Throughout human history, few people have been more consistently feared and abused than the insane, and our misunderstanding of mental illness has typically determined how sufferers are treated. From ancient times – when psychological disturbances were attributed to demonic possession – to attempts in recent centuries to place insanity under the umbrella of medicine, where it belongs, the story of mental healthcare in the western world is fraught with misdiagnoses and crackpot therapies: purging and bloodletting, shackles and straitjackets, trepanning and lobotomies.
I touch on some of these misconceptions in my novel Dark Water, set in 19th-century Boston and Nantucket, Massachusetts – and on the open waters of the Pacific Ocean, where my narrator, Hiram Carver, takes up his first position as ship’s doctor on USS Orbis in 1833. Among the officers is a man who will obsess him for the rest of his career: William Borden, the Hero of the Providence. Years before, Borden saved several men from mutiny and led them in a dinghy across the Pacific to safety. Now he breaks down, in what seems like an irretrievable slide into insanity. Carver meets Borden again as assistant physician at the Charlestown Asylum for the Insane in Boston, where he devotes himself to Borden’s cure, convinced that it depends on drawing out the truth about that earlier voyage.
Carver rejects the usual forms of coercion when approaching his patient, pioneering an early form of talk therapy that will plumb the “dark water” of the mind. He faces all the challenges of working in a pre-Freudian age, prior to a developed concept of the unconscious, and before the advance of neurology and what we now call psychiatry. While writing Dark Water I took a look at how other books, both fiction and non-, have conceptualised mental illness and its treatment. Here are my top 10:
1. The White Hotel by DM Thomas
In this sly novel about Sigmund Freud, the father of psychoanalysis appears both as a character and author of the fictional study of Frau Anna G, who is tormented by “storms in her head”. The imperious Freud explains away his patient’s obscenely violent fantasies (which make up the early sections of the book) as the aberrations of a conflicted psyche. The novel’s shattering vision of the insane mass killings of the modern age, however, resists such neatly localised answers.
2. Regeneration by Pat Barker
It is 1917, and at Craiglockhart Hospital near Edinburgh psychiatrist William Rivers is tasked with curing shell-shocked soldiers and returning them to the front fit for purpose. Among his patients are the poets Siegfried Sassoon and Wilfred Owen, from whom Rivers – believing that the recollection of trauma is key to recovery – must coax their worst memories of active combat. Far from being a godlike figure, Barker’s healer is attractive because of his humility in the face of experiences he hasn’t himself shared.
3. Beyond the Glass by Antonia White
The last book in White’s May Quartet, based on her early life, gives us a nightmare glimpse of the punitive British asylum system of the 1920s. Like White, her heroine Clara Batchelor shows signs of mania following the collapse of a bad marriage, is certified as insane, and sent to Bethlem Hospital (better known as Bedlam) where “for months she was not even a human being; she was a horse. Ridden almost to death, beaten till she fell”’ – an unforgettable image of institutionalised terror.
4. The Divided Self by RD Laing
A groundbreaking exploration of sanity and madness that explains schizophrenia and its origins within the context of troubled family relationships. Though Laing’s theory has been challenged since he proposed it in 1960, his perspective remains exceptional due to its profound empathy with the afflicted. In his later writing Laing went even further, characterising madness not as an illness but as “a perfectly rational adjustment to an insane world”.
5. The Ha-Ha by Jennifer Dawson
The grand buildings and grounds of the hospital in this novel – published in 1961, after the passing of the reforming 1959 Mental Health Act but before the liberal mental health movement of the mid-60s and early 70s took off – are a prison where “the test of psychiatric cure”, as Dawson writes in an afterword, “was whether the patient was fitted back neatly into his (usually her) unquestioned slot” in society. Introverted Josephine Traughton, who lacks “the knack of existing”, seems set to be successfully “regraded” after a breakdown but hides out in the walled ditch, or ha-ha, in the hospital garden, and eventually escapes the roles forced on her.
6. Asylums by Erving Goffman
These four brilliant essays support Dawson’s and Laing’s intuition that confinement of the mentally ill can be a form of socio-political violence against non-conforming voices. In Goffman’s fiercely argued analysis, mental hospitals function as “total institutions” that aim to reinforce predicable behaviour – not just for inmates, but for staff, too.
7. An Angel at My Table by Janet Frame
New Zealander Frame relates without self-pity how she spent eight years in various psychiatric institutions in the 1940s and 50s after being misdiagnosed as schizophrenic, “a concentrated course in the horrors of insanity and the dwelling-place of those judged insane”. Against all odds she completed a volume of short stories, The Lagoon. In 1954 she was scheduled to have a lobotomy when the book won a national literary prize and she was released. She is not exaggerating when she says: “My writing saved me.”
8. The Drama of Being a Child by Alice Miller
A ringing rebuke to the Freudian model of childhood development, “according to which children are viewed as crafty creatures, dominated by wicked drives, who invent stories and attack their innocent parents or desire them sexually”. Miller is in no doubt that addiction, depression and other psychic disorders can be traced to actual mistreatment in childhood, however ordinary. In calling attention to how children internalise everyday punishments, Miller, writing in 1979, proved as influential as Laing in depicting the home as a primal war zone.
9. Equus by Peter Shaffer
The drama of being a child, writ large. Child psychiatrist Martin Dysart faces a challenge to his safe world view in the form of 17-year-old Alan Strang, who has evolved a private theology around the worship of horses and their primitive energy. Alan exhibits a Dionysian fervour which it is Strang’s job to tame, though he is secretly in awe of it. The catch: he can help Alan adjust to “normal” life, but the sacrifice will be the boy’s individuality.
10. Darkness Visible by William Styron
Styron’s account of being overtaken in late middle age by clinical depression’s “toxic and unnameable tide” is an urgent frontline report of how it feels when the mind turns “agonisingly inward”. Its publication in 1990 helped initiate a public conversation about the condition and launched the contemporary trend in depression memoirs. Yet the candour and paradoxical beauty of Styron’s remains unequalled. His description of the hospital where he slowly recovers as “a kinder, gentler madhouse than the one I’d left” is rich in tender humour; his final message charged with hope: that those who dwell “in depression’s dark wood” will at last emerge, like Dante climbing out of hell’s black depths, into “the shining world”.
• Dark Water by Elizabeth Lowry is published by Quercus, priced £16.99. It is available from the Guardian bookshop for £14.61 including free UK p&p.
