And so I circle back to the beginning of this essay and to the words of a person who was not prone to silly remarks: “Happily, we are not dependent on argument to prove that Fiction is a department of literature in which women can, after their kind, fully equal men.”
The Writing Self and the Psychiatric Patient
* * *
EVERY Tuesday for almost four years, I served as a volunteer writing teacher for psychiatric inpatients at the Payne Whitney Clinic in New York City. I taught two classes, one for adolescents in the North Unit and then a class for adults in South. Every Tuesday, before setting off for my weekly teaching stint, I felt dread. I didn’t know what patients I would find in my classroom or what stories I would hear. I had a student who had been raped by her brother, another whose parents had been imprisoned during the Cultural Revolution in China when he was six. One woman had set fire to herself. Others came to class wrapped in bandages after suicide attempts. A pleasant-looking aging man had seen green Martians. I saw two Messiahs during my time on the units, although neither one of them took my class. I had students who had been homeless and others who had left gleaming apartments and bulging bank accounts. One student, who had once been very rich, wrote about sleeping outside the elegant building where she had once owned a spacious apartment. I had students with PhDs and medical degrees and some who had dropped out of high school. Many of the patients in my classes were drugged to the point of torpor, and this fact, perhaps more than anything else, created the thick, benumbed atmosphere on the eleventh floor of the hospital, a multisensory version of the slow-motion technique one sees in films. And yet, every Tuesday when I left my class, took the elevator to the lobby, and walked out the hospital doors into the street, I felt elated. Elation was quickly followed by exhaustion.
Exhaustion need not be explained, but why did I feel elated? What can only be described as a raw, desperate, but somehow also hilarious affect pervaded my classroom, rather like a collective howl or sob or laugh that was about to be released. While this peculiar emotional weather made forms of order all the more important in class, it also made it useless to proceed as if everything were “normal.” That same lack of normality, however, stripped all of us of the pretenses we usually adopted for social situations beyond the walls of the clinic. “How are you?” is not a question that can be answered with a breezy “Fine.” Nobody is “fine” on a psychiatric ward and, because nobody is fine and everybody knows it, the language one uses to talk to other people, the niceties we use to oil the wheels of friendly but often meaningless chitchat, take on an absurdist glare. The stakes are high; emotions can burn hot; suffering is not hidden; and proximity to this undisguised human reality created in me a feeling of being more alive. It is a feeling I liked.
But I also stayed at my volunteer job because I came to understand that, for the most part, the students in my classes left feeling better than when they came in. Writing did seem to have a therapeutic effect on most of them. But how and why did it work? Is it possible to parse in any rigorous way what went on in those classes? Is it possible to think beyond the usual condescension associated with the idea of art as therapy? My class, like the others offered in the hospital in theater and visual art, served as a distraction, a palliative for patients against the paralyzing boredom that affects almost everyone on the units. We volunteers were fingerprinted, investigated to make sure we weren’t felons, told to wash our hands a lot, and instructed on what we should do in case of fire. That was it.
In contemporary psychiatry, writing plays a bit part, if it plays one at all. The case study, widely used when psychoanalytical thinking had the upper hand in American psychiatry, began to recede with the advent of antipsychotics in the middle of the last century and by the 1970s had become an artifact of another era. The extensive notes and expansive histories psychiatrists once recorded while working with their patients have turned into checklists of symptoms, from which physicians hope to extract a clinical diagnosis. Despite the emphasis on discrete categories, the diagnosis of mental illness remains an “iffy” business. I had many patients in my classes who had had multiple doctors and, with them, multiple diagnoses. Psychotic patients, in particular, were prone to being placed in wobbling categories—bipolar disorder, schizophrenia, or schizoaffective disorder. And there was a diagnostic hierarchy. Borderline personality disorder, given almost exclusively to women, carries a severe stigma. In the present era of the brain and the omnipresent prefix “neuro,” five letters now front-loaded onto almost every discipline to give it the legitimate stamp of hard science, psychiatry finds itself mostly on the brain side of the brain-mind problem.
Of course, the brain has long been implicated in mental illness. For the ancient physician Galen, whose views held sway for centuries in the West, madness could be caused by brain fevers, a blow to the head, or a disturbance of the humors. Since the seventeenth century, debates about the mind and the body have been crucial to medicine. What is a sick mind’s relation to a body? Treatments have swung between mental and physical, treating one or the other, while arguing about the relation or identity between them. The now vast research into brain processes has pushed psychiatry further toward what has been called a biological psychiatry, which favors pharmacological solutions and “evidence-based treatments.” No one can possibly absorb the data churned out daily in the neurosciences and published as papers in a host of journals devoted to the cause. I have read many thousands of them since the 1990s. It is interesting to note that between then and now, the papers have shrunk. Their standard form—abstract, methodology, results, and discussion—has become increasingly rigid, and the discussion at a paper’s end, always my favorite part, has become more restricted and less speculative.
It is ironic that the fear Freud articulated in Studies on Hysteria, that his accounts of hysterical patients had a strikingly literary quality and “lack the serious stamp of science,” is the same fear that plagues psychiatry in the post-Freudian era.1 Nevertheless, it is worth asking how writing narratives, diary entries, poems, or other forms of scribbling might be part of a science of the mind. Freud hoped that future science would clarify the biological origins of mental illness. And yet, psychiatry remains separate from neurology because neurology is the science of “real” brain damage and degenerative diseases of the nervous system, mostly those with lesions that can be detected.
The search for lesions or some direct relation between the brain and mental illness is very old. These efforts are ongoing and have proved frustratingly difficult. Although progress has been made in schizophrenia research, for example, the disease remains confounding on many levels, from genetics to behavior. On the other hand, August von Wassermann’s development of a blood test for syphilis in 1906 coupled with Alexander Fleming’s discovery of penicillin in 1926 rid the world of neurosyphilis, a disease that accounted for a large number of patients in insanity wards. Miracles happen, and it is not strange that brain scientists, now equipped with advanced technology, hope for discoveries that are equally momentous.
According to the German neuroscientist, psychiatrist, and philosopher Henrik Walter, we have entered the “third wave” of biological psychiatry.2 The first wave was in the nineteenth century. The second wave arrived with antipsychotics and discoveries in genetics in the middle of the twentieth century. The third wave, Walter asserts, can be traced to developments in molecular biology and brain imaging. He defines biological psychiatry as a science that understands “mental disorders” as “relatively stable prototypical, dysfunctional patterns of experience and behavior that can be explained by dysfunctional neural systems at various levels.” It is not at all clear that mental disorders are in fact either stable or prototypical, as changing nosologies have demonstrated throughout history, or that a focus on neural systems will yield full explanations. Nevertheless, Walter freely acknowledges the “continuous failure of neurobiology (with some exceptions) to sufficiently explain or predict mental disorders [which] shows that it cannot account for
such complex phenomena.”3 The problem, he argues, is that the model is wrong. He takes a stand against simplistic locationism that reduces a mental state to a brain region and recommends a multidimensional model based on the “4Es: the embodied, extended, embedded and enacted mind.”4 In other words, brains are of a living body, which is of the world, and no brain can be isolated and explained without taking its dynamic relations with the rest of the body and the environment into account.
Walter mentions the nineteenth-century German psychiatrist Wilhelm Griesinger, often called the father of biological psychiatry, who famously said that all mental illness is a disease of the brain. Walter rightly notes that despite this famous sentence, which was not at all controversial when he made it, Griesinger was not a reductionist. Walter does not elaborate further, but in Mental Pathology and Therapeutics, Griesinger writes that although human “understanding” and “will” must “refer” to the brain, nothing can be assumed about the relation between “mental acts” and the “material” brain.5 Further, he advanced a complex interactive, dialectical model of mental illness influenced by the philosophy of Kant, Herbart, and Hegel.6 Griesinger writes, “A closer examination of the aetiology of insanity soon shows that in the great majority of cases it was not a single specific cause under the influence of which the disease was finally established, but a complication of several, sometimes numerous causes, both predisposing and exciting. Very often the germs of the disease are laid in those early periods of life from which the commencement of the formation of character dates. It grows by education and external influences.”7 While it is certain that contemporary brain research has brought us much closer to the activities of the material brain than in 1845 when Griesinger’s book was first published, it has not brought us any closer to an understanding of the relation between mind and brain, which remains a philosophical quandary. Indeed, Walter plainly states at the end of his paper, “The main point which I would like to make here is that biological psychiatry has to take into account theories about how the mental is constituted.”8 Psychiatry must examine its philosophical foundations. According to both Griesinger and Walter, the mental is something beyond brain, and the causes of most psychiatric illnesses escape simple, reductive biological explanations, which is not to say that the same illnesses do not all involve the brain.
So how does one think about the question of writing as therapeutic in this third wave of biological psychiatry? Brain scans of patients before and after writing assignments would tell us something about what parts of the brain are activated but would tell us nothing about the person’s subjective experience while writing, nor would they explain in any subtle way how to make a writing class better or which of the areas or connective zones are crucial to beneficial effects. There is an empirical literature on writing therapy, most of it from the last thirty years and all of it on what is called “expressive writing,” three to five sessions of free writing about emotionally charged or traumatic events that last between fifteen and twenty minutes. Spelling, grammar, and elegant phrasing are not part of the exercises.
A summary of the findings in Advances in Psychiatric Treatment in 2005 begins with the following sentence: “Writing about traumatic, stressful or emotional events has been found to result in improvements in both physical and psychological health, in non-clinical and clinical populations.”9 Writing about neutral events did not result in any benefits. The authors of the review tell us that although the immediate effect of writing about distressing experiences resulted in “negative mood and physical symptoms,” the long-term effects when compared to controls include improved immune system functioning, lower blood pressure, improved liver function, and better mood. The list is impressive. Not all psychiatric patients are traumatized, but the fact that writing had a positive effect on “non-clinical populations” suggests that its effects are not limited to people with specific diagnoses.
The authors of the paper include a list of the “mechanisms” for why expressive writing might have these effects. These are considerably less impressive.
There are four:
1. “Emotional catharsis [the authors append the word ‘unlikely’ to this one].”
2. “Confronting previously inhibited emotions: May reduce physiological stress resulting from inhibition, but unlikely to be the only explanation.”
3. “Cognitive processing: It is likely that the development of a coherent narrative helps reorganise and structure traumatic memories, resulting in more adaptive internal schemas.”
4. “Repeated exposure: May involve extinction of negative emotional responses to traumatic memories, but some equivocal findings.”10
The psychologists have come up with some strong empirical evidence for this particular kind of writing as therapy but are philosophically cramped when they search for the reasons that might explain it. Surely the first two—emotional release or emotional release after inhibition—might be achieved with “a good cry” or kicking the door or howling at the moon. The third, “cognitive processing,” leaves emotion behind and draws its hypothesis from work on trauma and narrative. Talking (or in this case, writing) about a terrible event, an event reexperienced as motor-sensory shock, sometimes accompanied by visual images and hypersensitivity to reminders of the trauma, for example, has been shown to be beneficial. This, at least, addresses the role of language. The fourth appears to be drawn from work on phobia. When a person is repeatedly exposed to what frightens him, he can gradually come to understand that (most of the time, anyway) elevators, for example, are not terrifying enclosures.
The authors are very far away from asking “how the mental is constituted.” It is not that all four of these “mechanisms”—if they can be called that—may not somehow be involved in the beneficial qualities of writing, but rather that there is something at once flabby and superficial about their thinking, which doesn’t begin to address the specific qualities of writing as an act that might be pertinent to their discussion.
Writing is probably not more than 5,500 years old, a fact that still astonishes me. And yet, the truth that all literate people are capable of expressing internal and external realities by means of little hieroglyphs on a page that can then be read and understood by others who share those same little markings as symbols of meaning has a miraculous quality. The act clearly involves the mental, but what is the mental? It involves what we think of as social, psychological, and biological factors, but how are they parsed? Long ago I learned to write and now the act of moving a pen across a page or typing on a laptop has become unconscious and automatic, part of the motor-sensory systems of my brain and body that are clearly biological. Due to plasticity and development, the literate brain is notably different from the illiterate brain. Reading and writing have changed my mind over time.11 And although I don’t have to consciously think to type, I have to think to write, and thinking is a psychological, mental phenomenon, to be sure, but one that is also neuronal. Nevertheless, the words, syntax, and semantics of my sentences are the givens of a particular linguistic culture, a sociological inheritance, but my ability to learn to speak and write in ways a hedgehog never does suggests a native capacity for language with evolutionary and genetic implications. Despite the fact that this is all painfully obvious, I stress these ambiguities to demonstrate how quickly such categories turn to mush. It is this problem Walter tries to address through the four E’s. The mind is embodied, extended, embedded, and enacted.
A student in one of my classes—let her go by Ms. P—wrote a text about corpses lying on cold stone slabs inside an airless chamber. Over the course of her brief, bitter piece, the living and the dead became indistinguishable. She ended with the sentence “We are all dead.” Ms. P clearly let go of some dark feelings while writing, and it is possible they were cathartic or that she had inhibited them for some time. She had to use her “cognitive processes,” although she did not create a “coherent narrative” so much as a grim description of dead people in a crypt. When she read it aloud, no one in
the room felt good. And yet, she was engaged in the class discussion about her text, and she appeared to leave the room less depressed than when she entered. Can her lift in mood be attributed to writing, to talking, or to feeling less isolated because she was part of the group? No doubt, all three contributed to the change in her. The expressive writers of the many studies cited in the paper did not get “feedback” about their writing from the psychologists, so my class functioned differently, as a workshop. Ms. P surely underwent brain changes reflected in her shifting mood. Because brains are never inactive, even in what is called the resting state, when a person is doing nothing special, her brain could be monitored for changes. What would a change in her neurochemistry tell us?
Think of the widespread, popular notion that depression is caused by “a chemical imbalance” in the brain and that SSRIs will address that imbalance. I remember talking to a psychiatrist seven or eight years ago who, in response to my comment that the scientific evidence about serotonin was far from conclusive, assured me that the drugs were effective for his patients—astonishingly, in fact. And yet, not then and not now is there evidence that low serotonin levels cause depression.12 What does “chemical imbalance” actually mean? The SSRI story became an important cultural myth, buoyed by hugely popular memoirs of people living brand-new happy lives on the drugs and by advertising for them that employed, among other images, a cute cartoon character whose sad face was turned into a happy one. An early pamphlet for Prozac claimed, “Prozac doesn’t artificially alter your mood and it is not addictive. It can only make you feel more like yourself by treating the imbalance that causes depression.”13 This sentence is a rhetorical marvel. What does “artificial” mean here? Is any alteration of a person’s mood “artificial”? If I take a stimulant and feel peppy, is my mood artificial or natural? Am I not really peppy? Once a pharmaceutical substance is in my body, are the changes artificial or natural or both? Addiction is a further riddle. A person may not feel addicted to an antidepressant, but he or she cannot suddenly withdraw from it either without consequences, some serious. What it means to be left feeling “more like yourself” is a philosophical question too confounding to address in under a hundred pages. Exercise has also been shown to alleviate depression. It may be addictive in some people, if one employs the current understanding of addiction as any activity a person finds difficult to stop. One might ask, if expressive writing has been shown to lift people’s moods and increase immune function, might it play a role in treating depression?
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