Use of literature in teaching psychopathology.

Abstract

Using a broad range of fictional and non-fictional literature could enhance the teaching of psychopathology. The benefits to student learning are enhanced by interaction with health behaviors in the socio-cultural context of the particular story. Often, health issues are presented to students in a decontextualized manner, which takes away from student interest and learning. In this article, we present a case example of the use of literature to teach schizophrenia to graduate students in counseling. We also present a rationale for use of literature to teach about mental health in a multicultural context.

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Many scholars have acclaimed the teaching of psychology using literature (e.g., Banyard, 2000; Boyatzis, 1992; Chrisler, Anderson, Fleming, Piedmont, & Hiam, 2000; Napolerano, 1988; Norcross, Potkay, 1982; Sommer, & Clifford, 2001; Radford & Smith, 1991). Literature, in the context of this article refers to any material of a non-technical nature (e.g. novels, newspaper, religious texts, anecdotes, proverbs, poems, graffiti) that captures or illustrates significant psychosocial concepts and practices. The use of literature as a teaching tool has been associated with (a) stimulating and maintaining student interest; (b) providing a `lively' social context or `laboratory' for exploring practical and situational specific psychological constructs; (c) widening student experience; (d) providing an alternative approach to studying psychological concepts and constructs; and (e) enhancing students' empathy with people with psychiatric illness (Fingerman, 2000; Norcross, et al., 2001; Potkay, 1982; Poorman, 2002; Radford & Smith, 1991). Some students find the pedantic and reductionist approach of the regular academic psychology textbook unmotivating. Complementing readings from basic psychology textbooks with a selection of fictional, factual and religious literature adds to greater student involvement and engagement with the psychological constructs under study.

Theoretically, the teaching of psychology using literature is allied to a number of approaches to learning: experiential (Heron, 1993; Knowles, Holton, & Swanson, 1998), and constructivism (Gadamer, 1975; Mayo, 2001). Heron (1993, p. 65) defined experiential learning as learning "knowledge by acquaintance" in literal or symbolic form and involving action, reflection, emotion and imagination. Literature or narrative methodology is a form of experiential learning that involves symbolic rather than literal experience and appeals naturally to the learner's imagination. It typically elicits an emotional reaction from the learner through his or her vicarious participation in the world of the narrator or storyteller or the identified main character. Constructivism as a learning approach fosters learning by encouraging the discovery and explication of meanings through the use of personal lenses and validation of the learning experiences through inter-subjectivity or the convergence of personal meanings (Gadamer, 1975). Literature or narrative analysis as a teaching tool presents multiple opportunities for both personalized and inter-subjective learning. Experiential learning and constructivism share the assumption that true learning is rooted in evocative learning and both personal and collective. Unlike with the largely cognitive oriented traditional didactics, experiential or constructivist based learning appeals to more elements of the human psyche: feelings, emotions, and cognitions, and therefore, achieve a higher learner level of retention long after the initial learning episode (Heron, 1993; Knowles et al., 1998).

From the point of view of multiculturalism as a theory and philosophy in ethical health care, the use of literature as a teaching tool makes it more likely that students of the health sciences will recognize the socio-cultural context of experience. The socio-cultural context is a prism through which clients act their worlds and practitioners make sense of client behaviors. Differences in socio-cultural backgrounds often translate into differences in paradigms or world-views about health status and associated indicators (LaFosse & Zinser, 2002). For instance, a significant problem for psychiatric evaluators of Hispanic clients is that of language (Mpofu & Beck, 2000). Even with some fluency in Spanish, evaluators may diagnose Hispanic patients differently than professionals of the patient's own culture. Marcos, Urcuyo, Kesselman and Alpert (1973) conducted a study, which explored the differences in the verbal elements of behavior in ten Hispanic Americans with schizophrenia. They found that these patients acted in ways, which are rational when viewed within the culturally bound beliefs and attitudes reflecting "machismo" and "spiritualism," and that English-speaking clinicians associated these behaviors with increased psychopathology. The researchers concluded that Spanish-speaking patients interviewed in English were described as more severely ill than when interviewed in Spanish. Use of literature to learn about psychopathology would sensitize students of health sciences and practitioners about the potential cultural blind spots that are likely to negatively impact on health care delivery.

An Approach to the Use of Literature to Teach Psychopathology

Eighty-six percent of psychology programs in the United States offer a class in abnormal psychology (Christopher, Griggs, & Hagans, 2000). However, only a minority of these programs use literature as teaching materials, and the practice is more likely at liberal arts colleges (Golding & Kraemer, 2000). The few that use literature for teaching tend to use "lived experiences" literature or autobiographies (Chrisler et al., 2000; Golding & Kraemer, 2000, Mayo, 2001; Norcross et al., 2001). For example, Norcross et al. (2001) had undergraduate psychology students taking a class in abnormal psychology study a selection of autobiographies. The students then completed an Autobiographical Review Form (ARF) in which they identified the book's biographical details, client characteristics (demographics, diagnosis, and causal attributions for the disorder), treatments (history of hospitalizations, types of treatments, attitudes toward treatments), and summary evaluations (suitability of book for clients or family members, degree of liking the book). Golding and Kraemer (2000) described a multidisciplinary course sequence for a 4-year liberal arts college in which teams of instructors from different subject disciplines designed a complimentary teaching-learning program on ways of knowing that used narrative methodology together with other teaching learning devices. These researchers concluded that the use of literature to teach core psychological constructs matched the traditional didactic methods in effectiveness.

Most of the published reports are on the use of literature to teach developmental psychology rather than psychopathology, and to undergraduate students (Johnson & Schroder, 2000). With few exceptions (e.g., Banyard, 2000; Chrisler, 2000, Norcross et al., 2001; Potkay, 1982), a majority of the reports on the use of literature to teach psychopathology are anecdotal, or do not give the procedural details that would enable replication and evaluation of the teaching regimen. The bias towards presenting anecdotal kind of reports and with undergraduate students is understandable in view of the fact that the typical undergraduate psychology course has a high content load (e.g., the standard psychopathology textbook is about 400 pages long, with double columns per page). With that kind of content loading, students tend to be exposed to anecdotes as these can be more efficiently processed within the teaching-learning time and content constraints. The psychopathology classes also tend to be large (about 300 students per class), which limits the quality of in-class discussion.

In this article, we present our experience with the use of literature in teaching graduate courses in psychiatric rehabilitation, and medical aspects of disabilities. These students will normally have taken an undergraduate course in psychopathology and are seeking a more context sensitive and personal reaction to the understanding and interventions with people with mental illness. We have found that the use of a wide range of literature (i.e., fictional, factual and religious) is effective to illustrate, and invite debate by graduate students on the nature of psychopathology. It also encourages an empathic understanding of psychiatric illness. Use of literature also avoids the problem of presenting graduate students with a repetition of the largely textbook-bound learning experience of their undergraduate degree years. Below, we present an illustrative case example on the use of a short story novel to teach psychiatric illness to a class of 17 graduate students taking a class in psychopathology.

Use of the Novel

As an example of the use of the novel to teach clinical diagnosis and classification of a mental illness, students were tasked to:

* Choose from a list of five literary works that portray a neurosis, psychosis or other mental disorders,

* Compile a case history or description of the story's theme, plot and main character as background to the clinical study.

* Provide sufficient short quotations to support interpretations and following the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994).

The assigned works were Gogol's Diary of a Madman and Other Stories (as translated from Russian by Ronald Wilks), Joseph Conrad's Heart of Darkness, Shakespeare's Hamlet, Marechera's Mind Blast, and Samuel Taylor Coleridge's Albatross Book of Verse. The students worked in groups of three to five based on their choice of literary works. The group teaching-learning format facilitated student preparation for class.

Students could also choose a literary work other than the ones listed if the title was widely read (e.g., as a school text). The students who chose to study works outside the prescribed list were required to inform the instructor in advance of the class so that they could be paired up with peers who may be studying the same work. Students electing to study a title other than the prescribed ones were encouraged to join an existing group with a prescribed title. Two students choose to study titles, which were not listed for the class. They also choose different titles from each other and therefore, were assigned to existing groups. The class met once a week, for two hours. Therefore, the students had about a week to read the chosen literature.

Gogol's `Diary of a Madman' was nominated by eight of the 17 students. The story presents a case of paranoid schizophrenia. The main character is Axenty Ivanov, the "madman" who ascribed `logic' (in his eyes) to whatever happened to him. These "happenings" were documented by the fictitious character Axenty Ivanov, who is the main character of the story "Diary of a madman". The story was elected for presentation during the class immediately following one at which students selected their literature readings. Students had a week to prepare for their presentation.

Following a panel presentation of the synopsis of Diary of a Madman by one group of students, the second group developed a case for an appropriate diagnosis, clinical picture, etiology, and prognosis for Axenty Ivanov by documenting key indicators on a flip chart. The discussion was then opened up to the rest of the class who commented on the appropriateness of the psychiatric characterization. Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) (American Psychiatric Association, 1994) criteria were applied, as was information from other required readings on mental disorders. The following case description resulted from the composite efforts of the class.

Clinical Picture and Diagnosis. To meet the DSM-IV criteria for a diagnosis of paranoid schizophrenia, it was necessary to indicate thought disorder with delusions and hallucinations. The students made the following observations, which were also the basis for class discussion:

Disturbances of thought. Ivanov complained of "learning and seeing things" he had never seen or heard in the past (pp. 19-20). This has been called the trema phase in the development of delusions in people with schizophrenic (Kaplan & Shaddock, 1998). Prior to admitting to strange sensations, Ivanov had just convinced himself that two dogs had conversed within his hearing in understandable language. Subsequently, he `reads' a `letter' written by the dog Medji to Fidele (another dog), in which Medji described Ivanov as "a hay haired chap who is worse than a servant" (p.19). Such hallucinations in which `conversations' about the self are `heard' are typical of people with schizophrenia.

Students also noted that Ivanov showed some key characteristics of schizophrenic disorders such as perceptual distortions of time, private logic, abrupt blocking of a stream of thought and mystical-magical thought. For example, they noted that in dating his diary, Ivanov admits to days without dates and writes dates such as "April 43rd 2000" (p.33). Students observed that Ivanov's use of private logic is shown by the fact that he `discovered' that China and Spain are one and the same country, that every cock has a Spain under its feathers and that "women are in love with the devil" (p.36).

Delusions of persecution and jealousy. Students noted the fact that Ivanov was quite convinced that the dog Medji was jealous of Sophie's "increasing fondness" of him and that for the same reason, the head of department had "vowed undying hatred" for him and does him harm at every turn (p.31) as evidence of delusions of persecution and jealousy. They noted that Ivanov's imagined a pending marriage to the Director's daughter, Sophie, in which he foresaw great happiness for the two of them "in spite of hostile plots" against them (p.33) as further evidence of delusions of persecution and jealousy.

After being punished by some Spanish official for impersonating King Ferdinand, Ivanov concludes that France is the cause of his woes, especially Polignac (foreign minister in the French government during the early 19th century). He also concluded that he was a victim of the Spanish Inquisition. Students cited these citations as evidence for delusions of jealousy and persecution.

Delusions of grandiosity. In the story, Ivanov reports of perceiving "In a flash" that he must be the King of Spain and not the civil service clerk he had always imagined himself to be (of which he, in fact was). He signed himself as Ferdinard VIII on some official document at his place of work. Prior to this revelation of his kingly state, Ivanov had been quite positive that he could get promotion if he wanted, to the rank of "Colonel or even something higher" (p.23). Students noted that this self-perception was indicative of delusions of grandiosity.

Mystical--magical thinking. Students observed the following as indicating mystical-magical thinking by Ivanov: (a) Ivanov was quite convinced that the moon was made in Hamburg by some "lame cooper" whose poor workmanship "makes it stink" (p.38); and (b) A reason that Ivanov gave for not recognizing his own royal personage earlier was because the human brain is not situated in the head. Instead "it is carried by the wind from the Caspian Sea" (p.34).

Etiology. The students argued that a defective mother-child relationship was basic to Ivanov's psychosis. Their evidence for defective mother child relations was that toward the end of his diary, Ivanov pleads with his mother to accept him since no one else would accept him (p.41). The students also speculated that it was this feeling of rejection that he projected onto the world; and thus making him see other people as plotting against him. They also observed that office-work' with its formalism did not provide a surrogate mother parent. Instead, it might have reinforced the feeling of cold rejection experienced in the early years and thus adding to the psychosocial stress and psychosis. The students also considered Ivanov's mixed feelings toward Sophie as further evidence to support the mother-parent rejection hypothesis. As an example of unresolved mother-child conflicts, the students noted that although Ivanov was strongly drawn toward Sophie, he also felt that she was quite rejecting (for which reason Ivanov considered Sophie to be in love with the devil.).

Prognosis. Ivanov's initial experience of schizophrenia was at 42 years of age. Students regarded Ivanov's chances of recovery as good and on the basis that people with late-onset schizophrenia had a better chance of recovery than those with early-onset. The students also pointed out that Ivanov had been doing well at his job, which is further evidence in support of a good prognosis. In addition, the students noted that toward the end of his diary, Ivanov was quite depressed by his condition, a feature of the schizophrenic syndromeassociated with a good outcome (Kaplan & Shaddock, 1998). As evidence of depression in Ivanov, the students cited the fact that Ivanov referred to himself as "a miserable wretch" with nothing of his own (p.40).

Pedagogical Observations and Potential Applications

Our experience with the use of literature to teach psychopathology is that it challenges students to consider diagnosis, clinical features, etiology, and prognosis from the socio-cultural perspective presented by the story. For example, the students were able to note that delusions by Ivanov about the Spanish Inquisition were related to a historical fact of his period, and that the objects of delusion by people with mental illness may be selected from their broader significance in their society rather than purely from application of private logic. However, private logic may be an attempt to reconstruct those experiences in novel and personally satisfying ways. The opportunity to empathize with individuals experiencing mental illness from their historical period (or socio-cultural context) is a benefit to learning that is not possible with sole reliance on the brief anecdotal accounts that are found in most textbooks on psychopathology or psychiatric rehabilitation. Students reported a greater appreciation of the familial, cultural and gender features of psychiatric illness. They also reported a greater awareness of bias towards certain paradigms in explaining mental illness, and the need to consider alternative perspectives. In addition, students also realized from the story line that many of the behaviors of people with mental illness are similar to those by ordinary people, and that salience of these behaviors in people with mental illness is partly explained by the fact that they are identified patients, and held to a different and higher standard of behavior.

The students had a higher preference for psychodynamic explanations as compared to alternative explanations of the origin of psychosis in Ivanov. Students could also be required to consider a story from an alternative viewpoint (e.g., Anti-psychiatry) and as a way of enhancing their overall understanding of psychiatric illness. Yet another potentially profitable activity would be to consider how Ivanov's mental health characteristics could be regarded from the perspective of members of the students' culture of origin.

The use of literature to teach psychopathology has been well received by graduate students. In response to open ended questions about their experience with the literature based learning, 95% of the students reported that they remembered more of the diagnostic features for schizophrenia much more readily following the literature based experiences than was the case with previous (undergraduate) learning when they deliberately committed these to memory via a variety of mnemonic devices. Eighty-three percent of the students noted that their discussion of the presenting characteristics and potential rehabilitation outcomes was more spontaneous, and less bound by the need to remember technical phrases from the diagnostic manual. Ninety-eight percent of the students observed that the story provided a contextual understanding of the core constructs in psychopathology and encouraged critical thought in them. All the students noted that they found the literature based learning more engaging than the traditional didactic method. Ninety percent said that they would elect the literature based learning for other classes in psychology and health if that option was offered. The students' responses to learning about psychiatric illness through literature were consistent with the predictions of experiential and constructivist learning as previously described.

As we continue to apply literature in teaching psychopathology and psychiatric rehabilitation, we envisage having students do term papers based on prescribed literature (i.e. novels; plays; poetry; etc.). Students could be given a task such as "Consider a possible clinical picture, diagnosis, etiology, and prognosis for Kurtz in Joseph Conrad's Heart of Darkness. Support your findings and interpretations with close reference to the text. How would the diagnosis and treatment of Kurtz be similar or different for people of a culture you are familiar with."

Summary and Conclusion

There is considerable potential in the use of literature for teaching a broad range of heath related aspects. The literature is an invaluable complement to the regular textbooks, and provides a rich source of material for extended learning. Fiction and non-fiction literature has the advantage of presenting mental health issues in the context of a life story. Students also tend to be less inhibited in discussing mental health concepts if presented through the medium of a story. Graduate students may be more amenable to studying more extended stories and books as they already have a basic exposure to the basic psychological constructs from undergraduate classes. Undergraduate students may profit from studying shorter stories and vignettes due to the larger volume of factual content in introductory health science classes. The much larger introductory psychology classes may not allow for quality class discussion. In the international community, good use could be made of selected novels and plays written in the vernacular languages for greater cultural relevance.

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Elias Mpofu, The Pennsylvania State University Sonja Feist-Price, University of Kentucky 

Mpofu, Ph.D., is an associate professor of rehabilitation services at the Department of Counselor Education, Counseling Psychology and Rehabilitation Services. Feist-Price, Ph.D., is an associate professor of rehabilitation services at the Department of Special Education and Rehabilitation Counseling.