Fictional narrative and psychiatry

Abstract

This article addresses how mental illness and psychiatry are dealt with in fictional narrative. The starting point is Charlotte Bronte's novel Jane Eyre. The characterisation of madness in that novel provides the basis for exploring how the physical and psychological differences of mentally ill people are portrayed, and how violence and the institutional care of people with mental illnesses are depicted. It is also argued that the fact that in Jane Eyre, Bertha Mason, the madwoman in the attic, is rendered voiceless is not accidental but emblematic of the depiction of mentally ill people in fiction. A number of novels are used to illustrate these issues.

Charlotte Brontë’s novel Jane Eyre, published in 1847, sets the scene for how madness is perceived in society. It is a very popular work and the plight of Rochester’s mad wife Bertha Mason is iconic of madness. Her fiendish laughter and screaming characterise her difference from others. Rochester is so ashamed of her that he has her locked away from human intercourse and keeps her presence a secret, signalling that madness is best kept out of sight. Bertha Mason’s potential violence and the danger that she poses to Jane Eyre and Rochester link madness to violence very explicitly. The incurability of madness and the cost of providing specialised care and attention leave little room for optimism. Finally, the madwoman does not speak for herself, in other words, she is not granted the gift of speech that is the natural attribute of human beings. All in all, Bertha Mason, the madwoman, compels no compassion in us.

In this article, I explore the role of fictional narrative in shaping our knowledge, understanding and feelings about madness. It is impossible to give an exhaustive review of published novels that deal with the subject of madness: those examined here are only a means of exemplifying particular issues.

The amplification of deviance

Physical difference

Fictional narrative achieves its aims by making its characters stand out. This technique of magnifying aspects of characters in a novel can involve the amplification of physical characteristics, or the exaggeration of mannerisms, behaviour, speech or experience. One of the reasons insanity is of interest to writers is that already existent in the image of insanity is the implicit difference from others. When this difference is amplified, the result can be grotesque or a parody of what insanity is actually like. Cervantes’ Don Quixote is a 17th-century example of amplification of the physical characteristics of a subject that is then associated with his ineptitude, unusual thinking and behaviour. Quixote’s ungainly appearance, his comical bearing, the ‘mouldy and rust-eaten’ suit of armour, which had been his great-great-grandfather’s, and his less than healthy horse help to compose an image of the fool whose behaviour is rendered more comical because of the picture we already have of him (Cervantes, 1999). It is noteworthy that, although Don Quixote’s madness is explicitly referred to in the book, the character is more in the line of the ‘holy fool’ described by Erasmus in the 16th century (Erasmus, 1971 reprint). This method of amplifying physical characteristics is also used in Jane Eyre. Bertha Mason is the face of madness and she is described as follows:

‘Fearful and ghastly to me oh sir, I never saw a face like it! It was a discoloured face – it was a savage face. I wish I could forget the roll of red eyes and the fearful blackened inflation of the lineaments! … [It] was purple: the lips were swelled and dark; the brow furrowed; the black eye-brows widely raised over the blood-shot eyes, shall I tell you what it reminded me? … of the foul German spectre and the Vampyre … what it was, whether beast or human being, one could not, at first sight, tell: it grovelled, seemingly on all fours; it snatched and growled like some strange wild animal’ (Bronte, 1996 reprint: p. 317).

The association of the idea of madness with savagery and the less than human is clear. Thus, madness can be either comical or terrifying.

In Patrick McGrath’s novel Spider, the protagonist’s difference is symbolised by what he wears:

‘I am wearing all my shirts and on top of them a black polo-neck jersey, and on top of that the jacket of my shabby grey suit. Suit trousers, thick grey socks (2 pairs), and a large pair of thick-soled black leather shoes with 10 close-set lace shoes … I also have strips of brown wrapping paper and thin cardboard taped to my legs and torso, which crackle when I move’ (McGrath, 1990: p. 151).

The protagonist dressed in this way in an attempt to prevent prevent people from smelling the gas that he believed was seeping from his person.

However, the expected difference can itself be explored in such a way that madness can be made to inhabit an individual who shows no obvious stigmata, or at least the question can be asked whether any such stigmata exist. For example, the protagonist asks in Janet Frame’s autobiographical novel Faces in the Water: ‘I wondered if I had any distinguishing marks of madness about me?’ (Frame, 1980: p. 58). Also, in V. S. Naipaul’s novel A House for Mr Biswas, Mr Biswas is not wild or violent, he makes no speeches and does not pretend to be driving a motor-car or picking cocoa, the two actions popularly associated with insanity. In this depiction of madness, he only looks exasperated and fatigued (Naipaul, 1961).

Psychological difference

Physical difference is only one aspect of the expected difference. Psychological difference is another. Here it is the bizarre and unusual thinking processes that are paramount. Patrick McGrath’s two novels Asylum and Spider trade in this currency. In Asylum(1996) he explores the nature and consequences of jealousy, and in Spider(1990) among other things he examines the way that psychotic experience interferes with how the world is perceived. Asylum is as much about the social organisation of the asylum as it is an examination of sexual jealousy. As McGrath has commented, the story is a variation on Tolstoy’s Anna Karenina: a psychiatrist’s spouse has an affair with a patient, a transgression of social mores within a total institution (McGrath, 2002). As a study of morbid jealousy it succeeds. McGrath draws attention to the fact that delusional jealousy is justified by the production of trivial everyday occurrences as evidence:

‘a flushing toilet, a stain on the floor, the placement of a box of washing powder on a window-sill’ (McGrath, 1996: p. 8).

Furthermore, the narrative voice comments:

‘driven by morbid processes to suppose that his wife was betraying him with another man, he had reasoned first, that they must have ways of signalling their arrangements, and second, that their activities must leave traces. He had then manufactured evidence of such signals and traces from incidents as banal as her opening a window as a motorbike was going past in the street below, and from phenomena as insignificant as a crease in a pillow or a stain on a skirt’ (pp. 40–41).

Although the narrative in Asylum is compelling, it is in Spider that McGrath achieves his best effect. He manages to describe the world through the eyes of the protagonist, Spider, and the reader is taken in by the account. Spider’s conviction of the reality of his beliefs and psychotic experiences convinces the reader too. Authorial coherence authenticates the narrative and makes Spider’s account believable. It is true that Spider’s world is never entirely explicable but none the less it has the compelling force of reality. It is a study of the architecture of psychotic experience. The struts and girders upon which illusions, hallucinations and delusions are built are exposed. It is also a study of the mundane everyday life of an individual with chronic psychosis living in the community.

Perhaps the most impressive description of psychopathology relates to the experience of nihilistic delusions:

‘I was contaminated by it, it shrivelled me, it killed something inside me, made me a ghost, a dead thing, in short it turned me bad’ (McGrath, 1990: p. 97).

‘… for I am almost empty now, the foul taste in my mouth attests to this, and of course the smell of gas, and I wonder … what they will find when they cut me open (if I’m not dead)? An anatomical monstrosity, surely: my intestine is wrapped tightly around the lower part of my spine and ascends in a taut snug spiral, thickening grossly into the colon about half-way up, which twists around my upper spine like a boa constrictor, the rectum passing through my skull and the anus issuing from the top of my head where an opening has been created between the bones joining the top of my skull, which I constantly finger in wondering horror, a sort of mature excretory fontanelle.

‘… a single thin pipe takes water from my stomach … and this pipe alone drops through the void and connects to the thing between my legs that hardly resembles a formed male organ at all anymore’ (pp. 175–176).

What is remarkable is the accuracy of the psychopathology, and the question is whether McGrath could have achieved an insider’s feel for madness without close study, as a child growing up in Broadmoor (where his father was the medical superintendent), of those around him – in other words, whether creative imagination alone can make the psychoses comprehensible. It is likely that personal experience of psychopathology or close contact with individuals who have it make for a more true-to-life characterisation of mental illness.

Gogol’s Diary of a Madman, first published in 1834, describes the gradual mental disintegration of the narrator. The psychological deviance described is even more remarkable because we witness, as it were, the onset and steady progression of the decline. The diarist announces:

‘quite recently I’ve started hearing and seeing things I’d never heard or seen before’ (Gogol, 1972 English reprint: pp. 19–20).

Soon he becomes convinced that he is the King of Spain:

‘there is a King of Spain. He has been found at last. That king is me. I only discovered this today … I cannot understand how I could even think or imagine for one moment I was only a titular councillor’ (pp. 33–34).

There are examples of neologisms: ‘86^th Martober’ (p. 34), ‘Madrid, 30^th Februarius’ (p. 37). Once the primary delusion is established, the development of secondary delusions begins. For example, the diarist’s explanation of his detention and transportation to an asylum is as follows:

‘so I’m in Spain now, and it was all so quick I hardly knew what was happening. This morning the Spanish deputation arrived and I got into a carriage with them…. We went at such a cracking pace we were at the Spanish frontier within half an hour’ (p. 37).

He adds

‘a strange country Spain: in the first room I entered there were a lot of people with shaven heads’ (pp. 37–38).

Despite how he is treated, his primary delusion remains fixed and organises his subsequent beliefs:

‘Up to this time Spain had been somewhat of a mystery to me. Their native customs and court etiquette are really most peculiar. I don’t understand, I really do not understand them … I think I’m safe in hazarding a guess that I’ve fallen into the hands of the Inquisition, and the person I thought was a minister of state was really the Grand Inquisitor himself. But I still don’t understand how kings can be subjected to the Inquisition’ (p. 39).

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. However, 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.

Violence

Violence is linked to madness in the minds of the laity. Partly, this link is reinforced by literature. Often the theme of jealousy is the device that makes the violence comprehensible. In The Kreutzer Sonata, published in 1889, Tolstoy explores the nature of marriage in Russian society using his own marriage as a model. His wife, Sonya, was reportedly hurt that Tolstoy’s attack on marriage was based on private details of their own relationship. In the novel, through his narrator, he describes the end of affection, how

‘sometimes I’d watch the way she poured her tea, the way she swung her leg or brought her spoon to her mouth; I’d listen to the little slurping noises she made as she sucked the liquid in and I used to hate her for that as for the most heinous crime’ (Tolstoy, 1983 English reprint: p. 74).

Tolstoy also describes the development of the jealousy of the narrator when his wife took on a new piano teacher. The account of the misinterpretation of trivial events and the imaginary changes in his wife bring to life the emotional basis and the illogical reasoning characteristic of jealousy. For example,

‘a lewd electric current which seemed to give their faces the same expression, the same gaze, the smile. Whenever she blushed or smiled, so did he’ (p. 86).

The narrator continues,

‘What was really so horrible was that I felt I had a complete and inalienable right to her body, as if it were my own, yet at the same time I felt that I wasn’t the master of this body, that it did not belong to me, that she could do with it whatever she pleased, and that what she wanted to do with it wasn’t what I wanted’ (p. 105).

So, it is clear that sexual jealousy is at least linked to the belief in proprietary rights over the spouse’s body. In the end the narrator kills his wife:

‘it was only when I saw her dead face that I realised what I’d done. I realised that I’d killed her, that it was all my doing that from a warm, moving, living creature she’d been transformed into a cold, immobile waxen one, and that there was no setting to rights, not ever, not anywhere, not by any means’ (p. 118).

This association between madness and violence can, of course, refer to violence against the self. In Mario Vargos Llosa’s novels In Praise of the Stepmother (first published 1988) and The Notebooks of Don Rigoberto (first published 1997), it is the damage to family life that is evident. These novels are about sexual preoccupation, and fantasies are interesting enough from that viewpoint. But it is the ritualistic routines of Don Rigoberto, an obsessiveness not often met in novels, that is likely to be of most interest to psychiatrists:

‘His ears were large and prominent; … as a child he was ashamed of their size and their downturned form, he had learnt to accept them. And now that he devoted one night a week to their care alone, he even felt proud of them … He was removing the piliform excrescences from his right ear. All of sudden he spied a stranger: the solitary little hair was swaying back and forth, disgustingly, in the centre of his neatly turned earlobe. He pulled it out with a slight jerk, and before throwing it into the washbasin to be flushed down the drain, he examined it with distaste’ (Vargos Llosa, 1998 reprint: pp. 23–26).

Out of sight

In Jane Eyre, Bertha Mason is locked away in the attic and supervised by Mrs Poole. The locking away in secrecy speaks partly to the shamefulness of having madness in the family. Unlike Bertha Mason, most people at that time (the mid-19th century) would have been detained in asylums. Robert Musil, writing in Vienna in the interwar years, in his 1931 novel The Man without Qualities describes the sight of an asylum:

‘In this new ward a series of horrible apparitions crouched and sat in their beds, everything about their bodies crooked, unclean, twisted or paralysed. Decayed teeth. Waggling heads. Heads too big, too small, totally misshapen. Slack, drooping jaws from which saliva was dribbling, without food or words. Yard-wide leaden barriers seemed to lie between these souls and the world’ (Musil, 1931; 1995 English reprint: p. 1068).

He then likens an asylum to hell:

‘Hell is not interesting, it is terrifying … It is precisely the bare idea of an unimaginable and thereby inescapable everlasting punishment and agony, the premise of an inexorable change for the worse, impervious to any attempt to reverse it, that has the fascination of an abyss. Insane asylums are also like that. They are poorhouses. They have something of hell’s lack of imagination’ (p. 1070).

Musil was writing in the period before the Second World War, and the kind of asylum that he describes, a total institution with thousands of beds, is probably a thing of the past in most Western countries. However, the conditions within psychiatric hospitals and nursing homes may not have changed much since then.

The autobiographical novels The Bell Jar by Sylvia Plath (1963) and Faces in the Water by Janet Frame (1980) tackle the experience of institutional care. Plath, who herself suffered from depression and eventually killed herself, set her account in a private asylum in the USA, whereas Frame’s account is set in two asylums in New Zealand. Both deal with how a patient experiences the use of electroconvulsive treatment (ECT) in the period when unmodified ECT was routinely administered. Plath describes it as follows:

‘then something bent down and took hold of me and shook me like the end of the world. Whee-ee-ee-ee-ee, it shrilled, through an air crackling with blue light, and with each flash a great jolt drubbed me till I thought my bones would break and the sap fly out of me like a split plant’ (Plath, 1963: p. 151).

Following ECT,

‘all the heat and fear had purged itself. I felt surprisingly at peace. The bell jar hung, suspended, a few feet above my head. I was open to the circulating air’ (p. 227).

Frame’s account likens ECT to death in the electric chair:

‘we know the rumours attached to EST [sic] – it is training for Sing Sing when we are at last convicted of murder and sentenced to death and sit strapped in the electric chair with the electrodes touching our skin through slits in our clothing; our hair is singed as we die and the last smell in our nostrils is the smell of ourselves burning. And the fear leads some patients to more madness’ (Frame, 1980: p. 23).

These accounts of ECT are written for literary effect, yet despite this the ideas and feelings that they transmit are important. As psychiatrists, it may be that we underestimate the fear and awe with which patients approach ECT. Familiarity with the treatment may be said to have bred in us not so much contempt as indifference.

Both Plath and Frame describe the implications of having been in an asylum. For example, Plath says ‘a lot of people would treat me gingerly, or even avoid me, like a leper with a warning bell’ (Plath, 1963: p. 249) and furthermore she has one of her characters say ‘I wonder whom you’ll marry now, Esther. Now you’ve been in here’ (p. 254). Frame’s account documents the impact of institutionalisation: how the unkemptness of the old men

‘showed from within, beyond the shabby appearance of their braces hitching their pants anyhow, their unbuttoned flies, their flannel shirts bunched out, hanging loose’ (Frame, 1980: p. 50).

How there were patients who had

‘long ago given up attempts at speech and now made noises appropriate to their habitat: animal noises, whimpers; sometimes they bayed and howled like lonely dogs attending the moon’ (p. 92).

How easy it was to lose social graces because of the conditions of the wards and how, for example, the narrator would wet herself if she were refused permission to go to the lavatory. The particular hopelessness of the men is described as follows:

‘I once looked through at the men prowling unshaven in their tattered outlaw clothes, and I could not forget their hopelessness; it seemed deeper than that of the women, for all the masculine power and pride were lost and some of the men were weeping and in our civilisation it seems that only a final terrible grief can reduce a man to tears’ (p. 170).

However, the despair and the forlorn air described in these accounts is balanced by McGrath’s account of how dignity and communion are maintained:

‘Even when a man has nothing to call his own he finds ways of acquiring possessions; he then finds ways of concealing his possessions from the attendants. What you did on a hard-bench ward was tie one end of a piece of string to a belt-loop, and the other end to the top of a sock, then have the sock dangle down inside of your trousers. In it you kept tobacco, sewing materials, pencil and paper, other bits of string - whatever you had that was of use or value’ (McGrath, 1996: p. 164).

And,

‘no matter how deep a man may be sunk in his own melancholy, his own madness – adrift, you’d think, all lines to the social body cut – yet he’d never fail to give you his butt to light your own with, there is no madness, so deep that it excludes you from the community of tobacco’ [my italics] (p. 140).

It may be that McGrath’s different and more optimistic perspective, compared with Plath and Frame, is attributable to the fact he was never a patient in an asylum. Rather, he lived in one as a child and worked in another in adulthood, as a nursing assistant.

Asylum life was regulated by nurses and dictated by doctors. The relationship of patients to nurses and doctors respectively therefore forms a significant part of the accounts of the nature of the rhythm and life in asylums. The rare sighting of doctors on the wards and the precious little time that they had for patients are all well captured by Frame (1980):

‘the doctor would pause sometimes to inquire, smiling in a friendly manner, but at the same time glancing hastily at his watch and perhaps wondering how in the hour before lunch he could possibly finish his rounds of all the women’s wards and get back to his office to deal with correspondence and interviews with demanding puzzled alarmed ashamed relatives’ (p. 28).

As for nurses, because they were overworked they had become ‘sadistic custodians’ (p. 98) and were ‘most of the time without compassion’ (p. 106) and harassed and reluctant carers. Frame’s account is set in New Zealand between the First and Second World Wars, yet the pressures on the wards have a contemporary feel. What one hopes is that the indifference, ruthlessness and sadism are things of the past.

Frame also describes how it feels not to be consulted about her treatment and likely fate. She writes:

‘I felt remote from the arrangements being made for me; as if I were lying on my death bed watching the invasion of my house and the disposal of my treasures and glimpsing through the half-open door into the adjoining room the waiting coffin’ (Frame, 1980: p. 216).

Yet, the plans concern lobotomy and the thought of the operation becomes for her a nightmare:

‘today they will seize me, shave my head, dope me, send me to the hospital in the city, and when I open my eyes … the thieves wearing gloves and with permission and delicacy, have entered and politely ransacked the storehouse and departed calm and unembarrassed’ (p. 216).

This account emphasises the tremendous authority and power that we, as doctors, have in relation to patients and their treatment. And how passive and uninvolved the patient may feel, and how inevitable they may see the treatment regimens.

The gift of speech

Bertha Mason did not utter any intelligible speech in Jane Eyre. It took Jean Rhys’s (1966) novel The Wide Sargasso Sea to give her voice. Bertha Mason derived from a Creole Caribbean family, and Rhys’s novel is set in the West Indies and drew on the author’s understanding of the position of planter families following the Emancipation. In Rhys’s novel, Bertha Mason emerges as a woman, a person, with motivation and life goals within the strictures of a woman’s life in the West Indies and England of the 19th century. Although this is a fictional account, it undercuts the impression created inJane Eyre that madness is inextricably linked to a lack of logical and comprehensible motivation. The Bertha Mason in The Wide Sargasso Sea compels our compassion and understanding. It is Rochester whose motivation and behaviour are less than honourable.

Both Edward Said (1993) and Chinua Achebe (1988) have drawn our attention to the fact that literature tells us as much by what it is written as it does by what is taken for granted or left out. So, for example, in Conrad’s Heart of Darkness, published in 1899, the African viewpoint is unrepresented, so that, indirectly, the humanity of the African population is denied, simply by being denied a voice in the narrative. The same sort of thing seems to be the case in Jane Eyre. Although it could be argued that it is accidental that Bertha Mason is a Creole woman, this is unlikely to be the case. It is more likely that her being alien to England makes her alienation, her madness, more acceptable. It is as if Brontë were saying, ‘Having resided in foreign and hot climes such as the Caribbean, it is no wonder that Bertha Mason is mad!’ Feminist readings of Jane Eyre emphasise the fact that it is the patriarchal arrangements of the 19th-century English that explain Bertha Mason’s madness. So, for example, in 1979 Gilbert & Gubar argued that

‘the problems encountered by the protagonist as she struggles from the imprisonment of her childhood toward an almost unthinkable goal of mature freedom are symptomatic of difficulties Everywoman in a patriarchal society must meet and overcome: oppression (at Gateshead), starvation (at Lowood), madness (at Thornfield), and coldness (at Marsh End)’ (Gilbert & Gubar, 1984 reprint: p. 339).

This line of reasoning usually supports its thesis by pointing to narratives such as C. P. Gilman’s 1899 novel The Yellow Wallpaper to validate its case. Gilman explains that she wrote the book against the advice of her psychiatrist, the famous S. Weir Mitchell, that she ‘live as domestic a life as far as possible’. In opposition to him, Gilman went to work on the novella, a narrative based on her own experience of mental illness, because work is ‘the normal life of every human being’ and without it ‘one is a pauper and a parasite’ ( Gilman, 1998 reprint). In her novel Gilman describes the progression to puerperal psychosis. It is undeniable that the structures of patriarchal society deny women freedom and economic autonomy. How far these structures are responsible for psychosis is a moot point.

Conclusions

Beveridge (2003) has examined the arguments in favour of reading literature. He highlights how literature allows psychiatrists to engage imaginatively with the lives and inner worlds of a larger number of individuals, albeit fictional individuals; how a bioscientific model offers a limited and indeed an impoverished description of human life; and how literature may at least aid our empathic and ethical capacity. He also draws attention to the fact that literature is not written with clinical application in mind. What is obvious is that madness and abnormal human experience and behaviour are of great interest to writers. Whether psychiatrists read these fictional accounts or not, the accounts will undoubtedly influence how wider society perceives mental illness, how they react to it and, ultimately, how governments respond by way of policy. Novels are revealing insofar as what is implicit in them, the unexplained and unexamined context, tells us something about the assumptions that cultures make about mental illness. Fictional literature is an attempt to create and reflect, using the imagination, the world we as psychiatrists know well. It gives us the opportunity to stand back from that world, to contemplate it, before once again immersing ourselves in it, for better or worse.