North American writer David Foster Wallace wrote two short stories - The Planet Trillaphon As It Stands In Relation To The Bad Thing and The Depressed Person - that depict depression, in each one taking different yet complementary perspectives on this subject. Our aim is to analyze these texts and to discuss the role literature can have in regard to the apprehension of subjective experiences of others. Whereas the first text attempts to describe depression objectively, the second one describes the impossibility of doing so, focusing on literary techniques that create distressing subjective experiences in the reader, possibly resembling those felt by depressed persons. We suggest that literature might be helpful to comprehend some aspects of the experience of being depressed and that such an understanding may enrich psychiatric practice.
Literature; psychiatry; depression; David Foster Wallace
O escritor estadunidense David Foster Wallace escreveu dois contos - The Planet Trillaphon As It Stand In Relation To The Bad Thing e The Depressed Person - que abordam a temática da depressão, em cada um adotando perspectivas distintas e complementares. Nosso objetivo é analisar esses textos e discutir alguns aspectos do acesso à experiência subjetiva de outras pessoas, mais especificamente o papel da literatura nesse processo. Enquanto o primeiro texto descreve a depressão objetivamente, o segundo descreve a impossibilidade de fazer tal descrição, focando em técnicas literárias que criam experiências subjetivas desagradáveis, possivelmente semelhantes às sentidas pelas pessoas deprimidas. Nós sugerimos que a literatura pode ser útil na compreensão de alguns aspectos da experiência de estar deprimido, e que tal compreensão pode enriquecer a prática psiquiátrica.
Literatura; psiquiatria; depressão; David Foster Wallace
L’écrivain nord-américain David Foster Wallace a écrit deux contes - « The Planet Trillaphon As It Stand In Relation To The Bad Thing » et « The Depressed Person » - abordant le thème de la dépression, en adoptant dans chacun de ces textes des perspectives distinctes et complémentaires. Notre but est de les analyser et de discuter certains aspects de l’accès à l’expérience subjective d’autres personnes, en nous intéressant tout particulièrement au rôle de la littérature dans ce processus. Alors que le premier texte décrit la dépression de façon objective, le second décrit l’impossibilité d’en faire une telle description, se concentrant sur des techniques littéraires créant des expériences subjectives désagréables, potentiellement semblables à celles ressenties par les personnes déprimées. Nous suggérons que la littérature peut être utile dans la compréhension de certains aspects de l’expérience de l’être déprimé et qu’une telle compréhension peut enrichir la pratique psychiatrique.
Littérature; psychiatrie; dépression; David Foster Wallace
El escritor estadounidense David Foster Wallace escribió dos cuentos - The Planet Trillaphon As It Stand In Relation To The Bad Thing y The Depressed Person- que abordan la temática de la depresión y que adoptan perspectivas distintas y complementarias. Nuestro objetivo es analizar dichos textos y discutir algunos aspectos del acceso a la experiencia subjetiva de otras personas, más específicamente el papel de la literatura en ese proceso. Mientras que el primer texto describe la depresión objetivamente, el segundo describe la imposibilidad de hacer dicha descripción, centrándose en técnicas literarias que crean experiencias subjetivas desagradables, posiblemente semejantes a las sentidas por las personas deprimidas. Sugerimos que la literatura puede ser útil para la comprensión de algunos aspectos de la experiencia de estar deprimido, y que tal comprensión puede enriquecer la práctica psiquiátrica.
Literatura; psiquiatría; depresión; David Foster Wallace
The relation between literature and psychiatry is undoubtedly vast, and many perspectives can be taken on this field in order to understand how one can push the other even further - and it is not unusual to see those limits being blurred. For writers and readers alike the matter of mental disorders is a powerful theme with acclaimed pieces of fiction and non-fiction portraying heavy use of substances (for example, in Irvine Welsh’s Trainspotting), delusions (with Gombrowicz’s Cosmos) and mental states sometimes way too complex even to make suppositions about (Faulkner’s “Benjy” Compson in The Sound and the Fury); this list could go on exhaustively. Experiences involving certain elements of living with a mental disorder - such as alienation, the figure of the psychiatrist, and some aspects of treatment- are also richly depicted throughout literature, usually with critical lenses as one can observe in Sarah Kane’s 4.48 Psychosis or Machado de Assis’s The Alienist. If authors and readers can do so much with the mental health field, what is possible, on the other hand, for psychiatrists, people with mental disorders and their family’s to do with literature - a slightly more mundane variant of Italo Calvino’s question: Why (should a psychiatrist) read the classics?
A possible answer - and a “naive” one, to use the terms of writer and critic Orhan Pamuk (Pamuk, 2011)Pamuk, O. (2011). O romancista ingênuo e o sentimental. São Paulo, SP: Companhia das Letras. - could be that a psychiatrist can wonder how much of what is written in a literary arrangement is communicating a grander truth about the author’s life: a text could even suggest a diagnosis, one might say. Such attitude sounds, nonetheless, not much more than pure and rough curiosity, perhaps an invasive one since authors do not require anything of the sort when writing a book.
We believe that there are far more enriching ways to address a psychiatrist’s perspective on literature - more horizontal and productive ones, as least. One possible direction can be seen in the movement of narrative-based medicine articulated in the last two decades. It emerged as a reasonable response to complement the evidence-based model, providing a deeper understanding of patients and their context, a better doctor-patient relationship, and a therapeutic dimension in telling and in being listened to (Zaharias, 2018Zaharias G. (2018). What is narrative-based medicine? Narrative-based medicine 1.Canadian family physician Medecin de famille canadien, 64(3), 176-180.). This model can be extended to all medical areas, including psychiatry. Some authors suggest narrative psychiatry as a hybrid of therapy, clinical case elaboration and a tool for the profession’s self-understanding (Frank, 2012Frank, A. W. (2012). Narrative Psychiatry: How Stories Can Shape Clinical Practice (review).Literature and Medicine, 30(1), 193-197. doi: 10.1353/lm.2012.0009.
https://doi.org/10.1353/lm.2012.0009... ) - in practical terms, the usage of literary narratives to showcase the polyphony and the plural perspectives of mental illness in order to be connected with the real life of real people (Lewis, 2006Lewis, B. (2006). Listening to Chekhov: Narrative Approaches to Depression. Literature and Medicine, 25(1), 46-71. doi: 10.1353/lm.2006.0023.
https://doi.org/10.1353/lm.2006.0023... ). That is not to say that evidence-based practices do not create narratives - in a sense all practices do. However, narratives facilitated by this model tend to create disempowerment and generate “neurochemical selves” (Rose, 2003Rose, N. (2003). Neurochemical selves.Society, 41(1), 46-59. doi: 10.1007/bf02688204.
https://doi.org/10.1007/bf02688204... ), people revolving around the figure of the physician and of the pharmacological treatment to deal with their experiences. These narratives are carried in the third person, normally from the perspective of the physician or researcher, leaving the subjective experience of being mentally ill rather unexplored - this one often carried in the first person, even though that is not a necessary condition (Serpa et al., 2019Serpa, O. D., Leal, E. M., & Muñoz, N. M. (2019). The Centrality of Narratives in the Mental Health Clinic, Care and Research. Philosophy, Psychiatry, & Psychology, 26(2), 155-164. doi:10.1353/ppp.2019.0021.
https://doi.org/10.1353/ppp.2019.0021... ). In other words, evidence-based practice, albeit necessary, is not enough in face of how complex understanding, diagnosing, treating, and - most importantly - living with a mental illness actually is.
On the subject of depression, a fascinating analysis by Bradley Lewis (Lewis, 2006)Lewis, B. (2006). Listening to Chekhov: Narrative Approaches to Depression. Literature and Medicine, 25(1), 46-71. doi: 10.1353/lm.2006.0023.
https://doi.org/10.1353/lm.2006.0023... of one of Chekhov’s plays, Ivanov, allows us to understand how a piece of fiction can contribute to shaping psychiatric understanding and practice to some extent. Leaning on the fact that Chekhov was a physician, an exceptional writer, and a likely sufferer of depression himself, Lewis faces the multiple narratives concerning the main character’s illness, as articulated by the different characters throughout the play, against a single viewed elaboration of Ivanov’s suffering. This multiplicity of perspectives can be used as part of the reasoning against reductionist approaches of mental illness, as well as part of the apparel in a therapeutical relationship and in the decision-making process, the author argues - by not reaching one delimited approach to the problem, the potential to keep finding other approaches remains there, at least. We can suppose Chekhov had a determined view on the problem, as a physician or as someone who once experienced a similar scenario, but we can be certain he was open to and aware of many other perspectives. A “multiplicity” of them, to use Lewis’s terms.
While not disagreeing with Lewis, we state that a step can be taken in another direction on the matter of analyzing literary work, as we will try to demonstrate with the aid of a contemporary writer, David Foster Wallace. Focusing not as much on what is narrated as on how it is being narrated, we will attempt to show how literature could bring readers closer to the experience of being depressed - escaping the prison of representation. Expanding the narrative repertoire of psychiatrists has potential benefits, the same ones Rita Charon in her fundamental book “Narrative Medicine: Honoring The Stories of Illness” expects for all physicians carrying on this practice, that is to increase their “competence to recognize, absorb, interpret, and be moved by the stories of illness” (Charon, 2006, p. vii) and of the people experiencing them.
Writing about depression and writing depression
David Foster Wallace (DFW) was born in 1962 and died in 2008. He was a North American writer, mostly of essays and fiction, and as with many writers, his personal life and his creative work intertwine in a few different ways. It is known that DFW suffered from major depression at least since young adulthood and spent most of his life dealing with it alongside heavy use of substances - through medications and electroconvulsive therapy - until committing suicide (Max, 2013Max, D. T. (2013).Every love story is a ghost story: a life of David Foster Wallace. London, UK: Granta.). It is also of our knowledge that he wrote at least two pieces of fiction explicitly depicting depression. The first, published in 1984 in his college magazine, The Amherst Review, at 22 years of age, and the second one 15 years later, at Harper’s Magazine - perhaps one of the most prestigious in the United States - that was later on added to the collection of short stories called Brief Interviews With Hideous Men.1 What is objectively available for us, therefore, are the two texts in their differences and similarities over the same topic, separated 15 years one another, 15 years in which DFW kept experiencing depression and perfecting his writing techniques and style. Initially from the first person and with direct speech, and later on from free indirect speech, a very intense and characteristic one that granted him his unique style (Wood, 2017Wood, J. (2017).Como funciona a ficção. Sao Paulo, SP: SESI-SP Editora).
In the first short story, as matter of fact regarded as DFW’s first published work, with some autobiographical elements (Clare, 2018Clare, R. (2018).The Cambridge companion to David Foster Wallace. Cambridg, MA: Cambridge University Press,), The Planet Trillaphon As It Stands In Relation To The Bad Thing, we have a first-person narrator using direct speech that welcomes the reader with some sort of empirical authority that “qualifies” him to explain how antidepressants and how depression feels like:
I’ve been on antidepressants for, what, about a year now, and I suppose I feel as if I’m pretty qualified to tell what they’re like. They’re fine, really, but they’re fine in the same way that, say, living on another planet that was warm and comfortable and had food and fresh water would be fine: it would be fine, but it wouldn’t be good old Earth, obviously. (Foster Wallace, 2014Foster Wallace, D. (2014). The David Foster Wallace Reader [eBook Edition]. Penguin., p. 5)
As a matter of fact, many aspects of such experience - symptoms, family support, psychiatric hospitalization, psychiatric consultations - are approached in detail here. Classical psychopathological descriptions are brought with “the business of crying for no reason,” “feeling nauseated all the time” and even “what I guess now was a hallucination.” One may argue that very few elements are missing to elaborate a classical clinical story: male, twenty years, Economy undergrad, in use of imipramine, one suicide attempt, electroconvulsive therapy indicated. In this text, DFW gives details on a psychiatric infirmary, on how his family managed the situation, how doctor appointments go, and so on. Indeed, it is not a mere inventory of occurrences; the author delivers all this with a humorous glimpse, winding prose, high voltage irony, and a vertiginous vocabulary. In addition to that, here he delivers us several metaphors that depict somehow what he is experiencing; the narrator argues that it is difficult but not impossible to describe what is going on. In one of his most memorable attempts, he states that being depressed is as if every part, organ, cell, and atom in his body was feeling “ill”. In the utter end, being depressed is to “become the Bad Thing itself”. Another metaphor gives the short story its title: being on anti-depressive medication “feels like” living on another planet, with certain characteristics that do not feel like planet Earth, even though it is “fine”.
Several years later The Depressed Person, however, receives the reader in a very different fashion and uses radically different techniques for such. The narrator in free indirect speech - entangled with but different from the main character (Wood, 2017Wood, J. (2017).Como funciona a ficção. Sao Paulo, SP: SESI-SP Editora), the Depressed Person - is very transparent in admitting the failure in communicating what was going on this time:
The depressed person was in terrible and unceasing emotional pain, and the impossibility of sharing or articulating this pain was itself a component of the pain and a contributing factor in its essential horror.
Despairing, then, of describing the emotional pain itself, the depressed person hoped at least to be able to express something of its context - its shape and texture, as it were - by recounting circumstances related to its etiology. (Foster Wallace, 1998Foster Wallace, D. (1998). The depressed person.Harper’s Mag. 296, 57-64. Retrieved from https://harpers.org
https://harpers.org... , p. 57)
Other elements of description are rather scarce this time; at our disposal only a few facts regarding the character’s childhood and some details of her routine and therapy - it is considerably more difficult to create a “clinical case” as done previously or to match criteria for any psychiatric condition. Furthermore, in opposition to what was shown previously, here we have exactly one metaphor in the entire story - which even then is later on removed from the Brief Interviews With Hideous Men’s version. It is about the anguish of depression being precisely the impossibility of sharing what the character was feeling:
[…] as for example if her very life depended on describing the sun but she were allowed to describe only the shadows on the ground. (Foster Wallace, 1998Foster Wallace, D. (1998). The depressed person.Harper’s Mag. 296, 57-64. Retrieved from https://harpers.org
https://harpers.org... , p. 62)
Despite the several statements about the impossibility of being understood, this text gives the reader a humorous hint of how it could at least be read - through its “shape and texture”. Here, when some content is delivered - about some of the character’s habits or thoughts, for instance - how they are delivered gains the spotlight. All the descriptions provided, from other characters to the depressed person’s experiences, are all but simple - never a single sentence or adjective seems enough. Here we have extremely long adjectives and winding utterances, in the middle of which new utterances appear to set us even further apart from the conclusion and sense-making of the first one, taking paragraphs or even full pages to reach a final point. We can argue that the reader loses his breath - literally and literarily- in his attempt to understand what is being said. A fine example is the following paragraph, constituted of a single and arduous phrase:
The approximately half-dozen friends whom her therapist - who had earned both a terminal graduate degree and a medical degree - referred to as the depressed person’s Support System tended to be either female acquaintances from childhood or else girls she had roomed with at various stages of her school career, nurturing and comparatively undamaged women who now lived in all manner of different cities and whom the depressed person often had not laid eyes on in years and years, and whom she called late in the evening, long-distance, for badly needed sharing and support and just a few well-chosen words to help her get some realistic perspective on the day’s despair and get centered and gather together the strength to fight through the emotional agony of the next day, and to whom, when she telephoned, the depressed person always apologized for dragging them down or coming off as boring or self-pitying or repellent or taking them away from their active, vibrant, largely pain-free long-distance lives. (Foster Wallace, 1998Foster Wallace, D. (1998). The depressed person.Harper’s Mag. 296, 57-64. Retrieved from https://harpers.org
https://harpers.org... , p. 57)
The tiresome and practically obsessive descriptions - that use all the narrator’s and reader’s energy to never miss a detail of the circumstances - seems to corroborate what is said in the beginning: in the impossibility of describing depression itself, one must describe - depressively - all its surroundings.
Throughout this short story, we can sense an echo from the previous text, in which the author used the metaphor of “becoming The Bad Thing” - a transformation that includes all organs of perception, and therefore perception itself and the world that it reveals to the depressed person. There are no friends or family, but a “Support System”, never peace, but a “Daily Quiet Time” - there’s even no name for the character but “The Depressed Person”. In this ironic formality and concordance with medical terms and coping strategies, the narrator creates a world in which depression seems to have infiltrated itself to the very core of perception, a metaphor firstly told in The Planet Trillaphon and Its Relation to The Bad Thing and now fully demonstrated. In addition to that, we can point some sort of cautionary tale - that even these coping strategies and therapeutic alliances can be captured by distorted perceptions.
One final point is a matter of fact a parallel one. Throughout the text, we see a certain form of rumination when DFW’s narrator talks about the character’s therapist. First, a quick mention in the actual main text of the short story. Later on, when the subject of the therapist is once again mentioned, a footnote emerges and talks more freely about the same subject. This process carries on getting more intense, and the same topics are revisited several times trough out the “actual” story, up until the point of having footnotes as long as an entire page. This formal organization - that later on was remarked as one of DFW’s signature moves - creates a time within the time of the narrative, firmly attached to the past and sorrows, in such a way that the main text becomes muffled by the white noise of inescapable thoughts.
After exploring these literary techniques, we must cautiously remember that they must not be seen as a sign of someone’s depression. Such elements of style are not brought here with such intention - a naive one - and certainly not with such capacity. It is not of our knowledge or interest if those pieces of fiction were written about DFW’s depression or if he was depressed while writing them - indeed, as far as we know there was a long process of edition and modification of a piece of work intended to be published, and not of someone’s mental experiences or testimony, as detailed in documented letters between the author and his editor, as well as in his notes for The Depressed Person (Morsia, 2016Morsia, E. (2016). The Composition of The Depressed Person.Textual Cultures, 9(2). doi: 10.14434/tc.v9i2.19525.
https://doi.org/10.14434/tc.v9i2.19525... ). That said, our aim with this literary analysis was to point how some narratives about mental illness can have effects on their readers, particularly if carried on with exceptional literary talent, and that this is of great value for those who practice clinical psychiatry since it can be helpful to achieve a broader grasp of psychiatric phenomena. Utter-mostly, it is an attempt to decrease the gap between the patient’s illness experience and how physicians can elaborate it (Carel, 2015Carel, H. (2015). The cry of the flesh (The Art of Living). New York, NY: Routledge.).
We argue that a fictional narrative on illness is more than a sequence of utterances about statements and actions constituting a plot - even an allegedly objective non-fictional piece of writing carries arrangements and techniques in which a particular style emerges. Hence, several elements in a text - including core aspects of form, the order in which events are presented, narrator perspective, and used lexicon - tailor not only the reader’s experience but the very content of the narrative. In these two DFW’s short stories we approach the experience of being depressed with two contrasting results- one text tells us about what being depressed feels like, which can in many ways be very enlightening; the other, nonetheless, attempts to make the reader feels what depression is like- a true performance, given all the formal experimentations attempted by the author.
It follows that this text, in particular, can be seen as a way into Jaspers’ empathic understanding, a core dimension of his psychopathology, in which someones imaginative re-creation of someone else’s experiences through normative patterns can create meaningful connections between and amongst thoughts and reactions (Thornton, 2007Thornton, T. (2007). Should comprehensive diagnosis include idiographic understanding? Medicine, Health Care and Philosophy, 11(3), 293-302. doi:10.1007/s11019-007-9117-8.
https://doi.org/10.1007/s11019-007-9117-... ). The result of such procedure - a narrative - can highlight the particular, subjective experience of someone, in the midst of the general scenario taking place - with no downside to either perspective (Thornton, 2007), and hopefully for the benefit of both.
One may wonder if this sort of approach does not configure an excessively instrumental one: to read with a certain objective beyond the fruition of the text itself, leading to rather complicated “uses” of literature, such as school curricula or even recommendations to patients. This concern - not naive at all - lays in the core of literary criticism and in its intersections with other fields. Being a somewhat unresolved problem, however, at this point, we can only suggest that regardless of intentions and finalities, the experience of reading has effects and is prone to change someone’s perception of the very text being read, a view shared by other authors (Evans, 2009Evans, Martyn (2009). Roles for literature in medical education. In F. Oyebode (Ed.), Mindreadings: Literature and Psychiatry (pp. 15-24) [ebook Edition]. RCPsych Publications.). Hence, literary texts should not be “used”, but certainly considered.
To conclude, aware of the possibilities elicited by narrative psychiatry, we suggest that the experience of reading such texts can broaden the capacity of clinicians and family members to re-create imaginatively someone else’s experience - in a sense, giving it a context helps to give meaning to what sometimes appears to be a meaningless situation (Holmes, 2000Holmes, J. (2000). Narrative in psychiatry and psychotherapy: the evidence?Medical Humanities, 26(2), 92-96. doi: 10.1136/mh.26.2.92.
https://doi.org/10.1136/mh.26.2.92... ), a meaning now available to be shared, read and written about.
A previous version of this manuscript was delivered, as short oral communication, on August 24th 2019 at the 19th WPA World Congress of Psychiatry, Lisbon, Portugal.
Copyright: © 2009 Associação Universitária de Pesquisa em Psicopatologia Fundamental/ University Association for Research in Fundamental Psychopathology. Este é um artigo de livre acesso, que permite uso irrestrito, distribuição e reprodução em qualquer meio, desde que o autor e a fonte sejam citados / This is an open-access article, which permits unrestricted use, distribution, and reproduction in any medium, provided the original authors and sources are credited.
Financiamento/Funding: Este trabalho não recebeu apoio / This work received no funding.
- Carel, H. (2015). The cry of the flesh (The Art of Living) New York, NY: Routledge.
- Charon, R. (2006).Narrative medicine: honoring the stories of illness New York, NY: Oxford University Press,
- Clare, R. (2018).The Cambridge companion to David Foster Wallace Cambridg, MA: Cambridge University Press,
- Evans, Martyn (2009). Roles for literature in medical education. In F. Oyebode (Ed.), Mindreadings: Literature and Psychiatry (pp. 15-24) [ebook Edition]. RCPsych Publications.
- Frank, A. W. (2012). Narrative Psychiatry: How Stories Can Shape Clinical Practice (review).Literature and Medicine, 30(1), 193-197. doi: 10.1353/lm.2012.0009.
- Foster Wallace, D. (1998). The depressed person.Harper’s Mag. 296, 57-64. Retrieved from https://harpers.org
- Foster Wallace, D. (2014). The David Foster Wallace Reader [eBook Edition]. Penguin.
- Holmes, J. (2000). Narrative in psychiatry and psychotherapy: the evidence?Medical Humanities, 26(2), 92-96. doi: 10.1136/mh.26.2.92.
- Lewis, B. (2006). Listening to Chekhov: Narrative Approaches to Depression. Literature and Medicine, 25(1), 46-71. doi: 10.1353/lm.2006.0023.
- Max, D. T. (2013).Every love story is a ghost story: a life of David Foster Wallace London, UK: Granta.
- Morsia, E. (2016). The Composition of The Depressed Person.Textual Cultures, 9(2). doi: 10.14434/tc.v9i2.19525.
- Pamuk, O. (2011). O romancista ingênuo e o sentimental São Paulo, SP: Companhia das Letras.
- Rose, N. (2003). Neurochemical selves.Society, 41(1), 46-59. doi: 10.1007/bf02688204.
- Serpa, O. D., Leal, E. M., & Muñoz, N. M. (2019). The Centrality of Narratives in the Mental Health Clinic, Care and Research. Philosophy, Psychiatry, & Psychology, 26(2), 155-164. doi:10.1353/ppp.2019.0021.
- Thornton, T. (2007). Should comprehensive diagnosis include idiographic understanding? Medicine, Health Care and Philosophy, 11(3), 293-302. doi:10.1007/s11019-007-9117-8.
- Wood, J. (2017).Como funciona a ficção Sao Paulo, SP: SESI-SP Editora
- Zaharias G. (2018). What is narrative-based medicine? Narrative-based medicine 1.Canadian family physician Medecin de famille canadien, 64(3), 176-180.
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