Living with the Truth Stranger than Fiction This Is Not About What You Think Milligan and Murphy Making Sense

Monday, 7 September 2009

98 Reasons for Being

98 Reasons for Being - cover Having recently read about the experience of a young schizophrenic on the loose in New York – and subsequently thinking over what books I'd read about mental health (and realising there weren't that many) – it seemed like a good time to pull Clare Dudman’s 98 Reasons for Being from my to-read shelf where, to my embarrassment, it has been languishing for several months.

Ever since I was a teenager I've looked down on 'historical fiction' as being some kind of sub-class well beneath the 'literary fiction' I was gobbling up at the time, perhaps because I equated it with 'romantic fiction' since, at least some of the time, the two are combined. Up until recently I'd never done anything to try to adjust that view. By 'historical fiction' of course I mean fiction written out of its time; Dickens is not 'historical fiction' since it was contemporary when it was written. I don't really have much of an interest in history and the idea of sitting down and reading any 'historical novel' would not normally have me jumping for joy; I worry they might be hard work, full of dry facts and pages and pages of exposition. But when I read The Sonnets recently I was pleasantly surprised so maybe I was being prejudiced for no good reason, often the case with bigotry.

Exposition is, of course, a necessary evil that all writers have to contend with. But there are ways and means of approaching it. Science fiction authors have become adept at introducing us to entire universes without us feeling burdened by too many facts; they drip-feed us the information, what we need to know just before we need to know it.

So, how did Clare do? Not bad actually considering the wealth of information she decided to include. I found myself struggling more with the number of characters in the book than I did with all the 19th century technobabble. It took me a while to get the patients, orderlies, doctors and relatives all straight in my head, not that there were a huge number, just more than my muddled wee brain could cope with. People with non-muddled brains will do just fine I'm sure.

180px-HoffmannHeinrichPortrait The book has an interesting structure, 31 chapters that detail the admission and treatment of a young Jewish woman, Hannah Meyer (a fictitious character) by Dr Heinrich Hoffmann (an historical figure) followed by a postscript, a letter written by a father to his son seventeen years after the events recounted in the book. This manages to tie what could have been an open-ended storyline together for although Hannah's treatment comes to an end, there are still those other patients that Clare weaves into the narrative whose fates we never learn and there is also much about the doctor left unresolved.

Each chapter opens with an historical document, albeit a made-up one, a letter, part of an official document, a page from a medical textbook, a school report, something that is related in some way however indirectly to the chapter that follows. These varied information dumps are a simple and effective way of providing much of the exposition the book demands. The rest is slipped in here and there but not in the ham-fisted way that happens in so many TV programmes where characters explain things to each other purely for the benefit of the audience; I hate that.

The superintendant of the asylum, Dr Hoffman, is a fascinating historical character, as Clare explains on her website:

Peter Until now Dr Hoffmann’s life has been a search for what is important: he has written plays and satirical works; he has been a doctor in a charity hospital; a family physician; a freemason; a lecturer in pathology and anatomy; a politician championing the emancipation of the Frankfurt Jewish population; he has started many clubs and societies and is a supporter of the Arts. But his main claim to fame is as author of a book for children: Struwwelpeter (Shockheaded Peter) - an illustrated book of cautionary tales he drew and wrote eight years ago for his young son for Christmas when he was unimpressed at what else was on offer.

At the end of many of the chapters Clare includes one of the rhymes from Shockheaded Peter and there are also black and white copies of illustrations from the books, some of which I've reproduced in this post. You can see the full text and all the illustrations here. Oh, and just because all the children in the rhymes die in "ingenious and castigatory ways", to quote the Observer reviewer, don't assume that all the patients end up the same way.

I can see why she might have been attracted to him. He sounds like a colourful character but this is not how Clare paints him. After a year in the position, Hoffman is feeling the pressure of the job. This seems to have mirrored his father's experiences:

My father . . . had been such a cheerful man when I was young, but he turned into something quiet and taciturn. He seemed to be a different person. I felt so frustrated, I had learnt so much, and yet I knew of nothing I could do to help him. It was then that I first realised, I suppose, how little we doctors can do to cure. We know so little, we have explanations for diseases but in truth I do not believe them. Symptoms appear and are assigned causes, but how do we know? It changes from year to year like the shape of women's dresses and the cut of our coats. What causes cowpox to prevent smallpox? Where has cholera come from? What causes it to spread? No one knows anything.

If his ignorance in the face of physical ailments has frustrated him then his inability to even properly diagnose let alone successfully treat mental illnesses has pushed him to the edge.

The above quote is part of a conversation he has with Hannah, one of many, although most of the early ones are monologic since he's lucky if he can get a nod out of her. We readers though benefit from hearing the other side of these conversations, the one constantly going on inside Hannah's head although at first she's not really responding to him, or anyone else, she's just holding her own internal monologue. These are inserted into the body of the text in italics:

The Devil is watching us. Sometimes he takes one of us and rocks her in. His hellish place. I should not be here. I do not belong. Something must have happened, a mistake, someone thinking I was someone else. Someone must be taking my place, creeping into my life so I am not missed. What have I done? Why do you not come?

You might think it strange that the good doctor be telling his patient so much about his private life but then his treatment of Hannah is quite radical, part of a "Moral Treatment", basically a talking cure and although at first he does all of the talking after some time she starts to open up and we learn just why her mother (her father having committed suicide) has arranged for her to be seen by Dr Hoffman. Hoffman has been chosen because of his affinity with the Jewish race although Clare admits that in reality at the time Hannah would have been confined to a hospital on the Jugenesse where Hoffman would have attended her; Jews were not admitted to the Frankfurt's town asylum.

Twenty-two year old Hannah is an interesting case: for months now she has not been eating, sleeping or speaking and it is rumoured that she is suffering from nymphomania at least by one well-meaning neighbour who sends in an anonymous letter. Dr Hoffmann is confident that he will find a cure, and quickly although he has his doubts about her being even a latent nymphomaniac. The question is: Is she mad? Are any of the 98 patents in the asylum truly mad? And what is 'madness' anyway? According to the classifications given at the start of chapter 28 we have:

  • Mania
  • Partial insanity (or monomania)
  • General confusion
  • Terminal dementia
  • Symptomatic dementia
  • Inborn dementia (or idiocy)

Hoffman uses all the traditional methods at his disposal, from ice baths and blood letting to blistering and electroshocks, in an increasingly obsessed effort to cure Hannah.

At the time . . . bleeding and caustics, was a typical medical approach to most illnesses. Physicians did not understand much about the causes of disease and still relied on traditional remedies based on ancient Greek notions: disease meant that the body's system was out of balance. Consequently, bloodletting or purging restored the necessary equilibrium in the body. Blistering and caustics created a counterirritant, which drew poisons to the surface, and stimulated the body to return to its natural balance. Cooling baths, moderate diet, and sedatives calmed overstimulated nerves. This belief system was widely shared by both lay people and physicians. Doctors and patients alike looked to the results of strong emetics or bleeding as tangible evidence that the physician was resolutely treating the disease. – Carol Groneman, Nymphomania, a History

Throughout the book we learn a great deal about the attitudes of people towards the mentally ill. Early on in the book one of the orderlies, Angelika, has been told to arrange for Hannah to have an ice bath. The instructions say that the water should be tepid before beginning but it was a rule she routinely chose to disregard regarding "it as an unnecessary indulgence. The mad cannot feel the cold: this is a view widely shared by the assistants in the asylum, and as far as Angelika is concerned it is an undeniable fact."

So you can see that the Moral Treatment that Hoffman decides to try with Hannah is nothing less than revolutionary. At the start of the 18th century, the 'insane' were typically viewed as wild animals who had lost their reason. They were not held morally responsible and were often treated no better than animals. What the doctor quickly discovers is that his talks with Hannah are most therapeutic . . . for him. He is not insane, a little overanxious, perhaps a bit depressed, but then he is a man under a great deal of stress, both at work and at home and talking to Hannah helps because it looks as if he cannot talk to anyone else not the least his wife, Therese.

Outside the confines of the clinic he has two main concerns, his wife who is only interested in socialising and his eldest son, eleven-year-old Carl Philip, whose less than satisfactory school report introduces chapter 10 of the book. In part it reads:

LATIN: Carl Philip shows little aptitude for this subject. His understanding of the basic grammar is poor. No doubt his performance would improve if he were to listen more in class.

MUSIC: Progress poor. Lacks a musical ear. Will not sit still.

RELIGIOUS STUDY: Incapable of quiet contemplative study.

NATURAL SCIENCE: Carl Philip shows more interest in killing species than in studying them.

GENERAL PHYSICAL ABILITY: The boy is poorly coordinated and undisciplined. He is rash and will not wait his turn.

Not only is he disruptive at school, he also upsets the house staff who all demand a raise to stay. This understandably upsets the doctor and puts pressure on his marriage:

My wife, Hannah, is a very determined woman. She thinks there has to be another solution to all this, and if I can't think of anything then she will.

We're a third through the book at this point and we've hardly had a peep out of her. After he has unburdened himself he turns to her:

'Well,' he says at last, 'it's your turn.'

He looks at me but his words have let me go. There are too many other voices calling me away; talking quietly, wheedling, promising. I want to be rid of them all, back in the place where nothing hurts. He shifts in his chair, rests his head again on his hand, looks at me. He speaks but his words are indistinct, hopeless, devoid of power.

'Hannah? Will you not talk?'

I should speak. There was a promise. I try to remember.


A hand separating weeds, reaching out, pulling me down, covering my mouth.

'Not yet?'

Words come and go in my head. They are disconnected, unreal, cannot be spoken. I shake my head. He smiles, a dim glimmer of white. Never mind, he says, maybe tomorrow.

Nowadays, of course, any mental health professional worth his salt would be thinking that the boy was sufPhilipfering from attention-deficit hyperactivity disorder. That chapter in the book ends with 'The Story of Fidgety Philip'.

Hannah is not the only patient we get to learn about in the book. She is the new girl. Others have been there some time. And Clare allows us to follow the progress of a number of them. I suppose if you're being technical you'd call these subplots but they're really just asides, ways of exposing other conditions apart from Hannah's and the kind of treatments they receive.

Although we learn a bit about Ingrid, who is autistic, and Lise, who ends the book in solitary confinement, the main ones are probably Grete Richter and Josef Neumann. Grete has obsessive-compulsive disorder from the sound of things (obsessive counting of stitches in her case) but it also turns out she is not eating; chapter 20 ends with 'The Story of Augustus Who Would Not Have Any Soup'. During the course of the book there is only one other admission –Augustus the clinic is full to capacity – a man, Josef Neumann, well, a woman, Josephine Champagne, trapped in a man's body. Apart from Hannah, we learn the most about these two patients. Josef's is a particularly tragic case because what they strip him of is beauty and he goes to extreme lengths to acquire and hang onto it, if only something frilly or a bit of colour.

The relationships between staff members are also explored a little, particularly those between Angelika who loves Hugo (whom Josef/Josephine has a thing for) and Dagmar who lusts after Tobias who has shown some interest in the new girl, Beatrice, if he can tear himself away from leering at the female patients.

Towards the end of the book, once Hannah has started talking and we learn her story and who the mysterious Kurt is that she thinks about so much, the doctor raises an important issue:

'Antoni says that one of the assistant thinks Josef wasn't ill at all. He says he didn't need to be cured, that he just needed to be left alone. Do you think he's right, Hannah? Is all I'm doing here wrong? Are there really any mad people at all?'

'I don't know about madness, sir, but I am sure there are people who are so sad they cannot bear it.'

It is a perceptive remark. One that makes the doctor sit up. Up until Hannah he has treated his patients by the book because he has known no better but he has been keen to embrace new techniques, for example, when the electroshock machine arrives he can barely wait to use it – on poor Hannah as it happens – but the results are disappointing. In an Author's Note at the end of the book we learn what happens to Dr Hoffmann long after Hannah has left his care – although we also get a glimpse into her future in the final chapter – and we see the fruits of his labours too, the construction of a new 'modern' mental asylum on a large site outside of Frankfurt.

This is a very well-researched book. The facts I myself checked were all accurate down to quite minor details. There was the odd word or two that wasn't explained in the text but I got the gist of it. This is a novel after all. If I wanted to know more then I could open up one of the textbooks Clare lists in her bibliography at the end of the novel.

The question you have to ask is: If this story had been set in the present, would it stand up on its own without all the historical details to keep one entertained? I think so. Of course many of the issues in the book are time-sensitive but the big ones are not. When I was an IT trainer one of our students was a man in the process of undergoing gender reassignment and you had to feel for him – (s)he looked like a jakey in a frock. (S)he may have had boobs (36B and very proud of them) and curls but (s)he also had an eleven o'clock shadow and size 11 shoes. (S)he only lasted a few days – Glaswegians are not well known for their subtlety.

As long as there are differences between people they will discriminate. Governments can legislate all they like but that won't stop people being people. We have the Equality Act 2006, a Mental Health Act 2007 and a Race Relations (Amendment) Act 2000, a Sex Discrimination Act 1986 and the Sex Discrimination (Gender Reassignment) Regulations 1999; we no longer talk about insane asylums, we have psychiatric hospitals and a wealth of information about the mind. None of that existed when this book was written. If you strip away all the window-dressing, which I have no doubt it took Clare months to research and get down to the nitty-gritty, this is a story worth telling. People want to be listened to and all it normally takes is one brave soul to listen and one braver one to open his or her mouth to be heard.

If I had a criticism of the book it was the inclusion of all the documents at the start of the chapters and the poems at the end of most of them. I don't think the book would suffer without them and we would lose a good fifty pages but then this is the non-historian in me wanting to get on with the story and sod the detail.

So, if in the past you have found yourself passing by the historical fiction shelves think again. I cannot speak for all historical fiction but my suspicion is that any historical fiction where Clare Dudman has been involved will be worth investigating.

You can read an extract from the book here (the bit about the electrotherapy) and you can find an interview with Clare here where she talks about the writing of the book. A second more general interview can be found here, but it is worth reading because it shows her dedication as a writer and the lengths she is willing to go to get it right; if you read nothing else read her answer to the last question.


Clare Dudman Clare Dudman was born in North Wales and educated at Leicestershire comprehensive schools, the University of Durham and King’s College London. She has a PhD in Chemistry and has worked as a postdoctoral Research Associate in UMIST, a development scientist in industry, a science teacher, a lecturer and as a creative writing tutor for the WEA and the MA in creative writing at University College Chester. She is a member of the Welsh Academy.

Her first novel was for children: Edge of Danger which won the Kathleen Fidler award. Her second novel was for adults Wegener’s Jigsaw (published as One Day the Ice Will Reveal All Its Dead in the States) which is a fictional autobiography based on the life of revolutionary scientist and arctic explorer Alfred Wegener and won an Arts Council of England writers’ award. 98 Reasons for Being is her third novel and from all accounts is out of print which is why God invented libraries.

To research for her new novel A Place of Meadows and Tall Trees (based on the Welsh colonisation of Patagonia), which is due out later this year in the UK, she actually travelled across the Patagonian desert in a bus, and then took 'The Old Patagonian Express' in the Andes. Along the way she interviewed the descendants of Welsh settlers who came there in 1865. Other research for this novel included intensive courses in Welsh and shamanism.


Dave King said...

Reading your (excellent) review, I anticipated some of your comments. For instance, I was much put off by your mention of all the documents at the start of each chapter. Although this can work well, so much each chapter seemed like overdoing it. Overall, though, I was impressed by what you had to say and if I do get to read this book - as I well might - I have no doubt but that I shall enjoy it. Thanks for the intro'.

D.M. McGowan said...

Exceptional review! It’s entertaining and informative … just as any good historical novel should be.
Quite obviously a great deal of research went into this work and it sounds like a great read.

Clare Dudman said...

Thanks for all the work and the research you have put into this review Jim! That's very kind of you.

Dave King: just to set the record straight - there is only in fact a single (fictitious) document at the start of each chapter and these are usually very short.

Thanks to you and D.M. McGowan for the kind words.

Jim Murdoch said...

Dave, sorry I didn't make it clearer about the wee opening documents – I knew what I meant. The main thing I wanted to get over here was the amount of research Clare puts into her books. At the moment she's planning a research trip to China for goodness sake.

Dave McGowan, thanks for visiting. I hope I haven't overstated the research aspects of this novel. All that research without a good and plausible story would just make this a glorified textbook which it isn't, not by a long chalk.

And, Clare, you're welcome. I know this book is out of print but people can still pick up copies easily enough. The main thing was to highlight what kind of writer you are and hopefully attract a few people to see what else you've got on offer. Sorry it took me so long to get round to it. Quick I am not.

John Ettorre said...

VERY interesting, Jim. I'll be sure to pass along word of this book to several friends whom I know will have an interest.

Jim Murdoch said...

Thank you, John, that's good to hear.

McGuire said...

Interesting topic, Jim, I'm equally intrigued by madness and how we treat and deal with those who become institutionised.

I don't know if it would be better to read about madness via fiction but while I was in Italy I read a non fiction piece of social history called: 'Madmen: A social history of Madhouses, Mad doctors lunatics.

It's a rather long and verbose peice of prose but it gives such a vivid and detialed insight into the attitudes toward madness, what madness is, how we often contruct it, as well as, the old methods for 'curing madness' at least addressing the issue.

Rachel Fenton said...

I think what is most interesting about this work, and about much literature on mental health in fact, is the notion of mental illness as social construct. Think about how many cases of depression there are now, just as in the nineteenth century there were x number of cases of hysteria (- and before you all jump down my throat, I am not saying I do not think that depression exists, nor am I saying it is the equivalent of hysteria -) I think it is now sociably acceptable (western culture)to have depression and, therefore, more cases of it are diagnosed...madness is a construct, therefore, is what I am is only a thing which needs treatment because our society has made it so...other cultures have different benchmarks for such things. I'll give you an eg of what I mean, young black males are statistically higher sufferers of schizophrenia...I find that odd...there are questions to be answered...

Jim Murdoch said...

McGuire, to be honest, I think a book like this would be an excellent introduction to the subject because it makes the material easily digestible. This is not a textbook but, and this is a point I made about The Sonnets, I think a lot of textbooks would be improved if they presented the information like this. One of the things that gave me a wee bit of a shove in picking up this book was the programme Casualty 1909 which my wife and I watched faithfully. I've never actually seen an episode of Casualty but my wife likes medical dramas so we thought we'd give it a try and we were both quite taken by the detail. I could see Clare's book turned into a drama quite easily and if that encourages other to then look at heavier works like Madmen: A social history of Madhouses, Mad Doctors & Lunatics then all the better.

And, Rachel, as a card-carrying depressive I'm also keenly interested in the whole are of mental health. I can see clearly how attitudes have moved on since Dr Hoffman's time and yet I'm still surprised by the limited understanding that still exists surrounding mental health issues. Depression may be out of the closet but when I was diagnosed as suffering from Generalised Anxiety Disorder I found people didn't quite know how to cope with that. I certainly didn't. I was miffed that I didn't have a cool-sounding illness – GAD sound so . . . well, uncool. I usually tell people I have "an anxiety disorder" and leave it at that. Personally I think there are too many labels. They're not always helpful. Because as soon as I learned I had GAD my first thought was: Well, how do I do that right? I know what the rules are for depression but this is a whole new ball game.

Rachel Fenton said...

Exactly, Jim. And your condition has not suddenly sprung up - only the name is new. It is hard to explain to someone who is unfamiliar with an illness what theat means, to suffer from it, and more so if it is not well enough known about for them to have accepted it. But as soon as it is acceptable, more cases of it will appear. I'm not sure any of it helps anyone.
Depression has become the thing GPs dole out to everyone who persists in baffling them with symptoms that their general training hasn't equiped them for. I wonder how many people are routinely prescribed anti-depressants when they have another condition which requires more time and a skilled diagnosis? But it's so OK to have depression, what does it matter? Well, I think it matters a lot. I don't believe x number of black men have schizophrenia, more than I believe the moon is made of cheese, but no one wants to find out what IS going on.
And now I appreciate why you do not sleep.
Personally, I don't think society should view certain mental illnesses as needing to be cured...for whom are we curing people...not for the so-called sufferers in many cases...society makes problems by putting everyone and everything into boxes and categories...ADHD is now a condition to be 'cured' - people with it are 'wrong/bad'...what bollocks! Labels are there for people who are afraid of anarchy. New conditions are invented by pharmaceutical companies, specifically for their new drugs. As someone with close experience of mental illness/depression/anxiety disorders, I have had a long time to think about the issues.

Ping services