Mental Illness as Depicted in the Novel The Bell Jar

The Bell Jar is a semi-autobiographical representation of a young woman's descent into schizophrenia. Although presented as a novel, the book closely follows Ms. Plath's own descent into schizophrenia under similar circumstances and at a similar age. (Plath later committed suicide at the age of 30, only a month after the novel was initially released to mixed reviews.)

The story is set in the early 1950s, as Esther, the narrator, spends a one-month summer internship at a major New York fashion magazine. Although she receives no salary, she is given an all-expenses paid housing in New York at a women's hotel (the "Amazon," in real life the Barbizon Hotel), and feted with parties, fashion shows, luncheons, dinners, and multiple rounds of fashion gifts. Having come from a relatively unsophisticated family environment, this uproots her to a new environment where she feels isolated and stressed by her own ignorance of how to cope with this situation. This is the triggering event that sends her into a full-blown crisis.

Signs and Symptoms

Esther's ability to hide her inner distress is her coping mechanism. She displayed classic signs of severe depression but disguised it fairly well, particularly given the era in which mental illness was poorly understood and often not recognised. She consistently portrayed herself as detached from everyone around her. She was a poet surrounded by people who did not value her poetry. Her mother's choice of a fiance for Esther, medical sudent Buddy Willard, explicitly denigrated this essential piece of her persona. Perhaps it not surprising that her response to such treatment was to withdraw inside her "bell jar" where she was protected from those outside influences.

She suffered a major break near the end of her internship, as her behavior became more and more outside the norm. When she returned home to a mother still determined to convince her to marry a man who valued her for nothing fundamental to her character she also discovered she did not gain entry to a writing program she had counted on as an escape from her unbearable life. That combination resulted in greater despair: "I couldn't see the point of getting up. I had nothing to look forward to". Dark depression resulted in a suicide attempt and in hospitalisation in a psychiatric ward.

McMillan and Enns noted that adults with schizophrenia frequently exhibit comorbidity with Axis I and Axis II personality disorders. In Esther's case comorbidity with mood and anxiety disorders may have been necessary for a complete diagnosis, though there is insufficient information to be completely sure. At the least MDD should be considered carefully.

Treatments

Esther underwent two separate courses of "electric shock" treatments (now called electroconvulsive treatments, or ECT). Recognizing that the book is set in the early 1950s, no real medications seem to have been prescribed for Esther. She participated in talk therapy, both private and group, and was hospitalised to place her in a controlled environment.

Sienart described the current understanding of modern ECT in psychiatric disorders. The author noted that it is effective for MDD, bipolar disorder, and catatonia, and that when psychotic symptoms, suicidal thoughts or signs of catatonia were present ECT should be considered earlier rather than later. He also noted that modern ECT had reduced side effects than that of earlier decades, but that more studies were needed on using ECT in conjunction with pharmacotherapy or continued ECT after a successful course of treatment. Esther's symptoms would certainly meet these standards for consideration of ECT fairly early in her course of treatment.

The issue of the criteria for hospitalising a suicide has been investigated by Miret. These authors determined that those who attempt suicide were more likely to be hospitalised the more they met certain criteria including: being male, having previous psychiatric hospitalisation, having a diagnosed psychiatric disorder, not having a substance disorder, using a lethal method, delay of finding the attempted suicide of more than one hour after the attempt, previous attempts at suicide, suicide ideation, high level of planning the attempt, and not expressing criticism of the attempt. Esther initially had no diagnosed disorder, but she had no substance disorder, used a method that should have been lethal, was not found for several hours, had made previous attempts (though it is not clear that was expressed to others), used a highly planned method, thought a great deal about death, and did not express regret over her attempt. Even today, based on these criteria, it is likely she would be hospitalised.

Lin, Huang, Chen and Chen have noted that schizophrenics are sometimes hospitalised more frequently than is required when they can be treated with ambulatory care systems; however, in Esther's case, the need for hospitalisation seems clear.

Psychosocial Issues

Esther experienced a variety of psychosocial problems. Her relationship with her mother was dubious at best for reasons not clearly defined. At one point she wished that "they would leave me alone [so] I might have some peace". Her mother and the others around her didn't recognize in Esther the sensitivity of a poet. Her behavior was perceived as odd by neighbors and friends, though the specifics were not clearly outlined in the text.

One of the key problems Esther experienced was a feeling of distance from friends and family. Kring, Kermans-Gard, and Gard studied the emotional responses of schizophrenics and found that they were unable to maintain appropriate emotional responses over time, unlike non-schizophrenics; specifically they can react in the moment, but cannot anticipate or recall pleasure appropriately. This no doubt would have affected Esther's ability to emotionally related to other people appropriately. In line with that result, Heerey, Matveeva, and Gold found that cognitive defects in schizophrenics prevented them from being able to appropriately imagine the future, even for positive, happy events. This emotional flatness implies cognitive brain dysfunction that may lead to future more effective treatments for the disorder.

Discrimination/Labelling Issues

In addition to not fitting the expected social role of a young woman in the 1950s (i.e., get married and have children), discrimination worsened once she attempted suicide and was hospitalised. Even within the halls of the hospital, electric shock therapy was presented as stigmatising and a subject for horrified fascination and even shunning of those undergoing the treatment. As she neared her final release from the psychiatric hospital, she was warned by her doctor about how others would treat her: "...a lot of people would treat me gingerly, or even avoid me, like a leper with a warning bell. My mother's face floated to mind, a pale, reproachful moon... A daughter in an asylum! I had done that to her".

Smith, Reddy, Foster, Asbury and Brooks have noted that generally, the greater exposure of the public to a schizophrenic they know (i.e., family or friend), the greater the tolerance of the disease. While this seems supported by evidence today, this is not presented as true in The Bell Jar. It is entirely possible that the lack of scientific understanding of mental illness as a true physical illness is the cause for that lack of tolerance on the part of Esther's family, friends, and neighbors. Medical science of that time could not give them any real explanation of what was wrong with Esther.

Ethical Issues

It is difficult to assess the ethical issues of Esther's treatment from the distance of six decades, particularly when the text is often quite vague about details. However, Esther was first committed to a public psychiatric hospital before a doctor arranged her transfer to a private hospital. The ethics of that transfer seemed a little shaky - as if the doctor were "trolling" for patients; however, there was little doubt that Esther was much better off in the private hospital than the pubic one. She was committed involuntarily by her mother due to her suicide attempt.

The Mental Health Act 2000 (MHA2000) specifies specific case review protocols for patients such as Esther who were retained by an involuntary treatment order (or its 1953 equivalent). The three-person tribunal specified in MHA2000 includes an attorney, a psychiatrist, and an experienced third party to be part of the tribunal. In Esther's case, a very similar committee was waiting to determine if she were ready for release at the end of The Bell Jar, however, the implied makeup of that committee was solely doctors with no legal or familial representation.

MHA 2000 also requires a tribunal to review non-emergency ECT treatments; in Esther's case, this was not done, with her doctors having sole determination of whether she would receive that treatment. She was not consulted, nor even informed in advance of either series of ECT treatments.

Recommendations for a Better Outcome

It is somewhat unfair to judge the treatment protocols of the 1950s to today's treatments. No real options existed at that time other than talk therapy, ECT, and lobotomies. No antidepressants or other psychoactive medications seemed to be available; at least Esther does not mention any particular medication. Today's treatment would not follow the same pattern as Esther's. She appeared to have received that era's state of the art care once in the private hospital.

Esther's recovery was slow and uncertain, peppered by several attempted suicides, though not all were detected by others. She was hospitalised a second time under different doctors, having dubbed her previous doctor as "Dr. Syphilis." Her recovery was peppered by blow after blow - her own miscarriage that led to hemorrhaging, the suicide of one of her friends in the hospital who had seemed to be doing well.

Esther's ultimate recovery is uncertain. There appeared to be no real plan in place to monitor her progress or assist her in transitioning back into the real world. In real life, Plath's own recovery did not last. She suffered from severe depression for the rest of her all too brief life until her death by suicide at the age of 30.