The Bell Jar: Sylvia Plath's first-person narrative of core elements for diagnosing and treating clinical depression

Summary

The Bell Jar (1963) is a semi-autobiographical novel written by the confessional poet, novelist and short-story writer Sylvia Plath (1932–1963). It has been often cited as a recommended reading within the medical humanities, because of its powerful description of depression and the understanding-by-experience of the related psychiatric treatments. This brief article, primarily directed at the clinically oriented reader, presents a selection of excerpts from The Bell Jar to illustrate the main diagnostic features of clinical depression and the vital role of therapeutic relationship quality in hindering or facilitating treatment outcomes and recovery.

Sylvia Plath (b. 27 October 1932, Boston, USA; d. 11 February 1963, London, UK) has been acclaimed as one of the greatest poets of all time (Elinzano 2015) and one of the best-known female poets of the 20th century (Schmidt 2006). Plath's poems make a major contribution to the school of ‘confessional poetry’, which redefined American poetry in the 1950s and 1960s by highlighting extreme moments of individual experience such as mental illness and suicide. Although other winners of the Pulitzer Prize for Poetry also stand as major icons of that literary movement (e.g. Robert Lowell, 1917–1977; Anne Sexton, 1928–1974), Plath's poetry is uniquely confessional in its own genre by sharply and charmingly constructing literary depictions of nature, love, isolation, death and self-destruction that have resonated with many readers since the 1960s (Schmidt 2006). To tentatively illustrate this, we carried out an ad hoc word search in a PDF version of The Bell Jar (Plath 1963), revealing that the terms ‘life’ (35 quotes), ‘love’ (20 quotes), ‘death’ (17 quotes) and ‘queer[er/ly]’ (in the sense of ‘strange, weird’, 13 quotes) were regularly used.

Plath achieved worldwide recognition after her tragic suicide, and particularly after the posthumous publication of Ariel (Plath 1965), a collection of poems written during the last months of her life. Plath was posthumously awarded the Pulitzer Prize for Poetry in 1982, but one of her major works and most influential books, The Bell Jar (Plath 1963), is a semi-autobiographical novel that was published less than 1 month before her death. Originally published under the pseudonym of ‘Victoria Lucas’, The Bell Jar narrates the struggles with issues of identity and societal expectations of 19-year-old Esther Greenwood, the severe depressive disorder she experiences and the initial path of her recovery.

The Bell Jar provides a powerful and vivid description of depression (possibly with psychotic features) and its psychobiological manifestations, while accounting for common predisposing (e.g. a sense of emotional deprivation and detachment) and precipitating factors (e.g. adverse life events, such as being sexually assaulted at a party and, shortly after, failing to gain a longed-for place on a summer writing course) in case formulation of depressive disorders. The Bell Jar has been frequently revisited in the general context of the medical humanities as a means of illustrating the clinical phenomenology of depression (Brennand 2015), questioning the applicability of electrochemical procedures (Taylor 2018) or highlighting the portrayal of stigmatised psychiatric wards as spaces for effective personal change (McClure 2007).

Given its realistic description of depression and the understanding-by-experience of the related psychiatric treatments, The Bell Jar easily resonates with those who have been affected by the condition and enlightens those who have not; in any case, it ends up offering some hope that, regardless of depression severity, recovery is possible (Marcarian 2017). In this brief article, we present selected critical excerpts from The Bell Jar to illustrate the main diagnostic features of clinical depression (i.e. major depressive episode, as described in DSM-5; American Psychiatric Association 2022), as well as the vital role of therapeutic relationship quality in hindering or facilitating treatment outcomes and recovery. By using a strong metaphor to review the experience of having gone through (‘To the person in the bell jar, blank and stopped as a dead baby, the world itself is the bad dream’; Plath 1963: p. 209)^a and overcome (‘cracking the bell jar’; Brennand 2015) a severe depressive disorder, The Bell Jar also reminds mental health professionals that accurate empathy and shared intentionality are necessary for creative reflection to occur (Smith 2012). Therefore, through a selection of direct quotations from the novel, this article ultimately aims to invite mental health clinicians to read the full-text book of The Bell Jar as part of their continuing professional development.

Diagnostic features of clinical depression

The following excerpts from The Bell Jar (Plath 1963) were selected to depict how the contemporary DSM-5 diagnostic criteria of major depressive episode (American Psychiatric Association 2022) can be intuitively recognised in the narrative by the clinically informed reader.

Depressed mood (dysphoria)

‘The silence depressed me. It wasn't the silence of silence. It was my own silence.’ (p. 23)

‘I didn't know why I was going to cry, but I knew that if anybody spoke to me or looked at me too closely the tears would fly out of my eyes and the sobs would fly out of my throat and I'd cry for a week. I could feel the tears brimming and sloshing in me like water in a glass that is unsteady and too full.’ (p. 93)

Loss of interest or pleasure (anhedonia)

‘I felt very still and very empty, the way the eye of a tornado must feel, moving dully along in the middle of the surrounding hullabaloo.’ (p. 10)

‘I crawled back into bed and pulled the sheet over my head. But even that didn't shut out the light, so I buried my head under the darkness of the pillow and pretended it was night. I couldn't see the point of getting up. I had nothing to look forward to.’ (p. 107)

Weight loss or gain

‘[ … ] why I couldn't sleep [insomnia; see below] and why I couldn't read [decreased concentration] and why I couldn't eat [loss of appetite] and why everything people did seemed so silly, because they only died in the end.’ (p. 162)

Insomnia or hypersomnia

‘I feigned sleep until my mother left for school [to work], but even my eyelids didn't shut out the light. They hung the raw, red screen of their tiny vessels in front of me like a wound. I crawled between the mattress and the padded bedstead and let the mattress fall across me like a tombstone. It felt dark and safe under there, but the mattress was not heavy enough. It needed about a ton more weight to make me sleep.’ (p. 112)

Psychomotor agitation or retardation

‘After nineteen years of running after good marks and prizes and grants of one sort or another, I was letting up, slowing down, dropping clean out of the race.’ (p. 32)

Fatigue or loss of energy

‘After Doreen left, I wondered why I couldn't go the whole way doing what I should any more. This made me sad and tired. Then I wondered why I couldn't go the whole way doing what I shouldn't, the way Doreen did, and this made me even sadder and more tired.’ (p. 33)

Feelings of worthlessness or excessive/inappropriate guilt

‘[ … ] I felt dreadfully inadequate. The trouble was, I had been inadequate all along, I simply hadn't thought about it.’ (p. 73)

Decreased concentration or indecisiveness

‘If neurotic is wanting two mutually exclusive things at one and the same time, then I'm neurotic as hell. I'll be flying back and forth between one mutually exclusive thing and another for the rest of my days.’ (p. 87)

‘Every time I tried to concentrate, my mind glided off, like a skater, into a large empty space, and pirouetted there, absently.’ (p. 131)

Recurrent thoughts of death/suicide

‘I thought drowning must be the kindest way to die, and burning the worst.’ (p. 141)

‘I thought I would swim out until I was too tired to swim back.’ (p. 142)

Treatment features

After reluctantly accepting professional help, Esther is first referred to Dr Gordon, ‘a sinister psychiatrist’ (p. 517), who makes her undergo a dreadful electric shock therapy (Perloff 1972). Later, she meets Dr Nolan, another psychiatrist, who is ‘the only woman whom Esther never longs to imitate or to resemble’ (p. 521), certainly because ‘she [Dr. Nolan] is the instrument whereby Esther learns to be, not some other woman, but herself’ (Perloff 1972). In this sense, The Bell Jar shows ‘how the responses of those in the caring professions can make a difference – how an experience of accurate empathy conveyed in a relatively short time can go a long way’ (Smith 2012). Accordingly, the following excerpts aim to highlight the crucial importance of sensitive and skilful clinical communication in building a solid and constructive therapeutic relationship.

Negative experiences in the therapeutic relationship

‘What did I think was wrong? That made it sound as if nothing was really wrong, I only thought it was wrong.’ (p. 118)

‘“Well, Esther, how do you feel this week?”

Doctor Gordon cradled his pencil like a slim, silver bullet.

“The same.”

“The same?” He quirked an eyebrow, as if he didn't believe it, so I told him again, in the same dull, flat voice, only it was angrier this time, because he seemed so slow to understand, how I hadn't slept for fourteen nights and how I couldn't read or write or swallow very well.

Doctor Gordon seemed unimpressed.’ (p. 122)

Positive experiences in the therapeutic relationship

‘I told Doctor Nolan about the machine, and the blue flashes, and the jolting and the noise. While I was telling her she went very still.

“That was a mistake,” she said then. “It's not supposed to be like that.’“

I stared at her.

“If it's done properly,” Doctor Nolan said, “it's like going to sleep.”

“If anyone does that to me again I'll kill myself.”

Doctor Nolan said firmly, “You won't have any shock treatments here. Or if you do,” she amended, “I'll tell you about it beforehand, and I promise you it won't be anything like what you had before. Why,” she finished, “some people even like them.”’ (p. 169)

Medical humanities, especially when applied to psychiatry, may sharpen the clinician's faculties of empathy and sensitivity, and enhance the awareness of their necessity. In fact, literature may be more effective than most scientific texts in conveying subjective experiences of cognition and emotion. Besides, it may illuminate ethical dimensions that often challenge mental health clinicians (Bolwig 2006). In this sense, Sylvia Plath's The Bell Jar surely has an indispensable and indisputable place amidst the so-called ‘medical classics’, particularly as regards medical psychiatry and psychotherapy.