalytical and phenomenological philosophical traditions have emphasised the role of fragmentation in schizophrenia.4 ,12–,14 However, theorisation may have limitations in providing a deep understanding of the subjective experience of fragmentation. Additionally, first-person accounts of people who have emerged from psychosis have been used to study the subjective experience of schizophrenia, but may also be limited in the ability to capture this experience directly owing to a tendency for those who have experienced psychosis to retrospectively apply narrative order to a previous state of fragmentation in order to make sense of it or to communicate it effectively to a specific audience. This is consistent with recent descriptions of first-person accounts as a ‘genre of insight,’ which tend to be written from a perspective that is bereft of content that reflects ongoing difficulties associated with schizophrenia (eg, delusions, poor insight, thought disorder).7 Thus, by offering a first-person fictional account of psychosis, Jesus’ Son can directly reveal nuances of the phenomenology of fragmentation in psychosis. Throughout much of the book, the action and reflections of the protagonist are advanced through characteristic, disjointed prose: Georgie and I had a terrific time driving around. For a while the day was clear and peaceful. It was one of the moments you stay in, to hell with all the troubles of before and after. The sky is blue and the dead are coming back. Later in the afternoon, with sad resignation, the county fair bares its breasts. (p.63, Emergency)

One element of the experience of fragmentation that Jesus’ Son may reveal is a disruption in the normative assumptions of temporality and spatiality involved in the way humans experience the world. This appears consistent with disruptions in these dimensions theorised by existential psychiatrists.15 ,16 Early in the book, the protagonist's experience does not reflect a sequential series of points in time in which general rules of physical space apply. Instead, we follow the protagonist in and out of different periods of his life, moving at times seamlessly from one setting to the next. Of note, although episodic models of self-experience have been suggested as an alternative to more conventional notions of narrativity,17 what the reader encounters in Jesus’ Son does not merely appear to be an alternative to a more temporally-driven narrativity, but instead appears associated with profound disruptions in the protagonist's ability to make sense of his experience and engage in meaningful interactions. This is best exemplified in the stories Emergency and Happy Hour. In Emergency, the narrator-protagonist describes a series of fantastical events that involve him and a coworker at a hospital. In the story, a man with a hunting knife stuck in his eye speaks lucidly and has the knife removed by the protagonist's friend, Georgie. The narration shifts from this event to one in which the protagonist and Georgie drive to an indeterminate location. There, the protagonist struggles to distinguish a drive-in theatre from a cemetery and he unintentionally crushes a group of newborn bunnies. Or maybe that wasn't the time it snowed. Maybe it was the time we slept in the truck and I rolled over on the bunnies and flattened them. (p.69, Emergency)

An ever-changing interpersonal field

The second phenomenological element of psychosis that is revealed in Jesus’ Son is the quality of the protagonist's experience of his subjective interpersonal field as ever-changing, comprising poorly understood, amorphous others who do not appear to be temporally stable or have consistent personality characteristics. Consistent with our discussion of fragmentation, the presence of this amorphous interpersonal field affects the reader, presenting difficulties in discerning the relationships between characters and understanding what role in the narrative any given character may play. ‘Is everybody dead?’ ‘I can't tell who is and who isn't.’ (p.7, Car Crash While Hitchhiking)

By offering a view of an ever-changing interpersonal field, Jesus’ Son deepens our understanding of what it might be like to be a member of a social world while experiencing psychosis. The descriptions of others found in the text may be consistent with phenomenological models of interpersonal experience in schizophrenia characterised as being populated by ‘disembodied spirits and deanimated bodies,’ 18 or characterised by a sense of ‘unreality’ in which people appear strange and without vitality.4 Additionally, a number of other early theorists observed disruptions in interpersonal relatedness in schizophrenia marked by lability of affect and detachment.12 ,19 ,20 Much like its handling of psychological fragmentation, Jesus’ Son can uniquely deepen and enrich a phenomenological account of interpersonal interactions of this quality by placing the reader in the subjective position within these interactions: I had forgotten my friends had come with me. Once again I hated the two of them. The three of us had formed a group based on something erroneous, some basic misunderstanding that hadn't yet come to light, so we kept on in each other's company, going to bars and having conversations. (p.13, Two Men)

Throughout most of the stories, the protagonist demonstrates limited ability to make sense of others’ motives or to form meaningful connections to those with whom he associates. An early story, Out on Bail, describes a scene in which the protagonist observes a celebration at the bar where he is drinking. He struggles to make sense of his own personal connections and specific shared history with certain people he is watching, while also struggling to draw larger conclusions about the meanings of interactions: Suddenly I remembered that Hotel himself, or somebody connected with him, had told me weeks ago that Hotel was in trouble for armed robbery…I'd forgotten I'd ever heard about it. And then, as if to twist my life even further, I realized that all the celebrating that afternoon hadn't been Hotel's farewell party after all, but his welcome home. (p.31, Out on Bail)

In many stories, hollow, ghost-like characters come in and out of the action. The others are fellow drug users, sexual partners, accomplices in petty crime. It is typically unclear if the protagonist views those with whom he interacts as allies or enemies, or both. At times, others can be viewed merely as means to a temporary relief from his suffering and confusion. At other points, the other characters serve as disembodied figures by whose actions the protagonist is propelled forward in the interaction, albeit with a general absence of meaningful connection or intersubjective processes occurring between characters. Throughout, the protagonist typically fails to recognise other people as unique individuals with experiences, ideas and histories separate from his own. In an extreme example, the protagonist questions if those around him are actual others or mere figments conjured in the context of a dream. In possible contrast to theories of the phenomenology of schizophrenia that place a larger emphasis on hyper-reflexive processes and inwardness,4 the alterations in the interpersonal field emerge as a core dilemma for the protagonist as he attempts to navigate his world. Within these experiences, the protagonist's interpersonal field is not merely a flat and empty landscape made unmanageable by his poor social skills, but a vibrant and desperately labile world in which others change without reason, as though drawn from Ovid's Metamorphoses21: There was no doubt in my mind. She was the woman we'd seen flying over the river. As nearly as I could tell, I'd wandered into some sort of dream that Wayne was having about his wife and his house. But I didn't say anything more about it. (pp.50–51, Work)

Similarly, other moments can be found in which those he encounters merely serve as reassembled fragments of a number of possible others. For instance, at the end of Work, the protagonist may be sitting at the bar interacting with a bartender, but his representation of her as a caregiver includes partial representations of a mother, an angel and a nurse. It is unclear if his final description of her is based on knowledge of the bartender's fate, memory of his own mother's difficulties, or something else entirely: ‘Nurse’, I sobbed. She poured doubles like an angel, right up to the lip of the cocktail glass, no measuring. ‘You have a lovely pitching arm.’ You had to go down to them like a hummingbird over a blossom. I saw her much later, not too many years ago and when I smiled she seemed to believe I was making advances. I'll never forget you. Your husband will beat you with an extension cord and the bus will pull away leaving you standing there in tears, but you were my mother. (pp.53–54, Work)

Loss of agency

A third element of the phenomenology of schizophrenia with which the reader is confronted is the protagonist's stark loss of personal agency. Again, this element of his experience also affects the reader, who is left attempting to discern the motives of the character and the direction of the narration. The first nine stories of the book typically find the protagonist moving through misadventures without apparent self-direction. Rather, he appears buffeted by external circumstances or basic impulses to seek temporary relief from distress through substances. At times, he seems swept up in events in which his locus of control is entirely external and his difficulties swirl around him as though he is caught in a leaf storm. For instance, in the opening story, Car Crash While Hitchhiking, he passively transfers from car to car, travelling across the country, ingesting a variety of drugs, slipping in and out of sleep and ultimately finds himself witnessing tragedy befall a family in a hospital. Throughout the action, it is unclear what choices the protagonist recognises are at his disposal. Instead, the events described seem predetermined in the mind of the protagonist: I waited without hope of a ride. What was the point, even, of rolling up my sleeping bag when I was too wet to be let into anybody's car…I knew every raindrop by name…I sensed everything before it happened…I knew a certain Oldsmobile would stop for me even before it slowed and by the sweet voices of the family inside it I knew we'd have an accident in the storm. I didn't care. (p.1, Car Crash While Hitchhiking)

Similar to the previous two elements, loss of agency has been described as an element of schizophrenia.22–25 Looking again to early accounts of schizophrenia, one can find descriptions of a loss of goal-directed behaviour, with Bleuler making observations of behaviour of people with schizophrenia as ‘aimless or inconsistent,’ marked by ‘constantly changing aims,’ and ‘unreasonable actions corresponding with impulses’ (Bleuler,12 p.379). Again, though, traditional avenues of gaining knowledge about the phenomenology of core processes in schizophrenia may have limitations in their ability to provide direct access to the subjective experience of the phenomenon, with external descriptive accounts of the phenomenon forced to focus on observable avolition attributed to schizophrenia. Jesus’ Son positions the reader in the vantage point of the protagonist who is moved through life without agency: A bus came. I climbed aboard and sat on the plastic seat as the things of our city turned in the windows like the images in a slot machine. Once, as we stood arguing in a corner, I punched her in the stomach. (p.45, Work)

Throughout much of the book, the protagonist can only offer a description of the action and utterances of the individuals he encounters and he often finds himself in confusing, socially inappropriate, or dangerous circumstances. In Dirty Wedding, an apparent inability to reflect on, and make sense of, ostensibly painful affective states associated with accompanying his pregnant girlfriend to an abortion clinic lead the character to a series of socially inappropriate remarks and behaviours. The action in this story is suggestive of an utter loss of agency in the main character, as he moves about in the clinic, on a train and through neighbourhoods as though floating through a dream. When he is brought into the hospital room after the abortion, he unwittingly insults the nurse and his girlfriend and is removed from the clinic. After this, he finds himself riding the train around the city aimlessly, ultimately following a man off of the train through a neighbourhood and into a laundromat. Throughout, his motives and decisions remain outside of his awareness, although the reader can speculate that he is driven by distress over the abortion and unexpected sexual attraction to the man he follows: I turned away because my throat was closing up. Suddenly I had an erection. I knew men got that way about men, but I didn't know I did. His chest was like Christ's. That's probably who he was. I could've followed anybody off that train. It would have been the same. (p.80, Dirty Wedding)

Schizophrenia and the interruption of being

While we have sequentially described the first three elements of the phenomenology of psychosis revealed in Jesus’ Son, it appears that these elements are deeply intertwined rather than distinct. As the experiences of fragmentation, an ever-changing interpersonal field and a loss of agency are experienced in the mind of the protagonist and enacted in the mind of the reader, we think that Jesus’ Son can offer the reader a sense of an interruption of being stemming from the profound disruption of self that comes to characterise schizophrenia: That had been the meaning of the conversation I'd had with him that afternoon, but I hadn't understood what was happening at all. (p.32, Out on Bail)

One way to conceptualise this larger interruption of self as it is manifest in the lives of people with schizophrenia is that the elements of subjective experience described here: fragmentation, an ever-changing interpersonal field and a loss of agency may all be linked to a partial collapse in processes that several authors have referred to as synthetic metacognition.26 Metacognition has been conceptualised as a spectrum of activities ranging from discrete to more synthetic activities. Discrete metacognition includes abilities such as error detection, decoding irony and affect recognition, whereas synthetic metacognition refers to mental processes by which people can form complex mental representations of him- or herself and others, to think about his or her own mind and those of others and to use this information to adaptively deal with life's challenges. Synthetic metacognition thereby enables people to maintain a coherent, consensually valid storied account of themselves, to situate him- or herself in a broader social context, make sense of the world around them and to find meaning in their experiences. Recent research has developed a conceptual model proposing that deficits in the more synthetic forms of metacognition may serve as a link between brain processes and behavioural dysfunction.26

As made concretely manifest in Jesus’ Son, the phenomena of fragmentation, an ever-changing interpersonal field and loss of agency are intimately related to breakdowns in the ability of the protagonist to form complex representations of himself and others. As revealed in the first nine stories, the protagonist has profound difficulties in efficiently identifying his own mental contents, understanding his own mind, understanding the minds of those around him and resultant difficulty in navigating nuanced interplay between self and others. He has little to no sense of himself and the people around him as beings who exists across time with discernible emotions, motives, hopes or dreams. Events merely happen with no sense of history or any potential for reflection. The protagonist sees the world not as a subject for interpretation but a literal series of facts that must be accepted. Ultimately then, for the protagonist there is never a ‘why’ behind any specific activity he or another might undertake. There is no reason to persist, seek out connection, or pursue a larger purpose: But why is that outcome of the encounter obvious to everyone, when it wasn't at all obvious to me, the person who actually met and spoke to him. (p.90, The Other Man)

The protagonist certainly faces challenges and trials but absent any reflection these take place in a world without meaning and therefore those challenges are without meaning. It appears that the collapse in synthetic metacognitive processes leaves the protagonist with limited options for responding to challenges, which in the book tend to involve avoidance or managing distress through substances. Further, severe deficits in the ability to know himself and make sense of his situation seem to lead to difficulties in his ability to even plausibly define the psychological problems he faces: ‘There's nothing wrong with me’—I'm surprised I let those words out. But it's always been my tendency to lie to doctors, as if good health consisted only of the ability to fool them. (p.9, Car Crash While Hitchhiking)

The collapse of metacognitive functioning, corresponding with the protagonist's further descent into madness, culminates in the third to last story, Happy Hour. The prose in this story is arguably at its most fragmented and the processes highlighted above have become more pronounced. The protagonist interacts with a number of other characters that appear to emerge briefly and then disappear. He is only able to offer snippets of disjointed dialogue, with explanations of the motives of either himself or others becoming nearly absent. It is not entirely apparent if the entire story occurs at the same time or in the same city and the protagonist finds himself unintentionally making noticeable social faux pas, including riding the city bus aimlessly until ordered to get off and possibly unintentionally exposing himself at a public library.

By understanding the phenomenological elements of psychosis revealed in Jesus’ Son through a metacognitive framework, the assertions here build upon a growing body of research describing metacognitive deficits experienced by people with schizophrenia, as well as the numerous clinical and functional correlates of these difficulties.26 ,27 Additionally, the overall experience of the loss of self associated with the difficulties described here is consistent with literature emphasising the central role of disrupted self-experience and personal narrative in the experience of schizophrenia.28

This body of research is also linked with findings from the recovery movement, which suggests that it is possible for people with schizophrenia to make meaningful recovery.24 Consistent with this possibility of recovery, while the first nine stories in Jesus’ Son offer a glimpse into the subjective experience of the protagonist's psychosis, the final portion of the book shifts toward an account of the protagonist as he emerges from these struggles.

Recovery from schizophrenia: re-engagement in the world

Following the spare and painful third to last story, Happy Hour, the reader and the protagonist have been left in limbo as the subjective experience of the protagonist deteriorates to its most intense level of disorder. However, the tone shifts in the final two stories, Steady Hands at Seattle General and Beverly Home, which offer a glimpse into what the process of recovery from schizophrenia might look like. When the action resumes in Steady Hands at Seattle General, the reader finds the protagonist in an inpatient treatment unit, with the suggestion that he has been taking antipsychotic drugs. He appears more hopeful as he assists a roommate to shave and offers some supportive and encouraging words. The protagonist is clearer and has renewed agency, identifying himself to his counterpart as a writer who is interested in writing about the lives of others on the treatment unit. He asks questions about his roommate's history and seems curious about the man's emotional responses to past difficulties. This story thereby serves as a turning point in the narrative, as the protagonist shifts from a process of steady decline into recovery.

In the final story, Beverly Home, the protagonist has relocated again. He is sober and working part-time at a nursing home, writing the newsletter for the facility and interacting with the patients. He describes two relationships of increasing intimacy and care. There is evidence of higher forms of metacognitive processes, as he appears better able to synthesise and integrate information from his personal narrative and detect motives and feelings of others in order to situate himself in a social context, respond to psychological challenges and make sense and meaning out of his experience. This is not a Pollyannaish ending though, in which he is found to be problem-free and morally virtuous. For instance, part of his increased understanding of interpersonal interactions is cultivated in an ongoing pattern of spying on an unsuspecting Mennonite couple. He entertains fantasies of violence and sexual deviance, but does not act on these. The book closes with a poignant passage offering an account of his recovery: Sometimes I heard voices muttering in my head and a lot of the time the world seemed to smolder around its edges. But I was in a little better physical shape every day, I was getting my looks back and my spirits were rising and this was all in all a happy time for me. All these weirdos and me getting a little better every day right in the midst of them. I had never known, never even imagined for a heartbeat, that there might be a place for people like us. (p.133, Beverly Home)

This final passage describes an individual experience of recovery. Even with the lingering presence of positive symptoms of psychosis, the protagonist has emerged from a state of profound dysfunction, is better able to make sense of his experience and engage in meaningful activity. It is clear that in the protagonist's case, as well as for many people with schizophrenia, recovery does not merely mean the absence of symptoms or dissipation of pain.29 ,30 His past struggles have not been erased from his memory and the drugs he takes, while helpful, do not entirely eliminate his symptoms. What is clear, though, is that he is developing an account of himself as an agent in the world, one with a specific history, desires, wishes and disappointments. We would suggest that his increased ability to form complex representations of himself and others allows him to develop and implement more adaptive strategies for managing difficulties and forming meaningful connections with others. Consequently, his interpersonal field is more stable, he is less fragmented and he functions with a renewed sense of personal agency. In this way, it appears that the shift in the final two stories of Jesus’ Son is not merely behavioural or environmental.

Consistent with this, recent literature has suggested that much as deficits in synthetic metacognition are associated with a range of difficulties in schizophrenia, growth in metacognition is linked with subjective and objective elements of recovery.31 ,32 These observations have been accompanied by increasing emphasis on metacognition in the treatment for those with schizophrenia, with emerging evidence of trends involving development of recovery-oriented integrative psychotherapy models that emphasise metacognitive processes in therapy.33 This may reflect growing recognition of the importance of the role metacognition plays in self-experience, a central concept in recovery from schizophrenia.

Conclusions

The reading of fiction may offer a way to deepen a reader's understanding of the humanity within profound forms of human suffering. We have explored how one specific selection, Denis Johnson's Jesus’ Son, offers a deeper and more nuanced view of the phenomenology of schizophrenia involving a collapse of self which leads to an interruption of being in the world and also illustrates a process by which these difficulties might be resolved as people re-emerge into the world. The book does so by providing a first-hand view of a state of pronounced psychological fragmentation characterised by an amorphous interpersonal field and a loss of personal agency.

Of note, competing theoretical models have been posed conceptualising the processes leading to the phenomenological experiences described in this paper. Psychotic fragmentation, for instance, has been suggested in psychoanalytic texts as resulting from processes such as decathexis from external objects and regression to an early developmental stage,34 a view criticised by theorists such as Sass,4 ,14 who views fragmentation as occurring through a process of hyper-reflexivity in which hypertrophied reflexive processes lead to a state in which the self fragments under its own inward gaze. Our intention in this paper was not to resolve existing debates regarding the psychodynamics of fragmentation, but rather to explore how Jesus’ Son offers a descriptive entry for the reader into a state of fragmentation and to suggest how metacognitive processes may be one way of making sense of how these processes might work together in self-disturbances and the recovery therefrom.

Future work may explore similar routes of gaining insight into the phenomenological world of schizophrenia. As these insights come to light, additional work may be needed to continue to refine models of treatment as well as the training of clinicians working with those with schizophrenia. It has been suggested that reading of fiction in the clinical supervision of mental health trainees may be an effective strategy for humanising psychosis and making it clinically approachable, potentially decreasing the anxiety that can be associated with the challenge of offering psychotherapy to those with schizophrenia.8 Reading fictional works may offer a route to enrich clinicians’ understanding of the experience of psychosis, which may ultimately improve a clinician's ability to join with clients to develop a therapeutic alliance, thereby better enabling the clinician to assist persons with schizophrenia to make sense of their lives and move toward recovery.

By offering a first-hand view of these phenomenological elements, Jesus’ Son gives a direct, humanising account of the deeply troubling and confusing subjective state that characterises schizophrenia. By doing so, insights from Jesus’ Son may assist the reader in buffering against the risk of dehumanising, denying, or overly sentimentalising schizophrenia by turning it into an exotic object of study. In addition, whereas past comparative analyses have used literature largely to explore the experience of disorder in schizophrenia, 4 Jesus’ Son also offers a window into the process of recovery from a state of disorder.

While this paper focused on a specific work, similar study of other pieces of fiction or works from other artistic media may unearth new insights or build upon the concepts explored here. Other works of fiction may similarly reveal nuances of phenomena and deepen our available understanding of schizophrenia and the process by which people emerge from it. More broadly, using this type of study of literature to investigate the subjective experience of suffering may be one strategy for maintaining humanity within medical nosology and promoting humane forms of care therein. This is consistent with work suggesting that the study of the humanities may help us find human elements in the most profound forms of suffering.11 ,35 In doing so, the study of fiction for these purposes may work against movements within medicine that would reduce personal and deeply meaningful experiences to one-dimensional abstractions through objectification and reductionism.

References

Footnotes

  • Contributors All four authors participated in the literature review and conceptualisation for the manuscript. JAH was primary author for the first draft of the document. All four authors offered significant contributions to drafting and revising the final manuscript. All four authors had the opportunity to approve the final draft before submission.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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