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Literature & medicine Literature and medicine: narratives of mental illness Anne Hudson Jones Autobiographical accounts of mental illness have for illness as demon possession continued to appear in the 18th centuries provided a fascinating window on the world of and early 19th centuries,10–13 even as cultural beliefs about the madness for those fortunate enough never to have sojourned causes of madness were moving away from a religious model there themselves. Even with all the advanced brain-imaging to a secular one that considered mental illness as a defect or and other technologies of medicine, disorder of the faculty of reason.4,6 experience of mental illness can be conveyed only by those This secular way of understanding madness led to the who have lived it. Yet the nature of the experience poses development of both private and public asylums for the immense challenges for any author, for the very faculties confinement of the mentally ill. The goal of the earliest required to construct a narrative— asylums was simply to provide perception, memory, and reason— custodial care and to separate the can be profoundly altered by mentally ill from the rest of society.
illnesses such as depression, bipolar As new philosophies of humane care disorder, and schizophrenia, as well emerged in Europe at the end of the 18th century, conditions improved in electroconvulsive therapy (ECT) some institutions, and by the late and psychotropic drugs. Perhaps as 19th century there was cautious a result—or perhaps just to avoid the optimism about potentially effective stigma of being identified as a conditions, cruelty, and abuses that authors have sometimes chosen to persisted in many institutions evoked present their accounts as fiction.
narratives of protest from patients Whatever their choice in this regard, who recovered well enough to be the desire to make sense of what has released and to write about their happened to them, the wish to asylum experiences. These accounts reform abuses in the treatment of began to appear in the 18th century, the mentally ill, and the hope of and their incidence and urgency Christoph Haizmann's painting of his eighth vision helping other patients and their of the devil, in the form of a dragon increased as the numbers of asylums "The eighth time he came before me in this dreadful and their inmates grew during the motivations for the hundreds of guise of a Dragon after the exorcism in the Chapel of the 19th and early 20th centuries. Well- Blessed Virgin, and brought the scrap of paper which I patients who have written about known examples include Alexander had subscribed for him in my blood, dropping it at the their experiences of mental illness.1–4 lowest window on the right-hand side, whereupon the How these authors make sense of whole Chapel of the Blessed Virgin appeared to me full Exceedingly Injured (1739),13,14 John of flames." (Wien, Österreichische National Bibliothek, Perceval's A Narrative of the Treatment Cod.14.086, Bild 8).
episodes of mental illness has Experienced by a Gentleman, During a changed substantially from one age to another. In earlier State of Mental Derangement (1838, 1840),15,16 Clifford Beers' centuries, mental illness was often understood and portrayed A Mind That Found Itself (1908),17 Mary Jane Ward's as demon possession, to be treated by exorcism or other autobiographical novel The Snake Pit (1946),18 and Kate religious interventions. If these remedies failed, trials and Millett's relatively recent The Loony-Bin Trip (1990)19 about executions for heresy and witchcraft sometimes followed.
her involuntary commitment to an asylum in Ireland.
Indeed, early autobiographical accounts of mental illness Occasional narratives by those who were not mad but who have been compared to spiritual autobiographies in their were nonetheless confined to mental asylums are valuable for concern with the religious dimensions of the inner life.4 In the corroborating accounts they provide: for example, The Book of Margery Kempe (c 1436),5 which many regard as William Seabrook's Asylum (1935)20 and Janet Frame's An the first such autobiographical account in the English Angel at My Table (1984),21 as well as her autobiographical language,4,6 Kempe describes her first experience of mental novel Faces in the Water (1961),22 report much the same illness, which today might be called postpartum psychosis, as conditions and abuses as chronicled in the other works.
visions of devils tempting her to commit wicked deeds and Many therapies once believed to be efficacious have been to forsake her faith.7 More than two centuries later, the abandoned, sometimes in response to narratives of protest by Bavarian artist Christoph Haizmann recorded in his diaries former patients. Charlotte Perkins Gilman, for example, who and in a series of paintings his story of the devils that he was subjected in 1887 to S Weir Mitchell's "rest cure", believed were responsible for his eight episodes of madness8,9 during which she was forbidden to write or engage in any (figure). Autobiographical accounts representing mental intellectual activity, wrote the fictional story "The YellowWallpaper" (1892) based on her experience.23 Although sheoriginally had difficulty finding a publisher for the work, it Lancet 1997; 350: 359–61 has since become a feminist classic. In her commentary Institute for the Medical Humanities, Ashbel Smith Building Suite (1913) about why she wrote the story, Gilman reports that 2.210, The University of Texas Medical Branch, 301 University "many years later [she] was told that the great specialist [S Boulevard, Galveston, Texas 77555-1311, USA Weir Mitchell] had admitted to friends of his that he had (Anne Hudson Jones PhD) (e-mail: [email protected]) Vol 350 • August 2, 1997 treatment for schizophrenia when she was a teenager; Panel 1: The Voices of madnessIt was a hot night in August 1976, the summer of my seventeenth year, when, Frieda Fromm-Reichmann was her psychotherapist.
uninvited and unannounced, the Voices took over my life.
Greenberg's best-selling novel is still used in medical education for its vivid descriptions of the hallucinatory Since that time, I have never been completely free of those Voices. At the worlds that can characterise schizophrenic experience.
beginning of that summer, I felt well, a happy healthy girl—I thought—with a Despite the skill with which some of these illness normal head and heart. By summer's end, I was sick, without any clear idea of narratives are written and the fascinating experiences what was happening to me or why. And as the Voices evolved into a full-scale they record, contemporary readers may regard them illness, one that I only later learned was called schizophrenia, it snatched from merely as historical artefacts having no relevance to me my tranquillity, sometimes my self-possession, and very nearly my life.
current psychiatric practice, with its more biological Sometimes these Voices have been dormant. Sometimes they have been focus and more effective pharmacological treatments.
overwhelming. At times over the years they have nearly destroyed me. Many Contemporary patients' narratives, however, may have times over the years I was ready to give up, believing they had won.
special value for clinicians because these narratives offer Today this illness, these Voices, are still part of my life. But it is I who have rich critiques of newer psychiatric treatments.32 Some won, not they. A wonderful new drug, caring therapists, the support and love patients' accounts herald extraordinary breakthroughs of my family and my own fierce battle—that I know now will never end—have and successful remissions even in the most difficult of all combined in a nearly miraculous way to enable me to master the illness mental illnesses. Others caution against easy celebration that once mastered me.
by telling of patients for whom even the most promising Today, nearly eighteen years after that terrifying summer, I have a job, a car, new treatments have failed. Lurking in the background, an apartment of my own. I am making friends and dating. I am teaching always, is the spectre of suicide.
classes at the very hospital at which I was once a patient.
Still, I have been to a place where all too many people are forced to live.
In Darkness Visible: A Memoir of Madness (1990),33 Like all too few, I have been permitted to return. I want to tell others about my William Styron tells of the nearly fatal unipolar journey so that those who have never experienced it will know what life inside depression that suddenly afflicted him when he was 60 of my schizophrenic brain has been like, and so that those who are still left years old. As a highly successful, world-renowned behind will have hope that they too will find a path out.
writer, he had access to the best medical care available.
From Lori Schiller and Amanda Bennett, The Quiet Room: A Journey out of the Torment of But neither sessions with his psychiatrist nor taking the Madness (New York: Warner Books, 1994: 3, 7). Copyright 1994 by Lori Schiller and prescribed drugs helped. Styron, who had meticulously Amanda Bennett. All rights reserved. Reprinted by permission of Warner Books, Inc, NY,New York, USA.
planned his suicide, was at the point of carrying it outone night when, in a moment of lucidity, he woke his altered his treatment of neurasthenia since reading The Yellow wife and had her take him to the hospital. Although Styron Wallpaper".24 The treatment, based on the belief that women attributes his eventual recovery to the passage of time and the must be protected from higher education and all intellectual sanctuary of the hospital, his improvement also coincided and artistic work if they were to remain healthy, persisted, with a change in his drug therapy. Even Styron, who however. In 1913, the same year as Gilman's commentary, understands his illness in contemporary scientific terms, Virginia Woolf was subjected to a version of the rest cure in describes it with metaphors of hell and literary allusions to Milton's Paradise Lost and Dante's Inferno.
Lobotomy and ECT, both introduced in the 1930s, figure For the American actress Patty Duke, who has written two prominently in 20th-century patients' narratives and have accounts of her illness—Call Me Anna: The Autobiography of become symbols of psychiatric brutality. Many patients have Patty Duke (1988)34 and My Brilliant Madness: Living with written first-person accounts of ECT, and they have Manic-Depressive Illness (1992)35—the most difficult part of described the experience as a barbarous torture. Narratives her experience was getting the correct diagnosis. After her such as those of Ward,18 Frame,21,22 and Sylvia Plath in the illness was identified as manic-depression, she began taking The Bell Jar (1963)26 tell of the dread that ECT evoked in lithium and has been able to control her disease by her patients. Martha Manning's recent account in Undercurrents: extremely disciplined use of that medication. Yet even when A Therapist's Reckoning with Her Own Depression (1994)27 is lithium works well as a treatment for their illness, some unusual in its acknowledgment that ECT cured her severe patients are not willing to take it because they do not want to depression when all else had failed.
give up the highly productive manic phases that they enjoy.
In addition to this strong tradition of patients' narratives The controversial feminist writer Kate Millett, for example, seeking to reform psychiatric asylums and treatments, there stopped taking her lithium several times, with various results, are stories—such as Undercurrents—that offer hope to other as she reports in The Loony-Bin Trip.19 Even Kay Redfield patients by recounting successful treatments and recoveries.
Jamison, a clinical psychologist who specialises in treating Although Freud did not believe that psychoanalysis could be mood disorders and who suffers from manic-depressive an effective therapy for psychotic patients, two classic illness herself, writes in An Unquiet Mind: A Memoir of Moods and Madness (1995)36 of her initial unwillingness to stay on psychoanalytical treatment of what was diagnosed as schizophrenia. Autobiography of a Schizophrenic Girl (1951),28 understanding of the illness than Jamison, who has written by a young French woman identified only as Renee, depression,37 yet she reports needing intensive psychotherapy describes her experience from the age of 5 years with a to help her accept her need for chronic medication:36 "No pill mental illness marked by intense feelings of unreality. Her can help me deal with the problem of not wanting to take account is accompanied by an interpretive analysis written by pills; likewise, no amount of psychotherapy alone can prevent her psychotherapist, Marguerite Sechehaye. This kind of my manias and depressions. I need both" (p 89).
publishing collaboration between patient and therapist is not Contemporary narratives of schizophrenia record the unusual in cases of successful treatment.29,30 A decade later, success and failure of very recent drug treatments, such as clozapine and risperidone. Lori Schiller, with the assistance autobiographical novel I Never Promised You a Rose Garden of Amanda Bennett, has constructed a compelling narrative about her institutionalisation and successful Vol 350 • August 2, 1997 Panel 2: Thirty years in search of diagnosis and effective Peterson D, ed. A mad people's history of madness. Pittsburgh, PA:University of Pittsburgh Press, 1982.
Kempe M.The book of Margery Kempe: a modern version by Robert's diagnosis has changed frequently in the past thirty years, W Butler-Bowdon. London: Oxford University Press, 1936.
depending largely upon which drugs have been successful in keeping Porter R. A social history of madness: the world through the eyes of the him calm, stable, and/or compliant. He was schizophrenic when insane. New York:Weidenfeld & Nicolson, 1987.
enormous doses of Thorazine and Stelazine calmed him; he was Ober WB. Margery Kempe: hysteria and mysticism reconciled.
Lit Med 1985; 4: 24–40.
manic-depressive (bipolar) when lithium worked; he was manic- Macalpine I, Hunter RA. Schizophrenia, 1677: a psychiatric study of an depressive-with-psychotic-symptoms, or hypomanic, when Tegretol or illustrated autobiographical record of demoniacal possession. London: Depakote (anticonvulsants), or some new antipsychotic or William Dawson and Sons, 1956.
antidepressant—Trilafon, Adapin, Mellaril, Haldol, Klonopin, Freud S. A neurosis of demoniacal possession in the seventeenth century.
risperidone—showed promise of making him cooperative; and he was In: Freud S. Collected papers.Vol 4. London: Hogarth Press, 1925: schizophrenic (again) when various doctors promised cures through insulin-coma therapy or megadose-vitamin therapy or Marxist therapy 10 Trosse G.The life of the Reverend Mr George Trosse, late minister of the or gas therapy. At the same time, often in an attempt to minimize side gospel in the City of Exon, who died January 11th, 1712/13. In the eightysecond year of his age, written by himself and publish'd according to his effects, other drugs were poured into him: Artane, Benadryl, order. Exon: Richard White, 1714.
Cogentin, Kemadrin, Symmetrel, Prolixin, Pamelor, Navane . .
11 Brink AW, ed.The life of the Reverend Mr George Trosse: written by During these years, Robert also participated in a long menu of himself, and published posthumously according to his order in 1714.
psychotherapies: group therapy, family therapy, multifamily group Montreal: McGill-Queen's University Press, 1974.
therapy, Gestalt therapy, psychoanalytically oriented psychotherapy, 12 Cowper W. Memoir of the early life of William Cowper. New York:Taylor & goal-oriented therapy, art therapy, behavioral therapy, vocational Gould, 1835; 1816.
rehabilitation therapy, milieu therapy, et al. Most often, though—the 13 Ingram A, ed.Voices of madness. Gloucestershire: Sutton Publishing, more chronic his condition, the truer this became—he was treated solely with drugs, and received no therapy at all.
14 Cruden A.The London-citizen exceedingly injured; or, a British inquisition display'd, in an account of the unparallel'd case of a citizen of It is as if, I often think, the ver y history of the ways in which our London, bookseller to the late queen, who was in a most unjust and century has dealt with those it calls mentally ill has, for more than arbitrary manner sent on the 23rd of March last, 1738, by one Robert thirty years now, been passing through my brother's mind and body.
Wightman, a mere stranger, to a private madhouse. London:T Cooper, 1739.
From Jay Neugeboren, Imagining Robert: My Brother, Madness, and Survival—A 15 Perceval J. A narrative of the treatment experienced by a gentleman, during Memoir. (New York: William Morrow and Company, 1997: 4–5). Copyright a state of mental derangement; designed to explain the causes and the 1997 by Jay Neugeboren. Reprinted by permission of William Morrow and nature of insanity, and to expose the injudicious conduct pursued towards Company, Inc, and The Richard Parks Agency.
many unfortunate sufferers under that calamity. 2 vols. London: Effingham of her experience in The Quiet Room: A Journey out of the Wilson, 1838 and 1840.
16 Bateson G, ed. Perceval's narrative: a patient's account of his psychosis.
Torment of Madness30 (panel 1). Over a period of nearly 15 New York:William Morrow, 1974.
years, Schiller made many suicide attempts, was admitted to 17 Beers C. A mind that found itself. Pittsburgh: University of Pittsburgh hospital many times, and was treated with psychotherapy, Press, 1981.
numerous drugs, and ECT. Nothing worked until she 18 Ward MJ.The snake pit. New York: New American Library, 1973.
enrolled in a research trial of clozapine. That she lived long 19 Millett K.The loony-bin trip. New York: Simon & Schuster, 1990.
20 Seabrook W. Asylum. New York: Harcourt Brace, 1935.
enough to finally receive effective treatment is a testimony to 21 Frame J. An angel at my table.Vol 2 of an autobiography. New York: her courage and to the unflagging support of her family.
George Braziller, 1991.
Many patients, as Schiller is well aware, do not make it.
22 Frame J. Faces in the water. New York: George Braziller, 1982.
When the Music's Over: My Journey into Schizophrenia,38 the 23 Gilman CP.The yellow wallpaper. New York: Feminist Press, 1973.
strange autobiographical novel of Ross David Burke, is a 24 Gilman CP.Why I wrote "The yellow wallpaper". In: Golden C, ed.The captive imagination: a casebook on The Yellow Wallpaper. New York: haunting story of one patient who killed himself before he Feminist Press, 1992: 53.
found effective treatment. Jay Neugeboren's book Imagining 25 Virginia Woolf's psychiatric history: Robert: My Brother, Madness, and Survival—A Memoir39 (panel 2), which tells of a 30-year effort to find effective 26 Plath S.The bell jar. New York: Harper and Row, 1971.
treatment for his brother's illness, is another reminder that 27 Manning M. Undercurrents: a therapist's reckoning with her own depression. New York: HarperSanFrancisco, 1994.
for many patients successful treatment for mental illness is 28 Sechehaye M, ed. Autobiography of a schizophrenic girl.Translated still just a fantasy.
from the French by Grace Rubin-Rabson. New York: New American For all readers, these patients' stories give testimony to the Library, 1970.
remarkable range of human psychological experience and to 29 Yalom ID, Elkin G. Every day gets a little closer: a twice-told therapy. New York: Basic Books, 1990.
the extraordinary capacity of human beings to endure and 30 Schiller L, Bennett A.The quiet room: a journey out of the torment of prevail even through hellish torments. Stories of successful madness. New York:Warner Books, 1994.
treatment and recovery are extremely important for the hope 31 Greenberg J [Green H]. I never promised you a rose garden. New York: they hold out to others who have mental illness, and to their New American Library, 1964.
families and friends. But the cautionary tales—such as those 32 Jones AH.Voices from the darkness: narratives of mental illness. Med Hum Rev 1995; 9 (1): 9–24.
of Styron, Burke, and Neugeboren—are equally important 33 Styron W. Darkness visible: a memoir of madness. New York: Random for their reminders, especially to clinicians, that disease House, 1990.
manifests itself differently in each patient and that what 34 Duke P,Turan K. Call me Anna: the autobiography of Patty Duke. New works well as a treatment for one person may not work for York: Bantam Books, 1988.
another. We should not forget that many of these narratives 35 Duke P, Hochman G. My brilliant madness: living with manic-depressive illness. New York: Bantam Books, 1992.
are dedicated to the patients who did not recover.
36 Jamison KR. An unquiet mind: a memoir of moods and madness. New York: Alfred A Knopf, 1995.
37 Goodwin FK, Jamison KR. Manic depressive illness. New York: Oxford Alvarez WC. Minds that came back. New York: J B Lippincott, 1961.
University Press, 1990.
Landis C, Mettler F.Varieties of psychopathological experience. New York: 38 Burke RD.When the music's over: my journey into schizophrenia. Gates Holt, Rinehart and Winston, 1964.
R, Hammond R, eds. New York: Basic Books, 1995.
Steir C. Blue jolts: true stories from the cuckoo's nest. New York: Simon & 39 Neugeboren J. Imagining Robert: my brother, madness, and survival—a Schuster, 1977.
memoir. New York:William Morrow, 1997.
Vol 350 • August 2, 1997

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