According to some researchers, the startling effectiveness of SSRIs has probably been due to placebo effects.14 I know a number of scientists working on depression and the brain who have been furious about the stubborn hold the idea of a chemical imbalance has had, not just on the popular imagination, but on psychiatry as a profession. Research on the brain and depression is vital. I do not want to suggest it isn’t. SSRIs might have unknown and as yet unstudied effects that are truly helpful. Many people swear the drugs have changed their lives. My point here is that rash simplifications are not only unhelpful, they may distort reality altogether. As I have noted elsewhere, placebo can have powerful effects, which are now being studied. What role does language play in placebo? Could writing produce placebo effects? If it does, I would suggest that it is connected to language as relational. It is for communication and as such is addressed to another person. In some cases, the other person is one’s self, but always the self as an other.
I have long been attracted to M. M. Bakhtin’s theory of language as fundamentally dialogical: “Every word is directed toward an answer and cannot escape the profound influence of the answering word that it anticipates”15 (italics in original). Bakhtin emphasized words as inherently social with continually changing, open-ended meanings that depend on their use. A word in the mouth of one person is not the same as the same word in the mouth of another. When the doctor pronounces a diagnosis, there is a world of authority and settled language use behind her. When the patient utters the same word, its meaning has changed. Language is shot through with power relations.
By their very nature, words can be shared with others, but they also figure in our private mental geography, and their meanings are personally coded. The stone slabs in Ms. P’s story evoke both Poe’s macabre narratives and a host of cheesy horror films from the fifties and sixties, but they might have had other associations for her as well, some conscious, others unconscious. Her choice of stone slabs surely had a potent affective meaning, one that is part of her personal psychobiological history but that cannot be separated from the words and the images of the broader culture, all of which played a role in shaping her character and her illness.
My classes in the hospital might be described as adventures in response and dialogue. The students’ job was to respond to a text—often a short poem, always a good poem. I used works by Emily Dickinson, John Keats, William Shakespeare, Arthur Rimbaud, Marina Tzvetaeva, and Paul Celan, among others. The students could respond in any way they wanted. There were no rules. If something in the poem reminded them of a story, they could write a little story, true or fictional. If they wanted to respond with a poem of their own, they could do that. If a single word in the poem, “blue” or “pain” or “sky,” made them think of a person or place, and they wrote a description, that, too, was okay. All responses were welcome. The first twenty minutes of the hour were devoted to writing, and then each student would read his work aloud and the rest of us would comment on it.
I will call another writing student Mr. J. He had been diagnosed with bipolar disorder. I will say frankly that I loved Mr. J. He came to my class four times and was an eager and attentive student. His response to a Keats poem was to write his own beautiful poem in the same rhyme and meter. He produced this little masterpiece in twenty minutes. I wish I had asked him for a copy, but the students were free to give me their work or to keep it, and Mr. J took his poem with him. To say that this man had extraordinary gifts is an understatement. He was well educated and talented, to be sure, but his mania probably played a role in his writing facility.
I also had a schizophrenic student who suffered from the delusion that she was married to God. There is a long history in Christianity of the church as “bride” to the “bridegroom” Christ. For a number of Christian mystics, marriage to Jesus had a literal and highly erotic character, so in another historical context Ms. Q’s delusion would have taken on another meaning. This doesn’t mean that there might not be some strong neurobiological similarities between a fourteenth-century saint, such as Saint Catherine of Siena, for example, and Ms. Q, were we able to uncover them. Dopamine has been implicated in psychosis, its delusions and hallucinations in particular. But can the content of delusions and hallucinations be described as purely dopamine induced and left at that, even if, let us say, it becomes clear that dopamine levels correspond beautifully to Ms. Q’s fantasies of wedded bliss with the deity? The content of delusions and hallucinations are at once personal and cultural, and that content may affect the development of the illness. How exactly do we connect the third-person view that links dopamine to delusion to the specific first-person story of Ms. Q’s marriage to God?
For a number of my students, English was their second language, and they spoke it haltingly. I had them write in their own languages, even if I and the other members of the class did not understand what they had written. If this sounds like madness in the madhouse, I beg to differ. I would tell the student that the rest of us wanted to hear the music of her own tongue, that the unfamiliar words and their rhythms would give us a sense of meaning that was not denotational but nevertheless important. The assumption here is that meaning is carried not only by semantics but also in sound and melody. Afterward, I would have the student translate what she had written to the best of her ability, and its significance always came through.
Arguably, my class was a class in “expressive writing.” The workshop was not about teaching the students to become writers or even better writers. I didn’t correct their grammatical errors or smooth out their prose or advise them about strong verbs or sentence rhythms, but I did read every piece carefully and comment on its form, content, and meaning, as I had understood it. I never lied, but I always found something interesting to ask the writer. Their responses were often personal, often sad, often illuminating. Although some patients told stories about their lives, others were incapable of organizing narratives and wrote brilliant word salad. In Campbell’s Psychiatric Dictionary, it is defined as “a type of speech . . . characterized by a mixture of phrases that are meaningless to the listener and, as a rule, also to the patient producing them.”16 In my class, I treated word salad as meaningful art.
In his 1896 textbook on dementia praecox, what is now called schizophrenia, the psychiatrist Emil Kraepelin gave an extended example of a patient’s response to his question “Are you ill?” I will quote only the man’s first two sentences: “You see as soon as the skull is smashed and one still has flowers with difficulty, so it will not leak out constantly. I have a sort of silver bullet, which held me by my leg, that one cannot jump in, where one wants, and that ends beautifully like the stars.”17 Although the sentences take surprising turns, they do produce meanings, which I would call emotional-poetic but also motor-sensory. In the first sentence a smashed skull and a smashed vase for flowers appear to have collapsed into each other. A vase with flowers would leak water, but there is also the sense that thoughts flower only with difficulty from the speaker’s metaphorically broken skull. The word “smashed” is violent, and the semantic leaps in the following sentence are even more dramatic, but the silver bullet, the man’s leg, and an inability to “jump in” suggest forms of injury that nevertheless find their beautiful resolution in stars. Just as it is impossible to paraphrase poems, to assign them fixed meanings without disrupting their essences, it is impossible to supply an alternative, sensible, paraphrased meaning for word salad because it breaks up the rational motion of a sentence and twists semantics. Nevertheless, affective meanings “leak” through, to borrow the patient’s evocative verb, and those verbs are felt as a kind of imaginary or simulated action.
Kraepelin’s patient was talking, not writing. During my years at the hospital I read a host of texts like the one above, mysterious coded works that had to be unraveled by questioning the writer. My questions, born of genuine interest, if not outright fascination, required, I must say, my whole concentration, and my interest and concentration were vital to the therapeutic
effects in the room, whether one understands them as a form of placebo or transference or dialogical healing that takes place in the realm Martin Buber called “the between.” When people talk, the words, unless they are recorded, evaporate into air. It is difficult to retrieve them even a few minutes later. We may recall the gist of what we or another person said, but the exact wording has vanished. Writing is fixed. Once the words have found their way onto paper, they become objective, estranged from the body of the writer. Although they were born of a body and the hand that writes, the articulations have left it for another zone that can be shared with others, a static text that can be examined again and again.
In one class I gave the students the poem “Litany” by Robert Herrick (1591–1674). Its last line is repeated in all twelve stanzas. It begins:
In the hour of my distress
When temptations me oppress
And when I my sins confess,
Sweet Spirit, comfort me!
In response, a student wrote:
It was my last hour,
In my own bed.
No sickness was present,
And no doubts.
Herrick’s last stanza:
When the Judgment is reveal’d,
And that open’d which was seal’d,
When to Thee I have appeal’d,
Sweet Spirit, comfort me!
My student wrote in response:
No judgment
Or revelation came
As there was no appeal.
I sought not a sweet spirit,
Only the darkness to comfort me.
A depressed patient responded to Herrick’s deathbed poem with what is clearly an answering poem of despair in verses that may convey a suicidal wish. Did my use of the Herrick poem merely harden the patient’s depressive feelings? Why not choose a “happy” poem, as the volunteer writing teacher I replaced at Payne Whitney had continually done? “I try to give them hope,” she said. These words were addressed loudly to me in a classroom of adults, as if they weren’t present. She adopted the grating voice of a primary school teacher speaking to young children. This woman was my introduction to teaching at the hospital. I sat in on her class before embarking on my own.
The hopeful poem she had chosen was of the kind one finds on saccharine greeting cards. After the class, one of the patients passed the teacher and said loudly, “That poem sucked.” Indeed, it did. Mental illness causes suffering, but it does not necessarily cause stupidity or insensitivity. (I suspect it is far worse to haul in ignoramuses who know nothing about either literature or psychiatry into the units than to have no writing teacher at all.) Far from being insensitive, I discovered that the patients in my classes, perhaps especially psychotic patients, were almost preternaturally sensitive to what I came to think of as floating feelings in the room that were as potent as smells. The sentence “I try to give them hope” with its clear demarcation between “I” and “them” smelled to high heaven, as did the stupid poem offered up as a vehicle of said hope. At the very least, all feelings, whether manic or despairing, deserve to be treated with dignity. My classes succeeded, at least in part, because the students felt free to express gloom, frustration, hatred, paranoia, and black humor.
I praised the student’s response to Herrick. I called her poem a litany to “Litany.” I said I especially liked the last verse, which mimicked the simplicity of Herrick’s verse and noted the beauty of the borrowed words, the assonance of the long e sounds in “appeal,” “sweet,” and “me,” and the harsh wit of my student’s last line: “Only the darkness to comfort me.” Neither her writing nor my comments lifted the patient out of her depression, but they did have a visible lightening effect on her mood. The sullen, dejected young woman who had shuffled into the room became almost garrulous. We talked about her poem’s meanings, her turning away from a transcendent spirit. We joked about doctors and noted Herrick’s cynicism about them. The discussion was lively. It will surprise no one that many patients keep their negative thoughts from their doctors, that they flush and/or hide pills that make them feel bad or bloated or dull, or that they often worried I would show their writing to their psychiatrists. I did not. I went to the “authorities” only once. A man in my class declared loudly and angrily that as soon as he was out of the hospital, he was going to kill his family and then himself.
Writing is a perceived transition from inside to outside, and that motion is in itself a step in the right direction, a passage into a dialogical space that can be seen. Writing is always for someone. It takes place on the axis of discourse between me and you. Even diaries and journals are for an other, if only another self, the person who returns to the words years later and finds an earlier version of what he or she is now. Because written language exists in this between space, not the writer as her body, but the writer as her words for a reader—who may be an actual person addressed in a letter, for example, or an imaginary person out there somewhere—writing lifts us out of ourselves, and that leap onto paper, that objectification, spurs reflective self-consciousness, the examination of self as other. The writing rather than the talking cure uses the textual object, that alien familiar, as a site of shared focus in a classroom.
It is further true that I discover what I think because I write. The act of writing is not a translation of thought into words, but rather a process of discovery. In his discussion of language in Phenomenology of Perception, Merleau-Ponty writes, “It is the subject’s taking up of a position in the world of his meanings.”18 This taking up of meaning always already implies other people. Writing may have an additional value, however, for people who find themselves in the grip of delusions or manias, are overcome by obsessions such as compulsive washing, or are so depressed that the act of lifting a pencil feels close to impossible. Writing is a movement from one place to another, a form of traveling, and once the journey is over, the resulting text may help organize a person’s view of her subjectivity as she regards it now from the outside, instead of from the inside. The words become that alien familiar. Sometimes this externalized self on paper can become a lifeline, a more organized mirror image that makes it possible to go on. Near the end of a journal she kept during the year she suffered from acute psychotic disorder and was hospitalized, Linda Hart wrote, “Writing this journal has kept me on the edge of sanity. Without it, I believe I would have tipped over into the chasm of madness from where I could not be reached.”19 This is a dramatic statement from a single person, but we must be careful not to treat one person’s story as evidence of nothing.
It turned out that a number of the qualities that were important to teaching writing in the hospital are impossible to measure or downright intangible, but I will try to touch on them. Early on, it became clear that the fact that I was a “real” writer who had actually published books was important. I wasn’t a soft-hearted, well-meaning Ms. Nobody whom the volunteer department had snatched off the street of good intentions. This fact cemented my authority as a person who might actually have something to say about writing, which provided a context of seriousness for the class as a whole. My students also must have understood viscerally that I do not regard mental patients as members of another species. Each person has a story, and that story is part of her or his illness. As Hippocrates famously said, “It is more important to know what person the disease has than what disease the person has.” The zeal for diagnosis, represented by the DSM and its desire to isolate one mental illness from another, has created a static model of disease that inevitably collapses in on itself. Symptomology must be a study of dynamic forces—the motion of an illness that cannot be separated from a self or being, a self or being that has a narrative form and that may be described in plural terms.
The self is just as puzzling a concept as mental, mind, and consciousness, but let me simply say this: what has sometimes been called “the narrative self,” a linguistically constructed union of conscious bits and pieces of memory that together form a story and are connected temporally to
create a coherent “self,” beneath which there is more or less no self, is not at all my conception of the narrative self. The narrative self I am proposing involves prelinguistic motor-sensory-emotional-psychobiological patterns developed through interactions with important others from infancy onward. It is from this implicit rhythmic underground that explicit stories are created in memory, stories that are not strictly veridical in any sense of that word but are, rather, in varying degrees, forms of fiction.20 Whether one thinks of our continually revised autobiographical memories as produced through Freud’s “deferred action” or through the neurobiological term “reconsolidation” doesn’t matter. What has not been well studied, but which should be, is the role that language plays in conscious memory over time, how once it is retrieved, a memory is reconfigured through both emotion and the words one uses to retell it aloud to others or to one’s self.