Psychosis: the symptoms and the person
In order to understand how a psychotic disassociated voice is established in fiction, we must first understand the drive behind its creation; to review how and why writers have done this. And in order to do this, we must first establish what psychosis is and why such a condition leads to disassociation of thought and speech – the point where a person loses the ability to communicate effectively with the outside world; where their attempts to be understood no longer ‘make sense’ to the rest of society.
The World Health Organisation states psychosis is “the presence of hallucinations, delusions, or a limited number of severe abnormalities of behaviour, such as gross excitement and overactivity, marked psychomotor retardations, and catatonic behaviour” (World Health Organisation, 1994: 10).
However, this reduces the individual to a list of symptoms – the effect of the condition, not the cause. And many of those now working in mental health are making attempts to understand the ‘cause and effect’ of the condition, to get under the skin of psychosis by asking the ‘why’ as a part of the ‘what’.
For example, Feder (1980: 5) says: “I define madness as a state in which unconscious processes predominate over conscious ones to the extent that they control them and determine perceptions of and responses to experiences that, judged by prevailing standards of logical thought and relevant emotion, are confused and inappropriate.” (It is important to note that the terms ‘madness’ and ‘psychosis’ are used interchangeably in some texts.)
With this spotlight on the internal, it follows that first-person accounts are becoming common practice in studies that wish to capture this ‘why’ as part of the ‘what’. Prior to the interest in the individual’s journey through psychosis, sufferers were merely the subject at the bottom of the microscope – asked questions, but never asked to give their opinion on their own mental state.
Where medical and academic study are now venturing, fiction has long been bedfellow. Crawford & Baker (2009) point out that “From the short story to the novel, from linear narratives to postmodern fragmented narratives, from literary to popular fictions and to autobiographical narratives – the theme of mental illness is a feature” (237).
Keitel (1989) believes is it the very lack of medical and academic investigation that has seen fiction venture so deeply into the world of psychosis: “The literary communication of psychotic personality dissolution opens up an opportunity to re-enact the emotional dimensions of such an illness” (28). Clarke (2009: 19) agrees. He points out psychosis is one of the situations where “selfhood is routinely denied” – and that this “is where fiction can help, by commenting on experiences that impinge on psychiatric practice and its effects on human identities”.
Geekie et al (2012: 2) point out that in scientific research, the person suffering psychosis “has been marginalised, occupying the position of what the French philosopher Michel Foucault refers to as ‘subjugated knowledge’” – that is “knowledges that have been disqualified as inadequate to their task or insufficiently elaborated: naive knowledges, located low down on the hierarchy, beneath the required level of cognition or scientificity.” (Foucault, 1977: 82). Felman (2003) simply states “madness silenced by society has been given voice by literature” (15).
This explains ‘why’ we have attempted to fill the gap, but it does not explain ‘why fiction’ – why it was the preferred tool used by those doing the ‘attempting’. For King (2013) it is because fiction writers were intrigued by the questions going unanswered by medicine. Fiction started asking questions regarding “the nature of the mind, and dealing with similar issues of perception, motivation, identity and the agency of the individual” (688).
Oyebode (2002: 121) believes that, where psychosis is concerned, fiction and medicine are allies: “The psychiatrist, like the novelist, imposes structure on an abnormal phenomenon partly to render it innocuous but also to make it manageable.” Novelist Patrick McGrath agrees: “Novelists and psychiatrists have much in common. Both attempt to make sense of human experience, particularly when that experience is at is most disordered” (2002: 143).
For Crawford & Baker (2009) the “synergism” between literature and medicine is clear: “Psychiatry studies the human mind within a medical paradigm, exploring experience, response and reaction, emotion and affect. Similarly, writers of fiction explore within a non-clinical dimension the phenomena of the human mind” (237).
Oyebode (2004) feels our need to describe human experience through novels is because of “the intrinsic fascination that we all have for how the mind works, either in health or illness” (142). While Moran (2006: 80) points out fiction gives “a sense of what [mental illness] feels like from the inside rather than – as in a medical textbook – what it looks like from the outside.” Clarke (2009) agrees, stating “it is to fiction alone that we gain entry to a believable consciousness of others” (186).
For Pridmore & Walter (2013) it is narrative’s key role within society that allows fiction to experiment where medicine and academia have faltered: “Narrative products have a number of functions. These include serving as an abstraction or model of social experience, and allowing simulation of social experience, providing the opportunity to consider personal responses in a range of situations. As such, narrative products are powerful in transmitting and sustaining the culture of groups” (65-66). Lodge (2002: 10) believes literature is a “record of human consciousness” – and describes the novel as “arguably man’s most successful effort to describe the experience of individual human beings”.
Exploring psychosis in fiction
In medicine and academia, there is a search for an answer, for the truth. There is no such restriction on fiction. In fact, one of the reasons fiction is so successful is because it can present reality in an “incomplete status” – it isn’t weighed down by “expectations of psychology research with its hypotheses and anticipated outcomes” (Clarke, 2009: 186).
For Clarke (2009: 15), fiction is able to stretch itself to fit around the idea of psychosis: “Most mental health problems gather life around them problematically [and need] a literature that runs deep, is more conflicted, that courts the inexplicable things that conventional books don’t do.” Clarke also explains social order as “fictitious” and “chaotic” – and that in order to “construct realities from it [we] scrutinise, assimilate and reassemble events that make autobiographical sense” (2009: 179). It is the autobiographical element of our own narratives that allows us to connect so easily with similar narratives in fiction.
Since personal accounts became a significant part of the study of psychosis, it has become clear that many sufferers have their own narrative drive; they have a story to tell, not just symptoms to express. Sufferers were able to explain their mental state in words more closely linked to literature than medicine. As Moran (2006: 80) points out, “The ubiquity of metaphor in the pathographies of recent decades, where disease is often shown as rebirth, or battle or journey, suggests that patients are not going to stop thinking metaphorically about their illnesses.”
An example of one such personal account is that of Longden (2012), who says: “I struggled artfully with my psychosis and revelled in the whole frenzied repertoire: the voices, the visions, the bizarre intractable delusions and that cruel, infinitely prolonged living death of anguish and isolation that tortures you beyond endurance and bleeds you, through exhaustion, hopelessness and loss of self-respect, into a shadow of your former self” (179).
In her work on first-person recovery narratives, Ridgway (2001: 336) explains “questioning and reformulating one’s life story can renew a sense of meaning” – that what we do with our personal narratives mirrors what fiction can do for a character in a similar situation to our own. Geekie et al (2012: 9) explain that in telling stories, we provide “the opportunity to renegotiate the meaning, sequence and connection between past and present life events”.
What is available in such fiction is a structure that allows the reader to witness the disintegration of the mind of the sufferer but still be able to follow the narrative. Feder (1980) explains literary constructs are used to “portray the mind constructing and exposing its own symbolic framework out of fragments that all readers recognise as familiar – customs, attitudes, places, institutions, traits of character, desires and fears” (xiii).
Taking the familiar and distorting it can also work by “magnifying aspects of characters in a novel [involving] the amplification of physical characteristics, or the exaggeration of mannerisms, behaviour, speech or experience” (Oyebode, 2004: 140). Through fiction, madness has moved from a “position of exclusion” to become part of culture (Felman, 2003: 13).
This works because works of fiction “encapsulate parts of a reality beyond the text, such as certain social and historical norms and the sociocultural context in its broadest sense” (Keitel, 1989: 91) – the reader can place themselves in the position of the person with psychosis because they understand enough of the world they both inhabit to be able to bridge the gap between that world and the world where only the psychosis sufferer resides.
This seems to work especially well when a novel focuses on the self and where “madness is a mode of release and discovery” which revolves around how a character is at odds with society (Feder, 1980: 283). It allows anyone who is disillusioned with the world to relate to the character. Feder refers to this motif of modern fiction as the “abyss of the self” (272).
The representation of psychosis in fiction has reached a pinnacle – a point where academics such as Crawford & Baker (2009) believe medicine can now benefit from fiction – that it is “both valuable and effective to examine the human experiences, emotional responses and behaviours […] in coming to an understanding of the content of the narrative – the characterisation, aesthetics, emotion and affect of both protagonist (patient) and secondary characters” (239).
Challenging psychosis in fiction
When attempting to establish a character with psychosis, novelists are best to remember “fiction privileges itself above factual accuracy or historical truth” (Clarke, 2009: 47). This means as long as the reader is able to believe the views and actions of the character with psychosis, the facts do not have to match a specific case of psychosis explained within medicine or academia.
As Lodge (2002) explains, “science tries to formulate general explanatory laws which apply universally [whereas] works of literature describe the guise of fiction the dense specificity of personal experience, which is always unique, because each of us has a slightly or very different personal history, modifying every new experience” (10-11).
A novel is also an opportunity to “challenge dominant discourses and beliefs” (Knifon, 2012: 274). This is because fiction explores psychosis rather than establishing an absolute. Again, this aligns neatly with the idea that an individual’s narrative can “overturn ‘master narratives’ – the socially constructed stereotype accounts” (Ridgway, 2001: 336). Geekie et al (2012) go as far to say that stories “are a way of curing the wounds that illnesses often create, helping to make sense, to redraw maps and find new destinations” (8).
However, errors in representations of psychosis can cause damage, as Little-Fenimore, (2012: 157) explains: “Inaccurate media images lead to misconceptions and stigma, contribution to the confusion and misunderstanding about mental illness.” And as Feder (1980) points out, “it would be shortsighted in any study of literary madness to ignore psychoanalytic theories of mental functioning and psychopathology when they provide essential clues to the symbolic nature and expression of such characters.”
Which is why, when establishing such a character, a fiction writer should pay attention to the list of symptoms provided by the World Health Organisation and the extension of and explanation of these symptoms by those working in the field of mental health – both within medicine and within academia. However, it is important to remember “the human mind is too complex and unique to be reduced to a series of chemical and electrical responses” (Crawford & Baker, 2009: 239) – that, for example, knowing the name of a chemical (such as serotonin) which affects human mood levels doesn’t instil in someone the understanding of what it means to experience depression.
Voice of psychosis in fiction
Madness has been the subject of fiction for hundreds of years, but the idiosyncratic take on the subject is relatively recent – although there are some notable exceptions (such as Gilman’s 1892 novella The Yellow Wallpaper). For example, while Feder (1980: 3) points out that “madness has been a continuous theme in Western literature from its beginnings to the present time, Keitel (1989: 1) notes that “fear of death and the longing for it form the subject of a group of prose texts which have been published and read in increasing quantities since about the beginning of the 1970s.”
There are narrative tools and techniques used in both modern and postmodern fiction that lend themselves well to the establishment of a disassociated voice. Modern fiction has what Lodge (2002: 57) says is a “tendency to centre narrative in the consciousness of its characters, and to create those characters through the representation of their subjective thoughts and feelings rather than by describing them objectively”. When done well it is what Rieger (1994: 27) calls “a record of those elusive moments at which life is alone fully itself, fulfilled in consciousness and form”.
A stream of consciousness is very much a first-person narrative mode. Lodge (2002) believes this shift from objective to subjective within fiction is tied to Sigmund Freud’s view of psychoanalysis and the belief that we are driven by hidden motives. And Calvino (1986: 19) believes “The power of modern literature lies in its willingness to give a voice to what has remained unexpressed in the social or individual unconscious: this is the gauntlet it throws down time and again.”
Since the modernist period, writers have moved away from this stream of consciousness approach and have relied on other linguistic techniques to represent the disassociated voice. In fact, Crawford & Baker (2009) go as far as to say that postmodern novels – which are “characterised by their incomprehensibility, fragmentation of linear narrative and narrations, disruptions in spatiality and temporality” – are effectively “psychotic texts” themselves (244).
They highlight that, in postmodern fictions, “one can see elements of thought disorder, paranoia, word salad, neologisms, ideas of reference from the media and a host of other clinically-defined-as-psychotic symptomatology within these narrations” (Crawford & Baker, 2009: 244).
One ‘psychotic tool’ used in postmodern fiction is that of the unreliable narrator. As Bernaerts et al (2009) explain, “madness can offer the route to narrative unreliability; excesses of narratorial self-consciousness are presented as madness and more elaborate literary examinations of minds almost always bump into the problem of extreme mental instability” (285). Unreliable narration works so well because, as Crawford & Baker (2009) point out, it is found in real life as well as in fiction: “rarely do we admit to anyone (including ourselves) the deeper, painful and sometimes darker sides of ourselves” (243).
Keitel (1989: 19) explains writers used techniques to move the reader’s attention “away from what is being represented and focusing it on the way it is presented”. Along with the unreliable narrator, other popular tools used include “multivoiced narratives”, “genre dodging, satire and allusiveness” (Duguid, 2002, cited in Clarke, 2009: 11-12).
When used well, these devices deliver a disjointed voice that carefully cracks the shell of a novel’s coherent narrative structure. However, Clarke (2009) is quick to point out that what he calls “anti-narrative styles” can switch the reader off the text – with “novels careering into states of mind, linear story lines suddenly bewitched, bothered, bewildered” (12).
And here’s the rub. When we integrate psychosis into fiction it “raises the question of how the unreadable can as such be read: how and why does nonsense produce sense?” (Felman, 2003: 104). It asks the question “how can a literary text overcome certain specific limits of verbalisation, while at the same time allowing for a psychotic experience to be communicated?” (Keitel, 1989: 3).
And this seems to be the main difference between the modern and postmodern disassociated voice. These postmodern texts rely more on ‘linguistic tricks’ within a solid narrative form, often allowing the reader to witness the fracturing of a character’s mental state first hand – something which would be harder to achieve within a modernist novel, where there is no initial structure to break down. This approach allows a writer to balance the symptoms of psychosis – the hallucinations, the delusions, the catatonic behaviour – with the need to present the reader with something they can read!
Please note: There are books that use disassociated voice techniques which are outside the domain of representing psychosis – such as The Sound and the Fury (Faulkner, 1929), Flowers for Algernon (Keyes, 1966), The Curious Incident of the Dog in the Night-Time (Haddon, 2003), and A Girl is a Half-Formed Thing (McBride, 2013). These texts set out to achieve such a voice for reasons other than to present a psychotic character, and are therefore not discussed here.