“Wherever the art of medicine is loved, there is also a love of humanity.” -Hippocrates

Reading this declaration today, conjures an unsettling, or almost unpleasant feeling that this once foundational concept may today be lost in time.  A ‘love for humanity’, whilst still lingering in the minds of some clinicians has been largely side-lined by science, research, evidence based practice,  being mindful of patient’s rights, family criticisms and practicing medicine with caution against being sued or criticised ourselves. We may benefit to keep in mind the words of American, philosopher Will Durant, “Every science begins as philosophy and ends as art.”

Ironically, it seems that science may provide answers to the apparent diminution of humanity in medicine. A recent editorial advocated that empathy in medicine may have a neurobiological basis and therefore can be up-regulated through specific neurobiological correlated education methods, in order to enhance professionalism and compassion.[1,2] Suggestions such as these reflect society’s growing dependence, or perhaps near enslavement to science which may soon become a surrogate for what were once regarded as inextricable, innate, features of our humanity – empathy and wisdom.

Beveridge reminds us that, “Doctors need a deeper understanding of their patients that takes account of emotional and existential aspects.”[3] Literature offers us a multitude of human experiences that may serve to deepen our appreciation of the breadth of human consciousness. As T.S. Eliot stated, “We read many books, because we cannot know enough people.”[3]

Psychiatry is one field of medicine which demands a strong level of empathy and a sophisticated level of interpersonal communication. Psychiatry studies the human mind with its complexities of emotions, behaviours, motives, experiences and reactions. Crawford describes the existence of a ‘synergism’ between literature and psychiatry as they both focus on the human mind from two separate paradigms: first, a scientific, biomedical framework of medicine; second, an artistic, creative medium of fiction. He questions, despite this congruence, why does literature still ‘remain the poor relation of the medical textbook?’[4] The concept of two paradigms, or a dualisms of brain and mind is explored further by Australian philosopher David Chalmers who describes how these two entities are different and how understanding each one requires a unique method.[5]

It is at this junction, between clinical psychiatry and fictional literature that our journey begins. This essay will explore some of the reasons for why we, as students and health professionals should and should not engage in fictional reading. We will then delve into some literary examples that provide insight into mental illness.

Benefits of fiction

Reading fiction may allow us to better connect with individuals such as our patients emotionally by first connecting with fictional characters. Evans proposes that when we read for enjoyment, “Our defences are down – and we hide nothing from the great characters of fiction.”[6] He contrasts this to a doctor-patient interaction where doctors, “do [their] best to hide everything beneath the white coat, or the avuncular bedside manner.” Over many years, all that is left is a professional, clinical interaction at the cost of a personal connection with the patient. He reminds us that, “It is at this point where art and medicine collide, that doctors can re-attach themselves to the human race and re-feel those emotions which motivate or terrify our patients.”[6]

Psychiatry tends to place a greater emphasis on thought form when making diagnoses, whilst the patients are more concerned with thought content, even though a doctor may at times miss the subtleties in form too. Literature can make us more aware of the importance of the content to the individual and connect more closely with the patient’s experience. Sims illustrates this:

“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, […] 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. […] The nature of the content is irrelevant to the diagnosis.”[7]

The analysis of thought form leads us to a clinical diagnosis which justifies clinical interest in form over content; thought process over a patient’s narrative. Crawford hypothesises that with the increasing biomedical dominance in psychiatry, there is bound to be further marginalisation of content. He argues that in fiction, the content, which encompasses all human experiences, emotional responses and behaviours, is more valuable and effective in conveying an understanding about the narrative than the form.[4]

Shortcomings of fiction

Not everyone values literature in the context of medical progress – Wassersug proclaimed that, “Real medical progress has not been made by humanitarians but by doctors equipped with microscopes, scalpels, dyes [and] catheters, […] similarly psychiatry should be seen as a branch of the natural sciences.”[3] He argues that literature has nothing to offer to psychiatry, a field which should be led by advances in neurosciences, not narrative.

Reading has been described as a ‘selfish’ activity that can expand individual intellect but cannot instil a spirit of altruism or increased sensitivity towards others.[3] The physician Raymond Tallis illustrates how reading may in fact make us less empathetic; he quotes Tolstoy’s tale of an aristocratic woman weeping over a theatrical tragedy, while outside a real tragedy eventuates as her faithful coachman freezes to death. This anecdote highlights the ability of the arts to delude the woman, to believe herself to be sensitive, when in fact she is actually being inconsiderate.[3]  Some arguments against reading fiction may be valid. However, they are not sufficient to completely discredit the opportunity fiction provides us to expand our sense of enlightenment, self-development and inspiration in a way that a factual textbook simply cannot.

Fiction and mental illness

Literature is an instrument to present facets of mental illness that may not be captured through textbooks, lectures or case presentations. Oyebode suggests that fictional narrative achieves its aims by magnifying or exaggerating specific aspects of characters such as their mannerisms, behaviour or speech to make them stand out to the reader. Oyebode analyses Patrick McGrath’s Asylum to illustrate how delusional jealousy may be the result of multiple trivial everyday occurrences:

“Driven by the 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.”[8]

Oyebode presents a detailed, focussed magnification on the protagonist’s paranoid, obsessive thoughts about everyday occurrences. This allows the reader unrestricted access into the thoughts that occupy a person’s mind suffering with delusional jealousy.

Oyebode provides a glimpse into nihilistic thoughts through McGrath’s Spider:

“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 […] I wonder…what they will find when they cut me open (if I’m not dead)? An anatomical monstrosity surely.”[8]

The emotive and dark imagery in this writing serves to illuminate the depth of nihilism; the torment the protagonist faces at the mercy of his own mind. Once again, the account provides important insight into a paradigm of thought that may otherwise be foreign to an external observer.

Jenny Diski describes the experience of depression beautifully in Nothing Natural:

“Here it was again. Unmistakeably it. […] 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. […] The unreasonable difficulty of everything made more unreasonable, more difficult knowing that nothing physical was wrong. […] Depression was an excess of reality: intolerable and unliveable.”[4]

This detailed deconstruction of depression exposes the destructive power of depression to render a person physically powerless whilst they are mentally completely aware of what is happening to them. Literature forms a bridge between the internal world of our patients and our global comprehension of their condition. This bridge elevates us from helpless bystanders to active and effective treating practitioners.

Sometimes the words of fictional characters may attack the reader directly, encouraging the reader to engage in self-reflection. The protagonist, from Kristin Duisberg’s The Good Patient, expresses that mental health practitioners:

“have chosen their profession to deny a terrifying truth other doctors accept – there are ills for which there is no cure.”[4]

At first glance this idea seems completely bizarre, as no psychiatrist believes they can cure all psychiatric conditions. However, it is hard to completely dismiss it without the thought lingering on in our subconscious. This attack stimulates some introspection to determine whether there may be any truth behind it at all. The words of this fictional character have the power to leap off the pages, and into our subconscious to question our role and limitations when treating patients with mental illness.

Literature tries to ‘de-pathologise’ mental illness as evidenced by Sally Vickers in The Other Side of You:

“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 or less in a state of vigilance against one another.”

By addressing this ‘cracked’ nature inherent in all of us, the author indirectly places all of us on a spectrum of mental illness. She implies, the only difference between mentally healthy and ill is where we stand on this spectrum. Concepts such as this break down the differences between ‘normal’ and ‘mentally ill’ and help liberate us from our own inbuilt stigmas against mental illness.

An extensive list of texts and their relation to mental illness can be found at www.madnessandliterature.org

Commentary

Literature, good TV and theatre for that matter, may not completely depict psychiatric psychosis or other psychiatric conditions in their entirety and complexity. They do however give us a glimpse into the differences between internalising (major depression, generalised anxiety and panic disorders, phobias) and externalising (alcohol and drug dependence, antisocial personality and conduct disorders) disorders.

We find ourselves in an age where the growth of information, triumphs of science and expansion of technology appears to be propelling us into a biomedical dominated practice of medicine. The question that we must ask ourselves is whether this scientific dominance is encroaching on our capacity for empathy, understanding and appreciation? Fictional literature may provide us with an opportunity to re-connect to our humanity in a way that no other medium can. Literature may not make us better diagnosticians, or change the value system of our profession, but it will make us question ourselves, our thoughts, and our perception of others. This new level of reflection and understanding can result in a more wholesome interaction with patients which will strengthen the therapeutic alliance between patient and doctor.

The study of humanities should not take priority over crucial clinical elements, but it can be used as an adjunct to clinical education. There is evidence to suggest benefit of reading already, and a number of medical schools have implemented medical humanity subjects and faculties because of their appreciation of its inherent value.[9-11] However, reading is something that is not restricted to the classroom; it cannot be tamed by our teachers and it has a timeless ability to touch us if we let it. Alexandra Trenfor writes, “The best teachers are those who show you where to look but don’t tell you what to see,” and fiction is like this teacher – it provides us with a narrative, but leaves its meaning and essence for us to discover ourselves.

Conflict of interest

None declared.

Correspondence

K Makhija: karan.makhija88@gmail.com

Reference

[1] Kaptein AA. et al., ‘Why, why did you have me treated?’: The psychotic experience in a literary narrative. Med Humanit. 2012; 37: 123-26.

[2] Riess H. Empathy in medicine-a neurobiological perspective. JAMA. 2010;304: 1604-5.

[3] Beveridge A. Should psychiatrists read fiction? Bri Jour of Psychiatry. 2003; 182: 385-87.

[4] Crawford P,Baker C, Literature and madness: fiction for students and professionals. J Med Humanit. 2009; 30: 237-51.

[5] Chalmers DJ. The puzzle of conscious experience. Scientific American. 1995;volume?: 62-68.

[6] Evans M, Greaves D, Exploring the medical humanities. BMJ. 1999: 319: 1216.

[7] Sims A. Symptoms in the Mind. 2003; Philadelphia: Saunders/Elsevier Science Ltd.

[8] Oyebode F. Fictional narrative and psychiatry. Advances in Psychiatric Treatment. 2004;10: 140-45.

[9] Shafer A, Borkovi T,  Barr J. Literature and medical interventions: An experiential course for undergraduates. Fam Med. 2005; 37(7): 469-71.

[10] State of the Field Committee, Arts in healthcare. Washington DC: Society for the Arts in Healthcare, 2009.

[11] Bonebakker V. Literature & medicine: Humanities at the heart of health care: A hospital-based reading and discussion program developed by the Maine Humanities Council. Academic Medicine. 2003; 78(10): 963-67.