Representations of hallucinations and dissociation in young adult literature: using literature to challenge stigma about psychosis

Abstract

This paper explores the role that sensitively portrayed literary representations of hallucinations and dissociation may have in counteracting stigma associated with these experiences. In it, we focus on narratives of young people experiencing hallucinatory and dissociative phenomena in two award-winning, young adult novels: How It Feels to Float by Helena Fox and A Monster Calls by Patrick Ness. We identify and discuss three literary devices in these two novels that promote empathy for the characters and their experiences. The narrative accounts in both novels challenge conceptions of hallucinations and dissociation as unknowable and unrelatable experiences with their empathic portrayals of relatable characters that create comprehensible accounts of adolescents grappling with their sense of reality. Importantly, they highlight the potential role that literature can play in stigma reduction by positively shaping young peoples’ understandings of unfamiliar mental health experiences.

‘The world is full of strange wonders, darling. Maybe you’re just lucky enough to see them.’

–Helena Fox, How it Feels to Float

Introduction

There is a celebrated tradition of young adult (YA) literature portraying characters dealing with mental health challenges, including the iconic works I Never Promised You a Rose Garden by Joanne Greenberg (1964) and Susanna Kaysen’s (1994) Girl, Interrupted. The genre of YA literature is increasingly being recognised for its capacity to educate, foster empathy and help young people navigate challenging life experiences (Hébert and Kent 2000; Santoli and Wagner 2004; Groenke et al. 2010; Ivey and Johnston 2015). Aware of these benefits, some researchers have highlighted the need to further explore how YA literature can contribute to young people’s engagement with mental health (Richmond 2014; de Leon 2017). This includes the potential role of literature in reducing stigma associated with mental health issues.

Stigma related to mental health disproportionately affects young people (Kaushik et al. 2016). People with psychosis or experiences associated with psychosis are at particularly high risk of stigma (Jenkins and Carpenter-Song 2008; Kaushik et al. 2016; Gronholm et al. 2017; Wood and Alsawy 2018). Studies have found that using art or fiction to bring people into contact with differing perspectives can lead to increased empathy and potentially reduce stigmatising beliefs (Chung and Slater 2013; Ho et al. 2017; Bentwich and Gilbey 2017). In this paper, we explore how compelling narratives about young people who experience hallucinations and dissociation have the potential to promote empathy thereby challenging stigma. Hallucinations are anomalous perceptual experiences where individuals see, hear, feel and/or sense things that are not real. Dissociation refers to a continuum of phenomena that are defined by DSM-5 as ‘a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behaviour’ (American Psychiatric Association, 2013). Both hallucinations and dissociation can occur in the context of or in the absence of psychotic disorders (Healy et al. 2019; Iudici et al. 2019; Longden et al. 2020).

Choice of novels

We chose two contemporary, award-winning YA fiction novels, How it Feels to Float by Helena Fox and A Monster Calls by Patrick Ness, as case study examples of how sensitively portrayed literary representations of hallucinations and dissociation can promote empathy and reduce stigma associated with these experiences. Both texts offer strikingly nuanced portrayals of adolescent protagonists who experience hallucinatory or dissociative phenomena in the context of trauma and grief. Helena Fox, author of How it Feels to Float, has lived experience of both complex PTSD and dissociative disorder.

Novel summaries

How it Feels to Float is a first-person fictional narrative told by the protagonist, Biz, a 17-year-old living in Wollongong, Australia. In the novel, Biz’s father died ten years previously but she still sees and speaks to an apparition of her father who visits her in her room. As Biz navigates troubles at school and new friendships, she struggles to hold on to her sense of reality, experiencing panic attacks, auditory hallucinations, and dissociative episodes while trying to make sense of her traumatic past.

A Monster Calls is a third-person narrative of Conor O’Malley, a 13-year-old boy living in present-day England. Conor’s mother has cancer. Since her diagnosis he has been tormented by a recurring nightmare while facing isolation and bullying at school. One night Conor is visited by a monster in the form of a yew tree. The monster visits Conor multiple times, tells him three allegorical stories and then asks Conor to reveal a related truth that he has suppressed. That truth is symbolised in his recurrent nightmare. As Conor struggles to understand the usefulness of stories and questions the reality of the monster itself, he finds himself healing in ways he never thought possible.

Both novels concern childhood and adolescent confrontations with the death of a parent. Both tell the story of the social isolation and peer relationship difficulties that can result from such experiences. From A Monster Calls,

‘And so he waited by himself, leaning against a stone wall away from the other kids as they squealed and laughed and looked at their phones as if nothing in the world was wrong, as if nothing in the whole entire universe could ever happen to them.’ (Ness 2015, p.146)

In both, the young protagonists experience episodes of dissociation in the context of their personally held and internalised trauma. Both also experience anomalous visual phenomena. Biz sees her dead father.

‘And there was dad, floating, all hopeful on the end of the bed, looking at mum. But when she turned, I guess she only saw air. “Shhh, dad’s not here[…]”’ (Fox 2019, p.135)

Conor sees a monster carved from a yew tree.

‘Who am I? the monster repeated, still roaring. I am the spine that the mountains hang upon! I am the tears that the rivers cry! I am the lungs that breathe the wind! I am the wolf that kills the stag, the hawk that kills the mouse, the spider that kills the fly! I am the stag, the mouse and the fly that are eaten! […] I am everything untamed and untameable! […] I am this wild earth, come for you, Conor O’Malley. “You look like a tree,” Conor said.’ (Ness 2015, p. 44, italics in the original)

Literary devices that promote empathy and counteract stigma

We focus on three important literary devices in these novels that promote empathy for the protagonists: 1) emphasising similarity; 2) contextualising emotions; and 3) embracing ambiguity and contradiction. These devices act as a means of challenging stigma associated with hallucinatory and dissociative experiences. Emphasising similarity is a literary strategy shared by both novels where reader and protagonist similarities are emphasised, serving as a foundation from which each novel delves into their protagonist’s unique experience. Contextualising emotions and embracing ambiguity and contradiction were identified as the main devices in each text that encouraged understanding around the protagonists’ experiences. Each device is discussed below.

Emphasising similarity

Emphasising similarity is a device used in both novels. Both consistently present similarities between the protagonists and readers, starting with protagonists who are the same age as each novel’s target audience. Biz and Conor also speak like regular teenagers, using colloquial language and everyday references that young readers would be familiar with (e.g. Netflix, YouTube, and using emojis when texting).

‘Emoji of a heart, emoji of a heart, emoji of a heart. The whole conversation is over in a couple of minutes. I put down my phone and look over at Jasper.’ (Fox 2019, p.289)

The protagonists also struggle with similar problems to many adolescents, including schoolwork, friendships, bullying and sexuality. When discussing a new assignment given to her class, Biz participates in the ‘collective groan’ and uses first person plural pronouns that include herself in the group:

‘A collective groan from all of us.[…]We hunker down to do the assignment. That is, some of us do the assignment; some of us daydream.’ (Fox 2019, p.14)

In A Monster Calls, Conor is the victim of persistent bullying at school. His anger with all he is experiencing is captured in an exchange with his friend Lily, when she gets detention after coming to his defence when he was being bullied.

‘"I’ve got detention all week,” Lily said. “And a note home to my parents.”

“That’s not my problem.”

“But it’s your fault.”

Conor stopped suddenly and turned to her. He looked so angry she stepped back, startled, almost like she was afraid. “It’s your fault,” he said. “It’s all your fault.”

He stormed off back down the pavement. “We used to be friends,” Lily called after him.

“Used to be,” Conor said without turning around.’ (Ness 2015, p. 41-42, italics in the original)

This highlights another crucial similarity that is centred on the protagonists’ relationships. Like many readers, Biz and Conor have complex relationships; they fall out with old friends, form new friendships, and have a loving but at-times fraught relationship with their parents. For instance, even though Conor is angry at his friend Lily, he still registers her reaction to his outburst against his school bully:

‘Then they looked away […].Only Lily held his eyes for longer than a second, her face anxious and hurt.’ (Ness 2015, p.178)

Contextualising emotions: confronting trauma in How it Feels to Float

It is clear that the origin of Biz’s mental health struggles lies outside of her control. By placing her hallucinatory experiences and episodes of dissociation in the context of internal emotional upheaval resulting from trauma, readers may more readily understand Biz’s reaction to her circumstances. Furthermore, the use of evocative imagery gives life to this emotional experience, immersing the reader into Biz’s world so they can better relate to her reactions.

Trauma

Biz’s difficulties stem from her father’s death, which was itself a result of intergenerational trauma. Notably, Biz’s sometimes tenuous hold on reality is contextualised within her lived experience. When Biz’s sense of reality is shaken, it is preceded by an upsetting emotional experience:

‘Mum’s memory hits me so hard it’s difficult to breathe,’ (Fox 2019, p.147)…‘Who even is this woman standing here? What even is this room?’ (Fox 2019, p.152)

Conversely, moments of stability occur when Biz feels connected to others. For example, at one point when she is riding her friend’s motorbike with him:

‘And for a moment, everything felt real[…] Here is a curve; lean into it, Biz. Feel.’ (Fox 2019, p.205, italics in the original)

Evocative imagery

Biz has an impressive range of vocabulary, using words like ‘nano’, ‘urban sprawl’ and ‘revving’ (Fox 2019, p.7). Her diverse vocabulary contributes to the creation of a vivid narrative, while revealing her intelligence, sensitivity and rich inner world. Young readers are made aware of the extent to which Biz’s lived reality is permeated by an appreciation of the world around her. Further drawing the reader in, Biz constantly personalises and anthropomorphises her experience, imbuing her descriptions with sensory stimuli familiar to readers:

‘[…] it’s so hot the house feels like it’s melting. Cicadas scream through the windows.’ (Fox 2019, p.7)

Additionally, Fox’s frequent use of figurative language works towards bridging the gap between Biz’s unique experience and that of readers:

‘I walk home to my blue house with poetry inside me like a pulse.’ (Fox 2019, p.214)

The evocative imagery used throughout How it Feels to Float is often related to objects or scenarios easily recognisable to readers, such as when Biz describes resisting dissociation when she feels overwhelmingly happy during a day trip to the beach with her friend Jasper:

‘I don’t know what to say. I feel all the beauty and Jasper’s joy start to pull my feet off the ground. But I don’t want to float today. I want to be here […] The sand feels like a touch. It feels like my mother’s hand on my skin, cool against warm. It feels like talking at night. It feels like stories and it feels like being seen.’ (Fox 2019, p.225)

Embracing ambiguity and contradiction: resisting oneness in A Monster Calls

The frequent use of contradiction and ambiguity in A Monster Calls invites readers to resist the notion of a singular way of knowing and to question the very nature of reality. In A Monster Calls ambiguity and contradiction are central to Conor’s experience, starting with the debatable reality of Conor’s monster. Conor himself continuously questions if this monster is real, reflecting the reader’s own doubt around whether this is a fantasy story or a story about a boy experiencing a hallucination. This literary device is further developed when even the monster poses a question about the nature of reality.

‘But what is a dream, Conor O’Malley? the monster said, bending down so its face was close to Conor’s. Who is to say that it is not everything else that is the dream?’ (Ness 2015, p.48, italics and bold in the original)

It has been pointed out that Conor’s story could be understood as a case study of a young person experiencing a dissociative episode (Ghoshal and Wilkinson 2019). In fact, this ambivalence around the central premise of the novel contributes to the narrative’s insistence that reality is complex and multifaceted. In turn, by accepting that reality is multiform this opens the way for people with ordinary experiences to recognise Conor’s alternative experience as meaningful.

Ambiguity

The stories told by Conor’s monster are presented in a traditional fairy-tale style that is presently subverted. The monster itself is an ambiguous character who is at times scary then comforting, and whose heterogeneous portrayal challenges the traditional stereotype of monsters as ‘bad’. Similarly, while fairy tales conventionally have straightforward ‘good’ and ‘bad’ characters, the characters in the monster’s stories are perplexing. In the first of three stories the monster tells, the ‘good’ prince commits a terrible crime while the ‘bad’ witch needs to be saved. Conor’s confusion is evident:

‘I don’t understand. Who’s the good guy here?’ (Ness 2015, p.84),

while his confusion soon turns to anger at the unpredictability of the stories:

‘Is it a cheating story?[…]Does it sound like it’s going to be one way and then it’s a total other way?’ (Ness 2015, pp.123-124)

In response, the monster reiterates to Conor that his stories, much like real life, illustrate a complexity beyond the dichotomy of good and bad:

‘There is not always a good guy. Nor is there always a bad one. Most people are somewhere in-between. Conor shook his head. ‘That’s a terrible story. And a cheat’. It is a true story, the monster said. Many things that are true feel like a cheat. Kingdoms get the princes they deserve, farmers’ daughters die for no reason, and sometimes witches merit saving. Quite often, actually. You’d be surprised.’ (Ness 2015, p.84, italics and bold in the original)

Contradiction

Ambiguity is further stressed in the way that the novel repeatedly draws attention to contradictions and multiplicity. The monster tells Conor ‘I have had as many names as there are years to time itself!’ (Ness 2015, p.50), while statements throughout the narrative are laden with contradictions: ‘looking totally different but exactly the same’ (Ness 2015, p.110); ‘invisible weight pressing down on him’ (Ness 2015, p.210); ‘and I believed her. Except I didn’t,’ (Ness 2015, p.221).

The monster addresses the prevalence of contradiction when he tells Conor:

‘Your mind will contradict itself a hundred times each day[…]Your mind will believe comforting lies while also knowing the painful truths that make those lies necessary. And your mind will punish you for believing both.’ (Ness 2015, p.224, italics in the original)

Crucially, living with contradictory feelings and the tension they generate is presented as a defining feature of life. As discussed below, fostering a greater tolerance of ambiguity in readers through accepting contradiction may contribute to empathy and reduce stigma.

Discussion

Literary devices, such as those we have highlighted in this paper, have the potential to challenge stigma by providing sensitive and relatable insights into the often-stigmatised experiences of hallucinations and dissociation. Considering the three devices we identified in the context of empirical evidence provides further support for this perspective. We do this with an acknowledgement that the two novels we explored here were written within specific cultural contexts and recognising the need for young people globally to have access to narratives written and embedded within different cultures (Stewart and Ames 2014).

Emphasising similarity

Our observation of similarities between protagonists and the target audience is consistent with existing research where identification has been conceptualised as a way of combating discrimination against stigmatised groups (Chung and Slater 2013; Vezzali et al. 2015; Ferchaud et al. 2020). For example, understanding psychosis as existing on a continuum of shared human experience has been associated with prosocial attitudes and less desire for social distance (Schomerus et al. 2013; Peter et al. 2021). With regard to young people, presenting characters of a similar age to readers increases identification, leading young people to express greater empathy towards people experiencing emotional or mental distress (Secker et al. 1999). Young people are also less likely to use negative descriptions when others’ behaviour is understood in terms of their own personal experience (Secker et al. 1999; Schulze et al. 2003). The act itself of perspective-taking has been shown to increase empathy (Batson et al. 2007; Stietz et al. 2019). In fact, the degree to which adolescents identify with a target outgroup may modulate empathy’s effect on improving mental health-related stigmatising attitudes (Vescio et al. 2003). Therefore, encouraging identification with the protagonists in these texts, who are part of an outgroup, may increase empathy and reduce stigma. Additionally, they offer relatable accounts of dissociation and hallucinations as normative responses to traumatic loss, bullying and exclusion (Martindale 2007; Longden et al. 2012; Coughlan and Cannon 2017). In this context, the importance of developing anti-stigma mental health education focused on relatable stories and a shared humanity cannot be underestimated.

Accentuating similarities could simultaneously benefit young people experiencing mental health issues. In interviews with young people who hear voices they reveal that ‘the perceived “normality” of others in contrast to the perceived “difference” of the self was a source of anxiety’ for them (Parry et al. 2020). Young people have also expressed greater distress around feeling ‘abnormal’ than around experiences of hallucinations and/or delusions in themselves (Coughlan et al. 2022). Meanwhile, a recent study highlighted how young people repeatedly attempted to make sense of their experiences of hallucinations or unusual thoughts or beliefs by using culturally acceptable frameworks (Coughlan et al. 2020). Moreover, young people who hear voices have expressed a wish for treatment approaches focused on normalising and destigmatising (Newton et al. 2007; Kapur et al. 2014). Recent research calling for a broader biopsychosocial framework within which to conceptualise experiences of psychosis echoes this push towards a more holistic understanding of these phenomena (Kelleher and Cannon 2021). Thus, the narrative accounts examined in this study have the potential to both normalise these phenomena for other young people who experience them and to humanise such experiences for young people who don’t.

Contextualising emotions

In How it Feels to Float, Biz’s narrative challenges the widely accepted belief that it is not possible to understand someone experiencing hallucinations, delusions or dissociation (Jaspers 1963; Walker 1991; Kiran and Chaudhury 2009). Vivid descriptions of emotional upheaval infuse the narrative effectively bringing the reader into Biz’s inner world and rendering it more familiar.

It has been shown that increased familiarity and personal experience reduce stigmatising attitudes towards people with mental health difficulties (Link and Cullen 1986; Corrigan et al. 2001; Pinfold et al. 2003; Angermeyer et al. 2004; Morgan et al. 2018). Further, researchers have found that parasocial contact, referring to the psychological relationship created in the interaction between media users and mass media representations, can reduce stigma towards minority groups (Giles 2002; Schiappa et al. 2005). With regard to mental health, studies found that exposure to filmed social contact reduced stigma similarly to in-person contact (Clement et al. 2012; Koike et al. 2018). Correspondingly, engaging with a work of fiction is a form of parasocial contact (Schiappa et al. 2007). Fiction can be understood as a simulation of the world (Mar and Oatley 2008), where readers come into contact and empathise with characters, which may have an effect on how readers act (Mar et al. 2009). Biz’s engrossing descriptions allow readers to identify with certain aspects of her inner world, making her foreign experiences of hallucinations and dissociation more understandable since they are happening to someone the reader has already related to. This envelopment into the narrative world promotes perspective-taking on behalf of readers, which is crucial to reduce outgroup perceptions allowing for greater social acceptance (Chung and Slater 2013).

Children’s beliefs about causes of mental health difficulties influence their attitudes and behaviour towards children with mental health struggles (Juvonen 1991; Giles and Heyman 2003). More specifically, whether they perceive someone as being responsible for their behaviour significantly shapes negative attitudes (Dolphin and Hennessy 2014; O’Driscoll et al. 2015). In actuality, childhood trauma is a risk factor for the development of hallucinations and delusions (Janssen et al. 2004; Arseneault et al. 2011; Kelleher et al. 2013; Coughlan et al. 2019; Stanton et al. 2020). Contextualising Biz’s struggle within a story of intergenerational trauma that gives prominence to emotional pain may further counteract negative attitudes by evoking powerful emotions on behalf of readers. YA literature has been shown to elicit emotions in students even though they had not been in the same situations as characters (Hébert and Kent 2000; Govindarajoo and Mukundan 2013), marking the ability of YA literature to foster empathy towards alternative experiences. Moreover, in a study considering how photographs and fiction changed student’s attitudes towards people with HIV, evoking emotions was key to reducing stigma (Teti et al. 2019). In another study, when asked to come up with less stigmatising descriptions for people with mental health difficulties, students focused on emotions rather than labels (Pinfold et al. 2003). Importantly, these studies point to the power of eliciting emotion as a way of understanding alternate experiences and reducing stigma.

Embracing ambiguity and contradiction

Ness’s narrative unrelentingly shows readers the ubiquity of ambiguity, thus opening the door to greater empathy and understanding of Conor’s experience. As Hinshaw (2005) notes,

‘[…]reductionistic, unidimensional, and essentialist biomedical/genetic views may well be associated with punitive responses, probably because they cast persons with mental illnesses as chronically flawed, deviant, and even subhuman.’

Indeed, studies have shown that people, including children, who believe that experience is flexible rather than fixed did not believe as strongly in stereotypes (Dweck 1998; Levy et al. 1998; Levy and Dweck 1999; Corrigan and Watson 2007). Conor’s monster brings home the point that there is never a singular way of perceiving human experience and cautions against injustices that arise when assuming there is one correct perspective.

Evidence supports the benefits of addressing ambiguity, contradiction and complexity with young people through the arts. A recent study found that analysing works of art increased students’ tolerance of ambiguity and increased empathy (Bentwich and Gilbey 2017). The same study provided a theoretical framework to explain the relationship between tolerance of ambiguity and empathy. Acceptance of ambiguity is suggested as a prerequisite for imagining worlds that are outside of the single reality we experience. Imagination is thus posited as a learning tool that allows readers to enter into others’ thinking, leading to greater empathy. A greater tolerance of ambiguity has indeed been linked to empathy (Jones 1974). Significantly, there is evidence that empathy is associated with greater acceptance and prosocial behaviour towards outgroups (Batson et al. 1997; Malti et al. 2012; Abrams et al. 2015). Specifically regarding mental health, greater empathy has been associated with lower stigmatisation in adolescent and adult populations (Hsiao et al. 2015; Webb et al. 2016; Silke et al. 2017). Literature, by its ability to convey nuanced depictions of ambiguity, therefore emerges as a compelling choice for fostering empathy and fighting stigma. An estimated 75% of young people in the U.S. with moderate to severe depressive symptoms have engaged with accounts of other people’s health experiences through blogs, podcasts and videos reflecting young people’s interest in learning from stories (Rideout and Fox 2018).

Conclusion

Compelling, sensitively written YA literature has the potential to reduce mental health stigma. This potential has not yet been realised and the role and impact of literature in promoting empathy and challenging mental health stigma have been poorly researched to date. The availability of contemporary YA fiction novels, such as those we have explored here, offers potential for both researchers and educators to leverage their potential with young people. Some schools have already experimented with incorporating education and contact-based mental health anti-stigma interventions with positive results (Pinfold et al. 2003; Perry et al. 2014; Painter et al. 2017). Meanwhile, medical schools around the world have brought the study of humanities into their curricula (MacNaughton 2000; Erwin 2014). If young people are exposed to experiences of typically marginalised peers through literature, not only will this benefit marginalised peers, but young people will emerge more tolerant and accepting of the wide array of human experiences that they will encounter in their adult life.