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50 Signs of Mental IllnessA Beautiful MindA Beautiful MindA Bright Red ScreamA Casebook of Ethical Challenges in NeuropsychologyA Corner Of The UniverseA Lethal InheritanceA Mood ApartA Research Agenda for DSM-VA Slant of SunA War of NervesAbnormal Psychology in ContextADD-Friendly Ways to Organize Your LifeAddiction Recovery ToolsAdvance Directives in Mental HealthAggression and Antisocial Behavior in Children and AdolescentsAl-JununAlmost a PsychopathAlterations of ConsciousnessAm I Okay?American ManiaAmerican Psychiatric Publishing Textbook of Neuropsychiatry and Clinical NeurosciencesAn American ObsessionAngelheadAnger, Madness, and the DaimonicAnthology of a Crazy LadyApproaching NeverlandAs Nature Made HimAsylumAttention-Deficit Hyperactivity DisorderAttention-Deficit/Hyperactivity DisorderBeing Mentally Ill: A Sociological Theory Betrayal TraumaBetrayed as BoysBetter Than ProzacBetter Than WellBeyond AppearanceBeyond ReasonBinge No MoreBiological UnhappinessBipolar 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ChildrenEmotions and LifeEmpowering People with Severe Mental IllnessEssential PsychopharmacologyEssentials of Cas AssessmentEssentials of Wais-III AssessmentEthics and Values in PsychotherapyEthics in Mental Health ResearchEthics in Psychiatric ResearchEthics, Culture, and PsychiatryEverything In Its PlaceFamily Experiences With Mental IllnessFatigue as a Window to the BrainFear of IntimacyFinding Iris ChangFinding Meaning in the Experience of DementiaFlorid StatesFolie a DeuxFor the Love of ItForensic Nursing and Multidisciplinary Care of the Mentally Disordered OffenderFountain HouseFrom Madness to Mental HealthFrom Trauma to TransformationGandhi's WayGender and Its Effects on PsychopathologyGender and Mental HealthGenes, Environment, and PsychopathologyGetting Your Life BackGracefully InsaneGrieving Mental IllnessHandbook of AttachmentHandbook of DepressionHandbook of Self and IdentityHealing the SplitHerbs for the MindHidden SelvesHigh RiskHope and DespairHow Clients Make Therapy WorkHow People ChangeHow to Become a SchizophrenicHow We Think About DementiaHughes' Outline of Modern PsychiatryHumanizing MadnessHysterical MenHystoriesI Hate You-Don't Leave MeI Never Promised You a Rose GardenI Thought I Could FlyI'm CrazyImagining RobertImpulse Control DisordersIn Others' EyesIn Two MindsInsanityIntegrated Behavioral Health CareIntegrative MedicineIntegrative Mental Health CareIntuitionJust CheckingKarl JaspersKissing DoorknobsKundalini Yoga Meditation for Complex Psychiatric DisordersLaw and the BrainLaw, Liberty, and PsychiatryLegal and Ethical Aspects of HealthcareLiberatory PsychiatryLife at the BottomLife at the Texas State Lunatic Asylum, 1857-1997Life Is Not a Game of PerfectLithium for MedeaLiving Outside Mental IllnessLiving with AnxietyLiving With SchizophreniaLiving with SchizophreniaLiving Without Depression and Manic DepressionLost in the MirrorLove's ExecutionerLoving Someone With Bipolar DisorderMad in AmericaMad TravelersMad, Bad and 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the SoulOf Two MindsOn Being Normal and Other DisordersOn Our Own, TogetherOn The Stigma Of Mental IllnessOrigins of Human NatureOut of Its MindOut of the ShadowsOvercoming Compulsive HoardingPathologies of BeliefPathways through PainPersonal Recovery and Mental IllnessPersonality Disorder: Temperament or Trauma?Pillar of SaltPoints of ViewPoppy ShakespearePosttraumatic Stress DisorderPsychiatric Cultures ComparedPsychiatric Diagnosis and ClassificationPsychiatric Genetics and GenomicsPsychiatric Illness in WomenPsychiatrists and Traditional HealersPsychiatryPsychiatry and ReligionPsychiatry in SocietyPsychological Dimensions of the SelfPsychology and the MediaPsychopathia SexualisPsychopathologyPsychopathyPsychotic DepressionQuitting the Nairobi TrioRaising a Moody ChildRapid Cognitive TherapyRebuilding Shattered LivesReclaiming Soul in Health CareReclaiming the SoulRecollection, Testimony, and Lying in Early ChildhoodRecovery from SchizophreniaRecovery in Mental IllnessRedressing the 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Psychiatric Press Textbook of PsychiatryThe American Psychiatric Publishing Textbook Of Child And Adolescent PsychiatryThe Anger WorkbookThe Anorexic SelfThe Behavioral Medicine Treatment PlannerThe Betty Ford Center Book of AnswersThe Bipolar ChildThe Bipolar Disorder Survival GuideThe Body in PsychotherapyThe Borderline Personality Disorder Survival GuideThe Broken MirrorThe Burden of SympathyThe Cambridge Medical Ethics WorkbookThe Case for Pragmatic PsychologyThe Center Cannot HoldThe Chemical Dependence Treatment Documentation SourcebookThe Chemical Dependence Treatment PlannerThe Child and Adolescent Psychotherapy Treatment PlannerThe Clinical Child Documentation SourcebookThe Clinical Documentation SourcebookThe Complete Adult Psychotherapy Treatment PlannerThe Condition of MadnessThe Construction of Power and Authority in PsychiatryThe Couples Psychotherapy Treatment PlannerThe Criminal BrainThe Cultural Context of Health, Illness, and MedicineThe Day the Voices StoppedThe 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Sixteen classic short stories, sixteen case studies. That's the formula for this book by psychiatry professor William Tucker. How People Change explains the method Tucker uses to teach medical students about suffering, struggle and change. Tucker uses fiction for this purpose, having found the psychiatric literature too reductionist, given its tendency to "privilege pathological categories over experience" (cover notes). The book outlines Tucker's method of reading, group discussion, and analysis, and provides examples of analysis of each of the sixteen stories. The full text of each story is included, making the book both an anthology and a description of teaching and learning. Stories were chosen to reflect Erikson's eight stage model of human development, with the exception of the first stage (birth to twelve months) as that stage is not covered by any notable short story. The discussions provide a plot summary followed by five questions used as heuristics to further understanding of the story, and in particular the conflict of the central protagonist. The result is a book which could easily be used by teachers in other institutions either as it is, or by adapting the method to their own students' needs.
The short story is singularly suited to Tucker's purpose, providing as it does a "slice of life" without necessarily explaining what happens beyond the (usually) brief period covered. A well written short story should sufficiently reveal its main characters without the need to relate all the consequences of its key event. The rule of "show don't tell" is congruent with what a physician will encounter in clinical experience, a brief vignette of a fully developed life. Just as the author will not outline the full history of each character, patients present with complaints representative of their life course. It is up to the clinician to discern whether a pain is just a pain, or something that warrants closer investigation.
Tucker has chosen examples that represent a wide spectrum of the short story genre. They include The Overcoat (Gogol), two from Chekov (Gooseberries and Oysters), The Rocking-Horse Winner (Lawrence), The Adulterous Woman (Camus), two from Joyce's Dubliners (Araby and The Dead), Her First Ball (Mansfield) Good Country People (O'Connor) and others. The range of nationalities represented is impressive, and no doubt deliberate. It is noteworthy that Tucker has included The Overcoat in this collection, as this story is often regarded as the leading exemplar of the modern short story, and of much modern fiction. To paraphrase an expression attributed to Dostoevsky, the other authors in How People Change emerge from under Gogol's overcoat. Tucker's intention is to show the universal truths captured by each author. No contemporary authors are represented, probably because Tucker wanted to use stories that had proven themselves over time.
Tucker comments that students' responses to these stories are varied, with several interpretations emerging during group discussions. Some initially find the stories frustrating as there is no obvious change. It is only through rereading and discussion that understanding of the subtlety of the author's craft becomes apparent. In The Dead, for example, the full implications of Gabriel's thwarted night of romance are not immediately apparent. But given the opportunity to piece together the key elements of the story a pattern emerges of a man who has lost more than the opportunity for a night of romance. Tucker is aware of his own influence in bringing about this more in depth understanding, and concedes that his interpretation of the story is not the last word. However my impression is that Tucker is anything but a didactic teacher leading students towards one correct view. Something that is both notable and commendable is that there is no attempt to make a psychiatric diagnosis, even in cases that would readily lend themselves to this sort of unnecessary mediclization. Similarly, Erikson's stages are used as a guide, not as a means classification. The stories are not those that are discussed from time to time in the psychiatric literature as exemplifying mental illness, they are stories of the ordinary people physicians are likely to encounter in day to day practice. Another feature of the book, and something I'm sure Tucker's students are grateful for, is that there is no attempt to use literary theory to analyze these stories. That is simply not Tucker's purpose, and in How People Change he demonstrates the rich understandings to be gleaned from fiction without resorting to deeply theoretical analysis.
I found myself in broad agreement with Tucker's analyses, given that these are somewhat tentative. Leila (Her First Ball) has faced and responded to a challenge about her developing identity; Hulga (Good Country People) has learned a rough lesson in intimacy, but a telling one given her complicity in its execution (what a marvelous story this is!); Mrs. Verney (Sleep it off, Lady -- Jean Rhys) struggles with the same issues as her aged peers, but is compromised by alcoholism in her ability to respond to these challenges. The only exception to my agreement with Tucker's interpretations was his use of an alternative analysis of The Overcoat to make a point about public health programs. This was lost on me, although I found his earlier analysis of the hapless Akaky to be spot on.
A single reading of a short story is never going to exhaust its possible meanings. In many cases a wider lens of analysis would reveal other issues of relevance. For example Gabriel's concern with death is not just an individual affair, it is in one individual's expression of concern with the death of Ireland, at least the Ireland of Gabriel's past. Gabriel is quite explicit about this in his after dinner speech. Joyce also provides a metaphorical reference in the military colorings of the stout bottles that are assembled like an army regiment. Similarly, the adulterous wife who gives Camus' story its title is a French colonial in Algeria, awakened to the timelessness of the indigenous people and therefore to her own outsider status. Her transcendental moment can be read not just as an orgasm, but as a cultural epiphany. And Mansfield was always acutely aware of Englishness, not her own by birth, but by ancestry and tradition. Her debutante Leila then, can be read as the cultivated English rose confronted by a gruff colonial. Such readings do not so much compete with those of Tucker, but illustrate the multiple layers of meaning inherent in these stories.
Tucker's students are fortunate indeed to have this introduction both to the possibilities of literature and the real life struggles of people in the ordinary course of their lives. Not all patients will invite or welcome professional intervention, or as Tucker acknowledges, will necessarily need it. Physicians who are able to normalize rather than pathologize experience are well placed to provide humane and empathic care. Tucker does his students a great service by alerting them to the ordinariness of human experience. This is a great book for those involved in the medical humanities, and for all teachers in the health and social sciences.
© 2007 Tony O'Brien
Tony O'Brien is a short story writer, and lecturer in mental health nursing at the University of Auckland, New Zealand: [email protected]