A variety of literary genres utilise mental illness as a key theme. From the short story to the novel, from linear narratives to postmodern fragmented narratives, from literary to popular fictions and to autobiographical narratives—the theme of mental illness is a feature, and the student or professional does not need a degree in literature to benefit from reading such texts. Fiction has a focus on the human mind—on motivations, emotions, reactions and responses, experiences and affects. David Lodge articulates this particularly well in Consciousness and the Novel, writing, “literature is a record of human consciousness, the richest and most comprehensive we have […] Works of literature describe in the guise of fiction the dense specificity of personal experience, which is always unique, because each of us has a slightly or very different personal history, modifying every new experience we have; and the creation of literary texts recapitulates this uniqueness...”Footnote 1 Psychiatry studies the human mind within an increasingly biological, medicalised paradigm, yet it focuses on the same concerns as literature—human experience, reactions to events, emotions, behaviour and affect. The synergism between literature and psychiatry seems clear, as Femi Oyebode suggests: “The psychiatrist, like the novelist, imposes structure on an abnormal phenomenon partly to render it innocuous but also to make it manageable and there is, of course, also the aesthetic delight in imposing narrative structure on chaos. There is little doubt that psychiatrists owe much to fiction.”Footnote 2 So why, despite the recommendations of the United Kingdom’s General Medical Council in 2003 regarding the introduction of humanities special studies modules for medical trainees,Footnote 3 does literature—and in particular, fiction—remain the poor relation of the medical textbook? And specifically, why and how can fiction and autobiographical narratives be of particular relevance and value for psychiatrists and other mental health professionals and students?

The opinion that medical students in particular would benefit from a humanities-based aspect to their education has attracted much attention recently, including the introduction and evaluation of a diverse range of courses—poetry workshops,Footnote 4 philosophy of medicine modules,Footnote 5 haiku writing,Footnote 6 and history and literature courses.Footnote 7 Whilst these modules have largely focused on medical personnel, the same teaching principles can be applied to professionals and students of all levels and from a wide variety of disciplines, including nursing, psychology, occupational therapy and social work. One of the benefits of the array of literature available is that there truly is something to suit everyone, from avid readers to those who generally prefer the medium of film.

Like any development or change in opinion, the move towards the introduction of an element of humanities-based education for health care students and providers has been both welcomed and condemned. Martyn Evans suggests that literary studies, which he argues focuses on education rather than training, has several key benefits—the development of a sense of ethics and of communication skills; the growth in personal values given the age of most medical students; and the feeling of a “fitting and enduring sense of wonder at embodied human nature.”Footnote 8 Hampshire and Avery, evaluating a special study module on literature and medicine at the University of Nottingham, argue that students benefited from the course in a number of ways—the change and development of attitudes and beliefs; the development of insight into both patient and carer perceptions and beliefs around illness; and reflection on clinical practice following the development of a sense of understanding regarding the psychological impact of physical illness.Footnote 9

William E. Stempsey, on the other hand, articulates a common scepticism regarding the claims that literature can produce a united value system, writing:

I heartily recommend the study of great literature for physicians wanting to be more humane. I have doubts, however, that this will be enough to cut through the malaise. Reading stories can be inspiring, and may even be an effective way of influencing attitudes. However, it is just too much to expect to reconstruct a community of shared values through the study of literature, even in a limited realm such as medicine.Footnote 10

Similarly, Richard Meakin suggests that there may be cause for concern in terms of professionals from either discourse overstretching their realm of expertise: “For those of us who come from a medical background, there is the temptation that in our enthusiasm for what the humanities can contribute to the understanding of illness and health, we go beyond our expertise. Equally, similar criticisms can be made for those from a humanities background.”Footnote 11 As with any burgeoning discourse, contentious issues remain. While these theoretical arguments continue, it is pertinent to examine how literature can facilitate understanding, empathy and communication skills, specifically in psychiatry, in a manner that a textbook cannot—and, furthermore, to propose a series of texts that may be helpful in this respect.

Allan Beveridge provides a clear and balanced summary of the main benefits and disadvantages to psychiatrists reading fictions—again, his arguments can be broadly applied to students and professionals from a number of medical disciplines and at all levels. Beveridge summarises the arguments for psychiatrists reading fiction as: exploring the lives of individuals in an imaginative manner; offering a deeper existential understanding of illnesses; developing empathy; the clinical resonances of certain literary devices, giving the example of the figure of the unreliable narrator; and the development of skills of ethical reflection.Footnote 12 The disadvantages and limitations to psychiatrists reading fictions are summarised as: the arts are irrelevant to medical practice; “writers are attempting to do crudely and unsystematically what modern psychologists do in a sophisticated and rigorous manner”; reading is in fact a selfish activity as opposed to a giving one; reading is not “a substitute for experience”; many doctors do not actually read novels; and literature should not be approached diagnostically as this leads to the loss of overall aesthetic appreciation.Footnote 13 Perhaps the questions should not be ‘should psychiatrists read fiction?’ but how can healthcare professionals, in this case working in the psychiatric disciplines, benefit from reading fiction should they choose to?

An argument can be proposed that is specifically relevant to the reading of fiction in psychiatric training—one that goes to the heart of the practice of psychiatry. Psychiatry as a discipline is increasingly focused on biological causes of mental illnesses—at times to the exclusion of other relevant discourses—yet it is a study that focuses on the mind. The human mind is too complex and unique to be reduced to a series of chemical and electrical responses. Merely knowing that serotonin levels affect depression does not induce any level of understanding in a professional regarding the experience of depression, for example. The form and content divide in descriptive psychopathology is of relevance here. As Sims writes:

Clearly, form and content are both important, but in different contexts. The patient is only concerned with the content, ‘that I am pursued by ten thousand hockey sticks’. The doctor is concerned with both form and content, but as a phenomenologist only with form, in this case a false belief of being pursued. As far as the form is concerned the hockey sticks are irrelevant. The patient finds the doctor’s interest in form unintelligible and a distraction from what he regards as important, and he often demonstrates his irritation.Footnote 14

Furthermore, the “nature of the content […] is irrelevant in coming to a diagnosis.”Footnote 15 This irrelevance should not mean that the content is ignored—“Alongside the need of the psychiatrist to acquire skills in psychopathology and the elucidating of mental symptoms is the parallel requirement for cultural education and sensitivity.”Footnote 16 With the increasing biomedical dominance in psychiatry, there is a risk that content—already seen as of lesser importance to form in diagnostic terms—will become further marginalised. We argue that in reading fiction, it is less effective to perform diagnostic readings of characters—fiction is not written for this purpose. It is, however, both valuable and effective to examine the human experiences, emotional responses and behaviours contained within fictions. In direct paradox to descriptive psychopathology, the form of a fiction is of lesser importance in coming to an understanding of the content of the narrative—the characterisation, aesthetics, emotion and affect of both protagonist (patient) and secondary characters (carer). Through increasing the understandabilty of illness experience as explicated through fiction, the clinician can develop a deeper empathic understanding of the breadth of human experience. There is circularity to this argument—literary studies can also borrow from psychiatry in terms of deepening the multitude of discoursal interpretations available of the human mind.

What exactly is contained within the relevant fiction that may be of use? A useful starting point seems to be the representation of psychosis, as this—alongside depression—features most heavily in fiction. Oyebode explores Bronte’s Jane Eyre, McGrath’s Spider and Gogol’s Diary of a Madman in relation to the depiction of psychosis, arguing that novels “are not written as scientific studies of psychopathology. The novelist’s interest in psychopathology is because of the intrinsic fascination that we all have for how the mind works, either in health or illness.”Footnote 17 Our human fascination with how the mind works is taken one step further with those professionals working with mental illnesses—the fascination is not only with how the mind functions, but how, to whom, and why it sometimes becomes dysfunctional. This step is reflected in fiction—fiction is essentially and universally concerned with how the mind works, and it follows therefore that there is a concern with how it does not work.

Madness in fiction

It is important to remember that fictional texts are representations of illnesses—for example, Paul Sayer’s The Comforts of Madness, which explores in first person the inner workings of a catatonic patient—as well as some fairly horrific treatments tried on him—may be able to inform us of what it may be like to be catatonic, but this may not represent an actual experience of catatonia. The relationship between the real and the imaginary—and thus the representation or, literally, re-presentation—is as complex as individuals themselves, for precisely this reason. Individuals are unique; a single description of one character’s experience of psychosis or depression or Asperger’s Syndrome cannot be seen as universal. However, for certain conditions—catatonia being one of them—representations may be the closest we have to understanding and interpreting what seem to be incomprehensible and inexplicable experiences. In the case of Sayer’s text, the novel evokes empathy with a condition that causes frustration. Furthermore, the fact that two texts that utilise psychosis as a key theme may provide completely different representations of the illness reminds us of the diversity of human experience, of individual’s experience of illness, and of the need to respond imaginatively as well as empathically when considering treatment options.

The response of others around the unwell individual can serve to remind us of the difficulties that carers face. Jenny Diski’s character Esther in Then Again—theoretically anti-psychiatry in her youth and now mother to Katya, who is experiencing a frightening psychotic episode—articulates the dilemma of enforcing treatment that many parents may feel:

“Oh, I suppose we opted for the right to be as mad as a hatter, but we didn’t know what we were talking about. We never took the pain into account. Katya’s not thinking, she’s off her head. She’s dangerously mad, and someone’s got to do something. She’s hurting herself, she’s suicidal. She thinks she’s the Devil and she ought to die. Do I let her go on thinking that, and being in hell, or do I let her have drugs that take the terrible thoughts away?”Footnote 18

She also tries to empathise with her daughter’s incomprehensible experiences by reflecting on her own use of the hallucinogenic drug LSD:

So she did know what her daughter was talking about. But what she knew about it was that the human brain, given the right (or wrong) chemicals and conditions, could fabricate a world of mayhem, losing its capacity to draw lines around things, so that everything—yeah, everything, man!—flowed together. And real and knowing were the words that sprang to mind to describe what was unreal and unknown, because, actually, people had the most tenuous hold on reality and knowledge, and got easily confused. And God, in some rather vague, un-Jehovah-like Eastern formulation, was as often as not invoked, because utter strangeness was terrifying to a basically order-making creature, and divinity was needed to evaluate the disturbing fact that, when frazzled, the brain short circuited and made a complete mess of the world the body had to live in.Footnote 19

In this text, the reader is given access to Katya’s thoughts and emotions, though still through third-person narration, rather than being given only second-hand accounts of her behaviour—as seen, for example, in Bebe Moore-Campbell’s 72 Hour Hold. In this particular text the story is narrated from the sole perspective of Trina’s mother, who describes the difficulties of caring for a teenager with Bipolar Affective Disorder. This novel is interesting in its exploration of the legalities of the mental health system in the USA and touches upon ethnic concerns—the relatives of ethnic minorities with mental illness do not attend the support group that Trina’s mother goes to because of the huge stigmatisation of certain health problems in sections of society (49).Footnote 20 In comparing these two texts, one examines the inside of experience and presents it to us, while the other examines the exterior fallout of the illness. Echoes of the form and content divide are clear here—one text explores the form that, in this case, BPAD can take, while the other explores an experience of psychosis.

Diski writes eloquently on the deeply personal and acutely internal notions of depression in both Monkey’s Uncle and Nothing Natural. Diski’s description of depression in Nothing Natural is worth quoting at length here:

Here it was again. Unmistakeably it. She remembered depression through her fear of it, felt it lurking, knew it had happened before and could happen again, but when it came, when it felt so precisely as it felt, she was always taken by surprise. It was like malaria, you have a fever. Sometimes when you have a cold you wonder if you don’t have flu, but when you have flu you don’t wonder at all. Depression was as specific as that, an instantly recognisable condition as if a switch had been turned. A physical pain in her diaphragm, a weight as if she had been filled with lead, the absurd difficulty of doing anything—automatic actions having to be thought out to be achieved: how do you get across the room, make the legs move, keep breathing, think carefully about it all. An hour, 2 h, all day spent trying to get the energy and will to perform some simple task, feed the cat, take a pee. The unreasonable difficulty of everything made more unreasonable, more difficult knowing that nothing physical was wrong. And the shocking despair in her head.

It was impossible to remember or describe the hopelessness, the absolute blackness that descended: the blackness was infinite, she was hopeless because there was nothing to hope for […] Depression was an excess of reality: intolerable and unliveable.Footnote 21

Depression can be seen as inherently indescribable in traditional terms—symptomologically causing a numbing, a flattening of emotion and, paradoxically, a sharp intensification of bleak or anxious feelings. Diski captures this paradox beautifully in this passage, and it can act as a stark and poignant reminder to the professional and student of the sheer awfulness of depression. As Moran states, depression is a disorder that is experienced by individuals in an inimitable manner and thus it is narrated, and thus represented, in many different ways:

Depression is not merely a constellation of symptoms, but also the patient’s narrative of illness—an autopathography that has some relation to a broader autobiography. What a doctor calls “depression” may be experienced by the patient as a “crack-up,” as an exhibition of “the shamelessness of defeat” to be concealed at all costs, as “a dissolution of the mind,” or as one of the countless other types of narratives.Footnote 22

Individual biographies can indicate much about how and why an individual may react to an event as they do, how they conceive of and construct their illness, and how this relates to their self-construction. Literature, then, provides an opportunity to explore the relationship between personal history and present behaviors and emotions within a safe medium—there is no risk of causing further damage to an individual when borrowing a fictional character for the practice of illness formulation and understanding.

Charlotte, the protagonist of Monkey’s Uncle, suffers a psychotic depression following the death of her daughter—a random and inexplicable event that causes catastrophic psychic effects. This theme—of events searing through normality and the shattering of anything certain—can be useful in reminding us, as professionals, that life gets in the way of our plans, dreams and hopes, and that subsequent psychological challenges and illnesses are all the more tragic for this reason. Charlotte discovers a certain refuge in her psychosis, spending time with a talking orangutan called Jenny:

There was no doubt, however, that she was as far away from Charlotte-up-top as it was possible for one person to be from themselves. And she felt nothing but relief to discover that there really was another place to be. It seemed likely to her that madness was a closely guarded secret, in the way that a small, private island might be kept secret, so that the rabble might be kept from overrunning it. But she retained a decent amount of caution. This black otherness was all very well, and very pleasant, actually, but Charlotte guessed that there might be other aspects, other landscapes, as it were, and who could say how nice they were?Footnote 23

Charlotte’s situation also reminds us of the need to consider the relief that psychosis can afford some individuals when faced with an intolerably painful situation, as well as the treatment considerations when addressing dual conditions—in Charlotte’s case, “she was obliged to admit that in her heart of hearts she would, if given the choice, prefer madness to depression. No one, she realised, had asked her which aspect of her illness she wanted to be rid of, and now it struck her as strange that it should be assumed she would rather be depressed than mad.”Footnote 24 This notion of life changing in an instant due to a catastrophic and random external event is also key in the work of Ian McEwan—seen most starkly in Enduring Love, where he explores de Clerambault's syndrome.

Of course, madness, in the sense of psychosis, does not always provide a paradoxical asylum. Martin Amis demonstrates this in his brilliantly constructed short story ‘Insight at Flame Lake.’ Dan, the young man with schizophrenia staying with his uncle, his wife and their baby, suffers acute and irrational paranoia about their child. In a crucial passage, Amis demonstrates the paradoxical ability that Dan has for having theoretical insight into schizophrenia as a condition whilst simultaneously demonstrating no insight into his own relapse. He writes in his notebook his conviction that eight-month-old baby Harriet has schizophrenia, stating that “the condition is already far advanced. I’m afraid she is more or less a classic case.”Footnote 25 He continues by listing Harriet’s symptoms as he perceives them to be: “Deviant pattern of receptor preference”; “Repetitive and stereotyped behavioural patterns”; “Faulty depth perception”; “Motor-normalcy loss and abrupt personality mutation.”Footnote 26 He continues:

I could go on: time disperception, the way she often interprets humour as insult, her interludes of excessive affection, the hypomania which prevents her from sleeping. Of course, the baby is perfectly well aware that I am on to her, and that is why she has turned against me at night, she has deceived her parents very cleverly—schizophrenics often show great cunning—and I don’t think either Fran or Ned suspects for a moment that the baby can talk.Footnote 27

What does this story us about the nature of insight? It demonstrates that it should not be assumed that because an individual has little or no insight into his or her own situation, ergo he or she does not have insight into the theoretics of the situation. Recognition of theoretical knowledge can potentially be a useful starting point for work on developing personal insight.

In narrating his short story through alternating snippets from Dan’s and his Uncle Ned’s diaries, Amis neatly avoids the problem of the mad-therefore-unreliable narrator. Patrick McGrath, author of the acclaimed and oft-cited Spider, is renowned for his use of unreliable narrators—the over-involved sister Gin in Port Mungo who gives a vastly skewed account of her brother’s sexual abuse of his daughter, for example, and the tale of Spider, told through first-person layering of current descent into psychosis with his murdering of his mother, a fact held from the reader until the end of the text. Unreliable narration is a fact of life as well as literature—rarely do we admit to anyone (including ourselves) the deeper, painful and sometimes darker sides of ourselves. The literary device of unreliable narrator can serve clinically as a reminder to gather a multitude of known and establishable facts about individuals, as well as listening to self-interpretation and accounting in order to enable a wide-ranging perspective. Ultimately, this particular literary device indicates that the manner in which we narrate ourselves can speak volumes about who we inherently are.

Psychotic texts

McGrath writes that drawing from psychosis is a difficult task for authors, stating “it seemed to me that fictional narrative and psychosis were mutually exclusive entities. The latter, I thought, is characterised by chaos, irrationality, delusions, non-sequiturs and paranoia, whereas the novel demands a sort of swelling narrative progress grounded in causality and finally yielding a clear design”.Footnote 28 Similarly, Oyebode states:

for a story to work it has to be coherent and plausible. Therefore, psychopathology has to be comprehensible within the total structure of the narrative. Thus, even in an account of a disintegrating mind, the account still has to cohere. This means that Jaspers’ notion of ‘un-understandability’ as a criterion for psychosis is usually breached in literature. There are, of course, researchers such as Bentall (2003) who argue that psychotic experiences are understandable. On the face of it, fictional accounts seem to agree with him, but I suspect that this is because of the need for fictional narrative to be comprehensible and coherent.Footnote 29

However, one particular category of fiction breaches the rule of comprehensibility altogether. Postmodern fictions—characterised by their incomprehensibility, fragmentation of linear narrative and narrations, disruptions in spatiality and temporality, the use of various and often undifferentiated points of view, and a concern with the thematics of postmodernity (a loss of reliable knowledge of the world; the deconstruction and destruction of ‘grand narratives’ such as patriarchy; existential and ontological questioning)—can be seen as psychotic texts. In both their style and their content, they are psychotic—one can see elements of thought disorder, paranoia, word salad, neologisms, ideas of reference from the media and a host of other clinically-defined-as-psychotic symptomatology within these narrations.

The use of neologisms is particularly evident in Anthony Burgess’ A Clockwork Orange, which explores the psychopathology of adolescence and development of psychopathic traits, and the manner in which a dictatorial state deals with this. William Burroughs’ highly acclaimed Naked Lunch explores from inside the experience of one long drug-induced hallucination, complete with archetypically postmodern concerns with governmental control and power. Burroughs also takes a wry look at medical professionals and psychiatrists through the character of Dr Benway. In Blood and Guts in High School, Kathy Acker explores adolescence using the literary technique of collage and by plagiarising canonical male texts such as Hawthorne’s The Scarlet Letter, creating through the sexually promiscuous character of Janey a treatise of female madness and its relationship to the horrors of a patriarchal society. Perhaps the definitive postmodern text also explores a distinctly postmodern psychosis—Thomas Pynchon’s The Crying of Lot 49 features what appear to be frank psychotic symptoms of unknowable aetiology in the character of Oedipa Mass—but at various points in the narrative, Pynchon shifts the perspective, leaving fragments of psychosis that may or may not be psychosis, and that may or may not be real. Pynchon leaves the reader without confirmation of the psychiatric status of Oedipa at the end of the novel, making way for a multiplicity of ontological, existential and epistemological readings and interpretations. Like Burroughs, he also takes an ironic swipe at psychiatrists through the fantastic Dr Hilarious, who suffers from a florid psychosis after prescribing his patients LSD and refusing to take it himself. The social context of which the majority of postmodern texts were written is key to understanding their relevance in psychiatry, given the anti-psychiatry movement of the 1960’s onwards.

Variations on ‘normal’

A recurrent theme in fiction is of the need for, or the direct application of, a depathologisation of mental illnesses. Many texts do not specify the DSM-IV or ICD-10 diagnosis for their characters—labelling is of far lesser importance than the acknowledgement that we all, to a greater or lesser degree, are afflicted with some form of mental pathology. Salley Vickers articulates this clearly in two apt lines from her 2006 novel The Other Side of You: “The question is not to cure or be cured, but how to live”;Footnote 30 “We are most of us badly cracked and afraid that if we do not guard them with our lives the cracks will show, and will show us up, which is why we are all more of less in a state of vigilance against one another.”Footnote 31 Mark Haddon’s The Curious Incident of the Dog in the Nighttime is not only a delight to read but an important narrative in gaining appreciation of the inner worlds of individuals who exist on the continuum of Autistic Spectrum Disorders. The novel has an autodiegetic perspective, narrated by a teenager who has Asperger’s Syndrome, and explores from his inimitable perspective the manner in which he perceives and interacts with the world around him. It represents his fears, pleasures, behaviours—and they all become relatively understandable once explained from his perspective. He finds safety and comfort in logic and mathematics, both subjects at which he excels. He struggles with the interpretation of facial expressions and with social interactions, for two very rational reasons: “The first main reason is that people do a lot of talking without using any words” and “people often talk using metaphors.”Footnote 32 Citing two examples of metaphor, he goes on to state, “I think it should be called a lie because a pig is not like a day and people do not have skeletons in their closet.”Footnote 33 Christopher sees the strangeness of common language and reminds us of the necessity for plain speech—this has particular resonance with certain jargon-laden discourses, such as psychoanalysis. This text also teaches us much about the nature of communication, and the manner in which facial expressions, for example, can be theoretically taught but remain remote from inherent interpersonal understandings. The text demonstrates the frightening nature of touch for some people—in a tactile society Christopher cannot return his parent’s embraces, and they create their own way of communicating love through the touching of fingertips in a fan shape.

Possibly the most negatively stigmatised current psychiatric disorder, Borderline Personality Disorder, is seen as a variation on normal in fiction. Certain behaviours—manipulation of others, for example—are seen as extremes to which we’re all capable of rather than the acts of a small population. Deliberate self harm is dealt with calmly and non-sensationally in two particularly good texts—Kristin Waterfield Duisberg’s The Good Patient and Rebecca Ray’s A Certain Age. In Duisberg’s text, Borderline Personality Disorder is demonstrated as not being due to an individual’s nastiness or determination to be difficult but as having deeply rooted causes—in this case Darien’s twin-sister’s suicide and her subsequent blocking out of this. Main character Darien goes into therapy with Dr Lindholm after breaking her own arm, but after years of unsuccessful therapies, self-destructive behaviour, excessive drinking and varying degrees of deliberate self harm, she has very low expectations of therapy:

After five doctors, I have the first visit procedure down and can go through the routine on autopilot, laying out the relevant data points like setting the table for a five-course meal. Anorexia at age ten, bulimia at twelve, alcoholism and sexual promiscuity with the onset of puberty; lying, nightmares, and self-mutilation for as long as I can remember. Everything from the knife rest to the finger bowl. “I know why I’m here. I’m here because I broke my hand, and because that’s really just emblematic of a whole host of other things that are wrong with me, or that at least have been wrong with me in the past." I throw the last out there, eager for her to ask what those other things might be. Starving, puking, binge drinking, sluttiness, pathological lying—did I mention those before? I don’t mind talking about them.Footnote 34

Darien is eventually admitted to hospital following her complete psychological free fall and fragmentation of self after the emergence of repressed memories of her sister. This text may be of particular use to professionals working on the fragmentation of personality and dissociations of memory and personality. Darien ultimately comes to learn that “mental health will never be able to help me. Its practitioners have chosen their profession to deny a terrifying truth other doctors accept—there are ills for which there is no cure.”Footnote 35 This is not a self-pitying admission—Darien comes to learn that her self-destructive and self-harming behaviour is symptomatic of the memories that she has hidden from herself, and that time and talking will be of more use than medication and hospitalisation.

Rebecca Ray explores DSH in the form of cutting in a thirteen-year-old female, who becomes involved with an older man and lives in a functionally-dysfunctional family. This text is particularly relevant given the epidemic of self-harm in young people. Ray explores ‘normal’ elements of adolescence—peer pressure, struggling to find an identity that rebels whilst simultaneously fits in, burgeoning sexuality, arguments with her brother and parents. Set in parallel to this normal psychopathology is the disturbing intensity of her cutting behaviour, her abusive relationship with boyfriend Oliver, and the distinct numbing of emotion that she suffers. Cutting becomes a way of reassuring herself that she can still feel. The key reading of this text for professionals surrounds the need to treat teenagers with sensitivity, without displaying shock, and the need to be aware of seemingly innocuous but actually abusive relationships that confused adolescents can find themselves in.

Institutions and history

It is important to remember the, at times, brutal treatment of the mentally ill in the vast history of psychiatry. Clare Dudman’s 2004 novel, 98 Reasons for Being, explores asylum care circa 1850 – 1890. In this well-researched historical novel, Dudman reminds us of the need to remember the patient’s narratives in history as well as the medically authorised versions. She gives exclusive access to the internal thoughts of mute Hannah, the female character admitted with nymphomania and documents a range of other characters suffering from illnesses as diverse as melancholia, general paralysis of the insane, mutism and obsessive-compulsive disorder. Dudman also documents with accuracy a number of early treatments of mental illnesses, such as wet packs. Pat Barker’s highly acclaimed Regeneration trilogy explores the treatment of war neurosis using historical figures in a fictional context and documents psychiatrist and anthropologist River’s attempts to treat shell-shock through then-developing talking therapies and psychoanalysis as opposed to the other popular methods of this time. Barker returns to the theme of war and post-traumatic stress disorder in Double Vision, which addresses the problems faced by war reporters and photographers—those not involved in actual conflict—returning from Afghanistan.

Literature can tell us much about the manner in which various institutions contain and manage mental illness in both inpatient and community settings. Clare Allan’s Poppy Shakespeare, set in a day hospital, is a uniquely styled exposé of the peculiarities of the UK mental health system—for example, her sardonic examination of the Mad Money system is a thinly veiled mocking of the current Disability Living Allowance benefit. Allan realistically depicts a paradoxically surreal range of characters. Allan herself spent time in the psychiatric system, although this book is not directly autobiographical. Her focus is on the languages of madness and the inadequacy of language, rather than on the writing of experiences. In this respect, form takes priority over content, though the context is crucial. This is evident in her Bloomsbury press release, where she states:

Mental illness is a survival strategy. It is a means of reconciling the irreconcilable. At the day hospital I was constantly struck not by the frailty of those around me but by their resilience. Their experiences were unimaginable, impossible to survive… and yet here we were sharing a cigarette. In writing Poppy Shakespeare I didn’t want to focus on the experiences themselves; I didn’t want to write that sort of book. What I wanted to explore was how words cope with extremes of emotion and experience. Language is a very clumsy tool, even in the most skilful of hands it is only ever approximate and most people aren’t especially skilful, most people muddle along. It might seem strange you have to use the same language to describe your mother’s suicide as you do to order a pizza, but the fact is you do. The irony is that to my ear at least, the clumsiest people are often the most expressive. ‘Do you know what I’m saying?’Footnote 36

Allan’s text is one of the most resonant texts to have been written in recent years that explicitly and exclusively concerns mental illness. Similarly, in the opinion of this paper’s second author Paul Crawford’s Nothing Purple, Nothing Black is remarkable for its stark and unfortunately realistic portrayal of Crystal, a man with schizophrenia who, like many of his generation, is moved from the long-term care asylum he has called home into a community hostel with a ruthless landlady. Fictional texts like Nothing Purple, Nothing Black allow access to profound, emotive, personal histories of the developments in psychiatry, rather than the standard dry medical history.

Culture and psychiatry

Fiction can function as one way to gain an understanding of non-UK or US asylum care—for example, Gilad Elbom’s 2004 novel, Scream Queens of the Dead Sea, explores asylum care in Israel, while Paulo Coelho’s novel, Veronika Decides To Die, explores the care of patients in Slovenia. Furthermore, fiction that focuses on traditional and non-westernised healing—such as Lisa Carey’s Love in the Asylum which compares contemporary treatments for Bipolar Affective Disorder and addictions with treatments that were non-medical, focusing more on healing, and on the Native-American belief of epilepsy as a gift that enables healing of others through contacting the dead—can inform our understandings of non-western belief systems and stimulate an interest in the important but neglected realm of cross-cultural psychiatry. Alice Walker’s Possessing the Secret of Joy tells the story of Tashi, an underexplored character in The Color Purple. There are immediate and recurrent barriers to any successful treatment of Tashi’s mental distress, right from her initial image of the therapist with his “pen poised to at last capture on paper an African woman’s psychosis for the greater glory of his profession.”Footnote 37 Firstly, the doctor makes huge assumptions—that Tashi, a “Negro woman”, she only has one child is a surprise to him (assumption that African women have lots) and that she cannot be effectively analysed as she (because “Negro women” do) will refuse to blame her mother.Footnote 38 The central theme of the novel concerns rural African practices of female circumcision and facial scarring—Tashi’s second (female) therapist also fails to appreciate or understand fully Tashi’s emotions regarding the assimilation of her culturally marked body and self within an ignorant and assuming Western culture. Raye is brusque when Tashi initially describes what happened, curious and somewhat insensitive. Examples from fiction such as this can act as a lesson in the need to be culturally aware, sensitive and, above all, in not assuming the dominance of Western views over other cultural interpretations of mental distress.

Autobiography

There is an argument to be made that autobiographical narratives are perhaps of more use to professionals than fictions—they are, after all, focusing on actual experiences as opposed to created, imagined experience. Of particular relevance here is the growing subgenre of autopathography—the narrative of the patient.Footnote 39 In a review of autobiographies and their relevance to psychiatry, Oyebode states that the “hope is that these accounts will help to enrich the language and thought of psychiatrists. The subjective, the personal, the social and cultural context are hallowed ground in autobiography, whereas, in psychiatric texts, it is the objective and general that is stamped and reinforced.”Footnote 40 However, autobiographical accounts are, by their very nature, retrospective and thus run a risk of becoming skewed by the inaccuracy of memory and by the inevitable colouring of experience that comes with time, aging and reflection. Nevertheless, over the past 20 years there has been a huge increase in the number of autobiographical texts published—it appears that everyone has a tale to tell, and these tales should be taken to be valuable artefacts for the same reasons as fiction.

From childhood abuse, poverty, experiences of depression and psychosis, to texts such as Jimmy Boyle’s A Sense of Freedom, candidly exploring the extreme ends of violent behaviours, a range of psychological problems and issues are no longer taboo—in this respect autobiographies can help to dispel myths about mental illness and depathologise—to an extent—certain experiences. Lori Schiller’s The Quiet Room depathologises psychosis, as does Elyn Saks The Centre Cannot Hold. Saks’ text, like Kay Redfield Jamison’s An Unquiet Mind, also demonstrates that mental illnesses, while life-altering, are not always life-destroying—both authors are noteworthy because of their academic achievements. Furthermore, certain illnesses are demythologised through autobiography—one particularly relevant example here, given the recent explosion of media attention on the accuracy of the diagnosis, can be seen in Julie Gregory’s Sickened, in which she explores her childhood and experiences at the hands of a mother with Munchausen’s-by-proxy.

Conclusions

Both accurate representations and stereotypical misrepresentations in fiction can be of use. Texts which reinforce stereotypes and misapprehensions of mental health problems—for example Stephen King’s The Shining and John Neufield’s Lisa, Bright and Dark, which suggest that people with mental health problems are violent and that schizophrenia consists of a split personality in these two cases—can in fact be of use in deconstructing and decrying of such typecasts. They can also be beneficial to students and professionals alike in terms of allowing a critical reflection on practice and on our own inherent stereotyping. Furthermore, the fact that texts are open to a number of interpretations reflects, and can be reflected upon, the vast number of interpretations about mental health problems. A useful example is Elizabeth Wurtzel’s Prozac Nation, in which the protagonist may be said to be suffering from Borderline Personality Disorder, depression, drug and alcohol misuse, addiction to medication, adjustment or conduct disorders. Staff at differing levels of responsibility, and from different professional and personal backgrounds, will all read and interpret this text in their own ways—as can be seen in any Multi Disciplinary Team meeting. To return to the quote by Lodge cited above, not only is literature itself the most fertile medium for exploring the complexities of the human mind, but the interpretation of literature is in itself indicative of the individuality and inimitability that makes us autonomous creatures. What is important in reading these texts is not the diagnoses that can be applied to them, but the access given to, and insights into, a variety of mental states and challenges.

This paper focuses on fiction and autobiography from 1945 to the present, and on UK and US narratives, as this literature has most resonance with current health care systems and formulations of disorders. This paper is not intended to be an exhaustive review of fiction relating to mental illness, but an introduction to a selection of available and relevant texts. A fuller set of accounts is available at www.madnessandliterature.org. There is a difference between texts that are about mental illness and texts that use mental illness as a device for either entertainment or as a metaphor for society. Both can be of equal use. In a similar manner to the utilisation of fiction, film and television can be mobilised as a resource for those adverse to fiction.Footnote 41 Andy Bickle, in response to Oyebode’s 2004 article, writes that fictional narrative “is not well suited to conveying comprehensive knowledge of mental illness or the psychiatric profession—it simply deals in the wrong kind of data for that. However, it does offer the opportunity to explore heuristically these issues in an interesting way which helps us reflect on our practice.”Footnote 42 The study of the humanities—in this case, of literature—can and should form an important part of a medical and healthcare education. This is not to say that it should take priority over other crucial elements, but that it can be used as an adjunct to clinical education. Nor is our argument suggesting that all health care students and professionals will benefit to the same degree, or will gain the same advantages from a literary-based element to education. The most wonderful element of literature is that it reflects and refracts the uniqueness of humanity. Readers of literature then in turn further echo this uniqueness through the individuality of their readings. If a mere acknowledgement of the multiplicity of human responses and experiences is the only gained benefit from reading fiction, then it is a worthwhile pursuit.