Uncertain Truths: Resistance and Defiance in Narrative

I. Introduction

What do we learn from a narrative that does not just deny illness and pathology but is written or spoken against the illness - where the ‘patient’ is not simply saying, “I don’t have this particular illness” but “I don’t see this as an illness at all”? This attitude is not unusual in medicine and is particularly contentious in the field of mental health. Opposition to standard medical illness narratives has produced some forceful counter-narratives to the prevailing hegemonies and, when harnessed to a movement such as Mad Pride, can have potent political and clinical clout.
To some extent, counter-narratives can be incorporated into the psychoanalytic domain as 'resistant' texts. For example, the authors of these narratives are in denial about their illness; they are projecting their anger and anxiety about the illness onto the physician; they are displacing a sense of illness onto others. In other words, they make use of defense mechanisms, enact the phenotype of fractured selves or otherwise engage in distorting reality to protect themselves from the disturbing knowledge of their illness. By speaking out against their 'illness', they are unintentionally opening up the narratives to psychoanalytic interpretation: the very act of rebellion, their outrage, their resounding "no" can be laid on the couch where they refuse to lie.
Counter-hegemonic authors might argue that the interpretation and insight into illness presented by health care providers are a priori known, that for the health care providers it does not matter what one brings to the experience of illness, the providers' explanation for their experience - as anger turned inwards, or autoantibodies or atheromas, etc. - is already formulated.
The authors might further argue that resistance, rather than being a function of defenses, is better understood as an act of defiance against the pat interpretations and reductive insights provided by health care providers. Frequently, as suggested by texts like the Adbusters Mad Pride issue, people are concerned that their life-experience will be essentially reduced to the textbook interpretations: that, through the interventions of mental health providers, their whole being would be condensed to either an organic imbalance of neurotransmitters with dysregulation of neural circuitry or, to take the other cartoon of psychiatry, a dysfunctional development marked by, say, a "cold and distant mother and provocative and demanding father."
The purpose of this paper is to ask how we can read these counter-narratives, what we can learn from them and to ask how we can place them within the overarching metanarrative of medical experience and interaction. Doing so will first entail a deeper understanding of resistance and defiance. Then, I will discuss Michel Houellebecq's controversial novel Atomised because the novel is written to dispute any psychological interpretation, and we can see how he uses both style and content to defy a psychological, and particularly psychoanalytic, reading. A different perspective will be offered by John Kennedy Toole's A Confederacy of Dunces, where the question of defiance and resistance becomes more subtle and personal.
The psychoanalytic perspective will be particularly important to this paper, not in order to conquer the texts with psychoanalytic readings but as a means of examining and processing the uncertainty inherent in narrative. One of the most powerful challenges to both psychoanalytic readings and to narrative medicine (and yet where narrative medicine may be more resilient than other approaches to medical interaction) is how to manage that uncertainty.

II. Resistance and Defiance

Glenn Gabbard defines resistance as 'the patient's wish to preserve the status quo, to oppose the treater's efforts to produce insight and change' (Gabbard, 14). Resistance is central to the therapeutic process because if such insight and change were not difficult to attain there would be little need for therapy in the first place; and although the status quo may be sufficiently conflicted and the patient's equilibrium sufficiently problematic that treatment is undertaken, the status quo is more familiar and, intrinsically, defended than the unknown or unconscious, wherein resides the forbidden, treacherous parts of the self that are defended against. Gabbard goes on to say that all resistance 'has in common an attempt to avoid unpleasant feelings, whether anger, guilt, hate, love (if directed against a forbidden object such as the therapist), envy, shame, grief, anxiety or some combination of these' (Gabbard, 15). And from here, understanding that these unpleasant feelings may be playing an aetiological role in the conflict disrupting the equilibrium, we can see why Freud argues that rather than seeing resistance as 'a risk to analytic influence[,] the overcoming of resistances is the essential function of analysis and is the only part of our work which gives us an assurance that we have achieved something with the patient.' (Freud, Lectures, 360-361) It must be noted that resistance is also an essential function of identity: it is resistance that maintains an integrity and a constancy to the self in the face of suggestion, demands, an always shifting personal environment and a constantly stimulating world.
Several aspects of resistance provoke hostility and opposition in counter-narratives. First, the identification of a patient's behaviour or words as 'resistance' - implying a behavior open to the interpretation of the analyst, but mystifying to the patient - puts the power of knowledge squarely in the hands of another. When that knowledge is the knowledge of the self, it is even more alarming. Few would take comfort in thinking that the image they see in the mirror is a less accurate portrait that what is seen by another looking at the same image.
Second, for resistance to be resistance, it must warrant skepticism or cynicism in the resistant person. One's tardiness to a therapy session may be directly related to stemming uncomfortable insight that was developing in previous sessions, but it can also be consciously and speedily explained by a broken alarm, a stall in the train, a paper due at a conference - what Freud calls the 'chance events' (Freud, Lectures, 361). Note that akin to the first objection to resistance, we see here that what the patient considers explicative, Freud considers circumstantial.
This skepticism or cynicism is not simply frustrating for therapists (in that it frustrates the therapeutic process, as it is designed to do); it can be emotionally or affectively frustrating for those labelled resistant. As Mark Vonnegut writes in The Eden Express, an autobiographical account of his experience with mental illness: 'If you fail to benefit from psychotherapy, you stand a better than even chance of being accused of "resisting therapy." As if things weren't bad enough already, you are now accused of subconsciously or even consciously wanting them that way.' (Vonnegut, 209)
Mark Vonnegut, son of Kurt, shares his father's simple precision in tone and syntax and, like his father, wields with surprising gentleness the sharp blade of his wit. His account of his experience with mental illness is evocative and poignant. Given the author's powerfully anti-authoritative stance, The Eden Express is surprisingly not unsympathetic towards the mental health services. At the same time, one can note that in both of the sentences above he uses the word 'accused': one is accused of resistance as though it is criminal, illicit. This may not be the analyst's intention; nevertheless, for the patient, it may seem as though this is the case and, worse, that this charge is leveled against somebody who is already feeling both vulnerable and innocent and does not wish to be told that he or she is also responsible. Vonnegut's statement is a measure of the antipathy found in counter-narratives, even in a relatively sympathetic writer, towards the concept of resistance.
One of the first times we meet resistance in psychoanalysis is in Freud's account of his treatment of Dora:

My expectations were by no means disappointed when this explanation of mine was met by Dora with a most emphatic negative. The "No" uttered by a patient after a repressed thought has been presented to his conscious perception for the first time does no more than register the existence of a repression and its severity; it acts, as it were, as a gauge of the repression's strength. (Freud, Dora, 51)

As in so much of Freud's writing, he was capturing and examining phenomena in the human experience that had been seen but never explained, much as astronomers, when charting the skies, were analyzing what had been seen since humans looked up at night. There are, in this passage, more than faint echoes of Gertrude's much-repeated comment - 'The lady doth protest too much, methinks' (Hamlet, 3.2.230). Just as the defensive Gertrude observes, so Freud argues that the louder the "no" the more one should suspect "yes." Thus, infuriatingly perhaps, the more skepticism and cynicism one has, the more doubt one brings to the interpretation, the more wrong or misguided or defended one is. However much clinical experience and a century of psychoanalytic writing uphold the principles of resistance, resistance can appear to be a vicious catch-22, appropriating the very doubt and cynicism and skepticism about its existence as evidence for its existence.
Let us assume, fairly I think, that despite its voracious appetite, resistance is not all-consuming, and that sometimes "no" does mean no. Let us assume that those 'chance events' Freud dismisses did make the patient late or, from another perspective, that there is more to the tension between therapist and patient than the patient's own psychology. Then we have defiance. I would like to define defiance as an ideological position, consciously articulated, based on experience and conjecture; perhaps the defiant position respects psychology, but it will also draw upon anthropology and sociology, politics and culture. Defiance need not be all-rejecting, and it may have unconscious motives, but it prominently positions itself in opposition to the standard narrative, and it does so as something other than as a guard of the status quo. As I hope to show, one way to read and understand counter-narratives is to listen to the defiance and resistance at work in them.
Briefly, it is worth acknowledging that applying the concept of resistance and defiance to a novel - or any psychoanalytic terms to creative, edited texts - can be problematic, but I would argue that this is so only in the most abstract ways. These texts, narratives and counter-narratives are hardly free association, the optimal format to be discussed from the perspective of psychoanalysis. In fact, novels are artfully done, quite the opposite of free association. Even that most apparently subjective of novels, the one most attune to the verbiage, the shifts, the magpie attraction to glinting phrases, the eclecticism of the mind at work, Joyce's Ulysses, was toiled over for a decade, and cannot be analyzed naively. This question has been addressed fruitfully elsewhere (see Holland, 1993); for the purposes of this paper, we can seek insight into resistance and defiance wherever we may find it.

III. A Resistant and Defiant text: Houellebecq's Atomised

One need look no further than the literary accolades he has received, the debate his work has inspired and the lawsuit against him for defaming Islam to see that French novelist and literary enfant terrible Michel Houellebecq has polarized the reading public. His two recent novels Atomised and Platform have brought him significant fame - or infamy - and success: Atomised was a recipient of the Prix novembre (Houellebecq previously won the Grand prix national des lettres) and Platform was the basis for the failed lawsuit.
In many ways, stylistically, Houellebecq is the anti-Rushdie: his novels are carefully replete with dreary detail and lacking any rush of enthusiasm; there is no ecstasy, least of all in the descriptions of physical climax; and the writing itself can read almost painfully, as though each sentence were extracted against the author’s will. And yet, even if the novels are often sadistic without any corrosive frisson, even if they are cold-hearted and at times quite dull, they have much to offer both the casual and the critical reader and they provide a particular challenge to readers with a psychoanalytic bent. This challenge is evident in Atomised.
Atomised chronicles the lives of two half-brothers - Michel, a reclusive molecular biologist, and Bruno, who seems to live in a mostly unreciprocated lusty shadowland of frustrated desire - through the end of the twentieth century, an epoch described in the novel as the 'suicide of the West' (Atomised, 284), a death marked by the understanding 'that humanity must disappear, that humanity would give way to a new species which was asexual and immortal, a species which had outgrown individuality, individuation and progress' (ibid, 371).
What first makes it interesting to a psychoanalytic perspective is the way that Houellebecq explicitly derides psychiatry and analysis. His narrator's contempt for psychiatry is divulged in numerous passing comments, such as when he likens talking to someone who is not listening as 'talking to a wall, or a psychiatrist' (ibid, 199) - it is the comma, its subtle pause, that turns the simple comparison into a charmingly deadpan dismissal of the abstinent therapist.
He also parallels therapy with New Age spiritualism, describing both as a refuge for the wounded and the pathetic, where they can seek artificial solace and superficial escape. Houellebecq rejects psychoanalytic conventions as akin to New Age mythos; both are contrivances that draw on nebulous abstractions from eclectic sources in order to fix the human experience with meaning. Although the narrator mocks and derides New Age platitudes and eccentricities, they are at least embodied in the text with physical characterizations. The psychiatrists are not given any physicality at all: they are irrelevant, as bland as a blank wall, a true tabula rasae. At times, psychiatry comes out worse than New Age vagaries: one character notes that "Mantras and tarots may be stupid, but they're a lot cheaper than therapy." (ibid, 175)
In these generic condemnations of psychiatry, we see a dislike for the field that would prevent further scrutiny only in the most thin-skinned of analytically-oriented readers. As a critique of psychiatry, such comments and ideas only serve to buttress the most fragile of defenses, a snide devaluation, a denial. Freud, in listing external events that can be channelled and deployed by the patient as resistance, includes 'every comment by a person of authority in his [the patient's] environment who is hostile to analysis' (Freud, Lectures, 361).
Houellebecq, however, has more to offer. In chapter 12, we read an excoriating parody of the psychiatric interview:

The psychiatrist was less interested in the part of the story that followed, but Bruno thought it was important and had no intention of passing it over. After all, he was paying the bastard to listen to him, wasn't he? . . . When he had finished his story, Bruno paused for a moment. The psychiatrist cleared his throat and said, about nothing in particular, 'Good.' Depending on how much of the hour had elapsed, he would prompt Bruno again, or would simply say, 'We'll leave it there for today?', rising a little to make it a question. As he said this, his smile was polished and effortless. (Atomised, 85, 87).

To great effect, he describes the actual interaction between Bruno and psychiatrist as sterile, a possibly pointless and certainly commercial transaction. Therapy becomes a rote experience, a vacuous set of roles played out in a 50-minute drama with only the simplest of cues (a clock). Because the scene and the well-observed mannerisms of the therapist ring true, it is far more effective and caustic than the criticisms one finds elsewhere in the book, which have the casual insincerity of slander.
The same chapter begins with a quote:

In revolutionary times, those who accord themselves, with an extraordinary arrogance, the facile credit for having enflamed anarchy in their contemporaries fail to recognise that what appears to be a sad triumph is in fact to a spontaneous disposition, determined by the social situation as a whole. (Auguste Comte - Philosphie Positive, Leçon 48) [Italics Original]

Given the subsequent subject-matter, this may be a passing but damning reference to Freud and the centrality of his figure to psychoanalysis, or indeed the devotion of psychoanalysts to their prominent figures in general (not just Freud, but his daughter, Klein, Jung, whomever). It is consistent with novel's overall drive: that individuals effect little change, if any; it is the slow, grinding evolution of society as a whole that brings about movement and ideology, if not progress. Psychology, like New Age philosophy, is a simpering, mythic fairy tale, covering the brute biological story, attempting to give unwarranted value to the individual experience.
Houellebecq, well-aware of Freud (or at least popular Freudianism) appears to relish baiting readers of a psychoanalytic bent with juicy morsels demanding such an analytic interpretation, only to disappoint them or refute them. Throughout the novel, he describes dreams that are almost tantalizingly boring, just daring the reader to do anything but dismiss them. More explicitly, Bruno tells his psychiatrist about the summer he turned 18:

Sometimes Bruno altered or refined the details, but this is his standard version:. . . "I went into her room. They were still asleep. I hesitated for a moment or two and then pulled the sheet off them. My mother moved and for a minute I thought she was going to open her eyes; her thighs parted slightly. I knelt down in front of her vagina. I brought my hand up close - a couple of inches away - but I didn't dare touch her. Then I went outside and jerked off. There'd always been cats around the house, mostly strays. A black cat lay sunning itself on a rock. The land around the house was stony, white and forbidding. The cat looked over at me from time to time while I was wanking, but closed its eyes before I came." (ibid, 81-82)

He then picks up a rock and the 'cat's skull shattered and some of its brains spurted out.' (ibid, 82) We never hear the psychiatrist's response in any way, although we can imagine him as Houellebecq describes him, nodding thoughtfully and insipidly, ending the session with a blandly inappropriate, noncommittal 'good'. That there should even be a 'standard version' to such an outrageous story frames the telling of it powerfully: it has been told before, to other psychiatrists, with no useful insight provided, nor any sense of closure to its meaning. If Freudians cannot work with this frank oedipal scene, what can they do? The use of 'standard' is also an ironic attack on the perceived ubiquity of the oedipal complex, the much-sought disclosure of the sexual relationship between parents and child in psychoanalytic thinking; it is as if this grotesque, violent scene is, in psychoanalytic discourse, 'standard.'
If one wants to construct an oedipal argument from such a scene, or even a simpler discourse on the psychological effects of forbidden psychology, Houellebecq responds at the end of the passage: 'Bruno jumped, afraid that his mother had been awake that morning as he was staring at her vagina. In fact his mother's remark was banal: the incest taboo is well documented in the animal kingdom, especially among mandrills and grey geese. The car sped towards Saint-Maxine.' (ibid, 83) His choice of birds here is amusing and clever: large and familiar enough to be clearly related to mammals and yet surely the least psychological of beasts, if human experience can be paralleled to birds', one hardly expects it to be richly mythic and complex.
Throughout the novel, aspects of the characters' development and growth that could be described in psychological terms are examined in terms of highly reductive biological and physical processes. For example, when Bruno loses his grandfather, it is described thus: 'His grandfather died in 1967. In temperate climates, the body of a bird or mammal first attracts species of flies (Musca, Curtoneura), but once decomposition has begun to set in, these are joined by others, particularly Calliphora and Lucilia [etc] ' (ibid, 42) As in the passage on incest, we see him refusing to distinguish between animals and birds, and once again the individual psychological experience is subsumed to a larger biological process.
This reduction is applied to puberty (ibid, 66); romance; sexual arousal ("It all depends of Krause's corpuscles . . . The shaft of the clitoris and the glans of the penis are covered in Krause's corpuscles, rich in nerve endings. When touched, they cause a powerful flow of endorphins in the brain, [etc]," ibid, 168); and death and dying (ibid, 95).
Houellebecq is not simply saying, though, that humans are animals and thus offering biology as the only alternative to psychology. Rather, although most of what would be seen as psychological can be reduced to biology, what makes humans different from animals is better explained by physics ('Many years later Michel proposed a theory of human freedom using the flow of superfluid helium as an analogy', ibid, 108) and then history and society. Just as Houellebecq spends long passages dissecting the biological events that occur where one might expect an emotional explanation, so he re-contextualises other experiences, such as romance or even social development, in social and historical terms:

His only goal in life had been sexual, and he realised that it was too late to change that now. In that, Bruno was characteristic of his generation. While he was a teenager, the fierce economic pressures which France had suffered for two hundred years had abated. The prevailing opinion was that economic conditions tended towards a certain equality. The Swedish model of democratic socialism [etc.] (ibid, 73-74)

Houellebecq's most exquisite differentiation of human and animal, though, comes when he describes the birth of individuality: 'An animal's sense of self emerges through physical pain, but individuality in human society only attains true self-consciousness by the intermediary of mendacity, with which it is sometimes confused' (ibid, 89, italics original). The very notion of individuality, "self-consciousness", is created in mendacity; that lies can be communicated to another produces separation and individuation. Lying is itself dependent on social interaction, so the idea of the individual is thus based in the differentiating lie and, because the 'individual' comes to be only in a social context, is a lie itself. The character who realises this, Annabel, learns that 'life was an unrelenting succession of lies' and simultaneously it 'was then, too, that she became aware of her beauty.'
The novel, though, has other, more integral ways of resisting an analytic interpretation: it is not just the content of the novel that strong-arms any tackling analyst, but the style itself that seeks to evade a reader's grasp.
In what may be a coldly ironic self-referentialism (or quite possibly a completely un-self-conscious, but nevertheless instructive, rant), Houellebecq provides his critics with a neat summary of his own writing in Atomised, when Bruno says to Michel:

" . . . His writing is pretentious and clumsy, his characters bland ciphers, but he had one vital premonition - he understood that evolution of human society had for centuries been linked to scientific progress and would continue to be. He may have lacked style or finesse or psychological insight, but that's insignificant compared to the brilliance of the original concept." (ibid, 188)

Bruno is talking about Aldous Huxley. His criticism, if applied to Houellebecq himself, is accurate to a striking degree: pretentious, clumsy, lacking finesse of psychological insight and, above all, a creator of characters who are bland ciphers. Platform was heavily critiqued - and sued - for the almost boorish way in which he used his characters as ciphers for lambasting Islam, even introducing a nameless 'dark-skinned' Egyptian to launch a three-page assault on Islam (Houellebecq, Platform, 250-253). He gets some practice for this in Atomised, the earlier novel, where Houellebecq allows his female character, Christiane, to attack feminists: 'Stupid bitches always going on about the washing up [etc].' (Atomised, 173)
His style itself is an act of resistance, a renunciation of the psychological. First, the narrators are pointedly affectless and Houellebecq blunts the affective intensity of his writing. He achieves this in a variety of ways. The sentences themselves are often a staccato drilling, giving the pages a machine-like quality; he throws in mundane observations with only the briefest of descriptions, so that no rich world is evoked in the mind of the reader; he shifts focus to defy expected emotional trajectory ('The canary [Michel's pet] was dead, its cold white body lying on the gravel. He ate a Monoprix ready-meal - monkfish in parsley sauce, from their Gourmet range - washed down with a mediocre Valdepeñas.', ibid, 14); and, most superficially, but most sensationally, he provokes his readers with his impolite cruelty.
There are, of course, some pleasures to be had in his style: amidst the gravel and coal of Houellebecq's pronouncements and digressions, one finds gems: 'He does not know it yet, but the infinity of childhood is a brief one.' (ibid, 34). And, the comic style of bathos that he deploys is, appropriately, a reductionist style, bringing the high low, and Houellebecq can be rather amusing when he uses this rhetorical device (ibid, 108).
Overall, though, Houellebecq limits the range of affect with a sterility of tone that refuses to build emotional crescendos. He does not permit the reader to engage with the text affectively: he is not looking for emotional connection. One might say that there is a schizoid quality that defies such empathic attachment or transference.
In so doing, the novel omits, disdains and dismisses the reverberations and richness of the psychological. Psychology is just baroque decoration - a florid poetry as anachronistic as sonnets in iambic pentameter, as grotesque as a mediaeval gargoyle stuck to the modern facade of a glass and metal skyscraper.
The implications of this are significant. The novel dismisses psychic agency; people move as a herd, not as individuals; that herd has values, which are derived from history and science, and when some find those values hollow or shallow or contrary, they split off - not as self-realised or self-actualised individuals, but atomised, fragmented. The point is well-taken and it does respond to a crisis in modern experience that may, or may not, be accounted for in psychological examination and rumination. This may resonate with certain trends in modern neuropsychiatry where the focus is on study cohorts, MRI and SPECT scans, the wild forest of synapses and neurotransmitters, rather than individual experience.
What does this resistance to psychic agency, to analysis and therapy show us? The privileging of the individual, the individual's experience and the individual's narrative in psychology are historically derived (with the rise of 'individual'), socially sanctioned (with the advent of the autobiography in the last two hundred years of human experience) and, most importantly, but an approximation of 'reality' - and the contrivance of the individual is only an approximation of that patient's internal experience (or lack thereof). Whether or not the other biological and physical theories and ideas espoused in Atomised will eventually usurp psychology is unimportant; that there are other ways of framing even the staples of psychology, such as romance or relationships with one's parents, can be enlightening in and of itself.
What is most surprising, though, is that with the novel's dismissal of the psychological comes the dismissal of moral judgment. There is no conscience or superego, punitive or otherwise, to speak of in Atomised. The character Michel imagines a faultless determinism where 'no one is to blame' (ibid, 104). Many of the characters may have anxiety or guilt ascribed to them, but it is intellectual and abstracted (one might refer to an isolation of affect, but the whole novel is isolation of affect). To take this a step further, the object relations are blank, resulting is no sense of abuse - and judgment is ultimately a position taken on an abuse. The vituperative, ugly milieu the novel creates, evacuated of psychology, is also evacuated of judgment. It is astonishing to see such a tight association between judgment and psychology. One of the analyst's roles is to be a non-judgmental figure, and yet the novel suggests, inherent in a psychological understanding of the individual is judgment. This may provide some insight into the discrepancy between the psychologically-minded, who pride themselves on being non-judgmental, and the defiant, who say that they are being judged.
Of course, most recognise that terms such as antisocial or narcissistic do not float free from moral judgment. Sexual behaviours that are considered perverse or forbidden by society may actually have their transgression reified by the confessional of therapy; in this particular context (an interesting one for Houellebecq, judging from the orgies and sexual libertines that stud Platform and Atomised) individual therapy appears to be particularly fruitless role-playing when what it is most often being transgressed is a herd value, but when what is being avoided is a sense of atomisation. The language, affect and empathy of psychology cannot ultimately be dissected free from the fallacy of individualism and the terrors wrought by judgment: and it is 'the confused and arbitrary' concepts of '"personal freedom", "human dignity" and "progress" . . . which might explain why human history from the fifteenth to the twentieth centuries was characterized by decline and destruction.' (ibid, 371)
It must be noted that the epilogue reframes the whole novel as a dystopian 'fiction' (ibid, 369) written by the clonal progeny created by Michel's scientific theories long after his death, who have themselves overcome 'the monstrous egotism, cruelty and anger' (ibid, 378-379) of humanity. This does provide Houellebecq with a loophole, an alternate reading: that the whole novel itself is supposed to be wrong. Read as an inverted science fiction - where the past (the present) is described from a scientifically-advanced future - the novel's alien quality takes on a roguish humour at the sincere reader's expense, much as the alien quality ascribed to our time by science fiction from a century or two ago often seems comically quaint and inaccurate. One does not read H.G. Wells to understand the science and society of the early 21st century as much as one does to enter a world of his imagining and one that, despite some clever prophecy, says more about the society and science of his own lifetime than our own. Houellebecq turns this around, to show how a future free from the values and the tortured psychologies of our time might imagine this age; the problems in the text then are the result of the future's inability to get the past quite right, and the novel as a whole a mournful testimony to where we are going.
Houellebecq, the bastard child of Camus (see the opening to Platform, which almost plagiaries the opening to L'Etranger), refuses to become the bastard child of Freud, a difficult stance in this psychologically-oriented environment.

IV. Defiance and Dunces

John Kennedy Toole's Pulitzer Prize-winning A Confederacy of Dunces has an unusual and tragic provenance. Brought to the attention of Walker Percy by Toole's mother after his suicide, the novel was published posthumously to much acclaim. As Percy aptly puts it in his introduction, 'The tragedy of the book is the tragedy of the author - his suicide in 1969 at the age of thirty-two. Another tragedy is the body of work we have been denied.' (Toole, 9)
My first encounter with A Confederacy of Dunces occurred prior to medical school. I found it funny, charming and eccentric, as well as a delightfully easy read not because it lacked depth or profundity, but because it was so smoothly, almost effortlessly, written. Re-reading the novel as a psychiatric resident and re-acquainting myself with the protagonist, Ignatius Reilly, I was struck by how frequently he reminded me of patients in the clinic, the emergency room and in psychiatric wards. His bizarre clothing and improper carriage, his mannerisms, his obstinate and proud perseveration on Boethius and on his ‘valve’ (the former an obsessional fascination with a figure in theology and philosophy and the latter a somatic obsession with his own gastrointestinal tract) all smack of heady Axis II, and perhaps even Axis I, psychopathology. As has been commented on before, ones eyes change with education. Even if Ignatius Reilly is laden with numerous characteristics of psychopathology that can be organised and labelled- schizoid, schizotypal, narcissistic, body dysmorphic and somatisising to name a few - he remains one of the unique characters in twentieth-century literature.
More than any other constellation of illnesses, mental illness - or its manifestations - is inextricably linked to social and cultural beliefs of what constitutes health and what constitutes illness. Those around him are quick to label Ignatius Reilly as mentally ill, in that rich, syrupy New Orleans dialect Toole employs. George calls him a "nut" (ibid, 173); Darlene identifies him as "that big crazyman" (ibid, 360); his mother’s friend, Santa tells her: “If you had any sense, you woulda had that boy locked away at Charity Hospital a long time ago. They’d turn a hose on him. They’d stick a letrit socket in that boy. They’d show that boy. They’d make him behave . . . They’d make him listen. They’d beat him in the head, they’d lock him up in a straitjacket, they’d pump some water on him.” (ibid, 276-277)
Whether or not hosing with cold water, electroconvulsive therapy or pharmaceuticals would actually have helped Ignatius Reilly is not explored in the novel. Rather, he emerges a hero, with his delusions, preoccupations and strangeness intact, and with no insight into the origin or genesis of his delusions, preoccupations and strangeness - or for that matter, with no insight into the fact that he has delusions, preoccupations and strangeness - and he rides off into the sunset with his partner-in-Axis-II-pathology. The narrative arc is a victorious one, but that is not all: it is victorious on Reilly’s terms. He doesn’t gain any wisdom - his firm and fixed beliefs are not changed - or undergo moral improvement. The material may be there for an analysis of the text or an analysis of Ignatius Reilly (and, as we have seen from George, Darlene and Santa's comments, it was eminently clear to Toole that a psychiatric aetiology is a possible explanations for his behaviour), but it is simply rejected, in style and content.
A brief digression into one of Ignatius Reilly's historical ancestors, James Tilly Matthews. As described in Mike Jay's biography, The Air Loom Gang, Matthews was a Welsh pauper held as a lunatic in Bedlam for much of his life following a public outburst: on December 30, 1796, as Lord Liverpool spoke in the House of Commons, Matthews stood up in the public galleries and shouted “Treason!” (Jay, 18) Mike Jay, subtitling his biography "The Strange and True Story of James Tilly Matthews and his Visionary Madness", relates Matthews’ story not so much as a pathography of lunacy culminating in that sensational and very public charge, but rather as a complicated synthesis of psychosis and personal and public history. Determining which parts of the story fall neatly into the category of psychosis and which into the category of history is difficult, if not impossible. Matthews, it turns out, played an active role in political intrigue and espionage in the years leading up to the French Revolution; importantly, though, his bizarre behaviour coincided with the epoch's equally revolutionary scientific upheavals, including Mesmerism and Priestley’s discovery of oxygen (“dephlogisticated air”), and of course the emergence of psychiatry, or “mad-doctoring”, in the infamous confines of Bedlam. Matthews’ lavishly-articulated delusions and the ambitious investment in Matthews by what we would now call his primary caregiver, Bedlam’s resident apothecary John Haslam, is an early tale of resistance and defiance. Of course, Jay does speculate on the psychiatric aetiology of Matthews' behavior and his psychological motivation. Like Toole, though, he refuses to allow these terms and criteria to re-institutionalise Matthews.
What we see in both texts is that psychiatry is being recruited into the service of social and political control. Both Jay and Toole disclose this element of social control and generously, quietly release their 'patients' from the grasp of institutions.
There is a moral and cultural dimension to mental illness, and it is firmly rooted in the fear that mental illness evokes and the kinds of fears it evokes. In an attempt to counter this social and cultural bias, NAMI (National Alliance for the Mentally Ill) and other mental health advocacy groups ground mental illness in neuropsychiatry, as a biological, amoral process (see www.NAMI.org and its argument that it is a no-fault illness).
In a book that seeks to report on the state of mental health care services and, specifically, the management of dangerousness (or, the fear of dangerousness that leads to its overmanagement) in the mentally ill population, Jeremy Laurence notes that '[w]e are more tolerant of some kinds of dangerous behaviour - driving fast, drunkenness - than of the irrationality associated with mental illness.' (Laurence, 43) This may be why, as Laurence asserts, '[w]e will still tolerate standards of provision in mental health that we would not tolerate in other branches of medicine.' (ibid, 16)
The purpose of the defiant text is not just in detailing abuse, but defiance against abuses (whether political misuses, as was perhaps the case with James Tilly Matthews, or the abuses that are threatened against Ignatius Reilly). Defiance has a serious role to play and that role is to check the subservience of psychiatry to larger, if not greater, social goals. At the same time, this defiance provides an opening for the ambiguity of the truth, the extent to which madness is a type of truth and can be speaking truth.
Like Wallant's The Tenants of Moonbloom, another novel with frequent references to psychiatry as dissatisfying ways of organising narratives, A Confederacy of Dunces has another story to tell; or rather, like Wallant's novel, it has numerous other stories to tell, ones that cannot be accounted for or described by DSM criteria or through simple analytic principles, The defiance does not simply seek to re-explain the grander meaning of things with another all-explaining theory (unlike Houellebecq, who offers other first principles), replacing black with white, but to highlight the greys.
Nevertheless, while celebrating Confederacy's paradigm of defiance, the resounding caveat is the aforementioned provenance of the novel itself. Toole's suicide sadly speaks volumes alongside this comic masterpiece. That an intervention might have saved Toole is optimistic speculation; that the same intervention might have rendered him incapable of creating a virtuoso encore is another speculation. Nevertheless, any celebration of defiance, in this case, is tempered by the two tragedies identified by Walker Percy.

V. The Broader Picture

Now we can return to the original questions posed: What do we learn from a narrative that does not just deny illness and pathology but is written or spoken against illness and pathology? How does the resistance and defiance in counter-narratives contribute to our understanding and practice of medicine?
For one, counter-narratives speak to a fuller experience, refusing to diminish the anger and anguish and despondency that cannot be expressed in terms like 'anhedonia' or 'negative symptoms' or even 'gout' and 'rheumatoid arthritis'. At the same time, from a more positive perspective, they can also celebrate the oddness, the difference, the potential of people like Ignatius Reilly, Moonbloom's tenants, James Tilly Matthews. A common thread running through narrative medicine and the medical humanities, and an essential principle of psychiatry and psychoanalysis, is just such a deepening of our understanding of illness and the ill person: the resistant/defiant text can force us to confront this in a language of its own choosing, on and in its own terms.
On a more concrete level, counter-narratives can oppose problematic hegemonies and medicine's own commonly held beliefs. Clinically, they may shed a light on providers' own resistances and defiances.
Robert Whitaker's Mad in America asks the contentious question why people with schizophrenia not only do not do better in the United States, a country where numerous medical, psychiatric and pharmacologic resources are deployed on their behalf, compared to other countries, but are worse off in the United States now than they were thirty years ago. These may be shocking claims to regular readers of medical journals. In these texts, introductions and abstracts often include optimistic and enthusiastic histories like the one provided by Daniel E Casey MD in his introduction to a volume of CNS Spectrums: The International Journal of Neuropsychiatric Medicine (funded by an "unrestricted educational grant" from Pfizer):

The introduction of clozapine in 1989 and additional antipsychotics during the past decade has ushered in a new era of optimism for physicians who treat patients with schizophrenia. Unlike older agents, the atypical antipsychotics effectively treat a broad spectrum of symptoms with a reduced liability for extrapyrimidal side effects. (Casey, 4)

Similarly, in the introduction to a supplement of The Journal of Clinical Psychiatry on the anti-psychotic ziprasidone, John M. Kane MD makes a common claim:

One of the challenges of treating this disorder [schizophrenia] is its relapsing/remitting nature, which requires pharmacotherapy that can rapidly improve symptoms . . . Atypical antipsychotics are now widely considered first-line treatment agents for schizophrenia and other psychotic disorders. These agents are at least as effective in controlling psychotic symptoms as are older, conventional agents, and indeed may possess superior efficacy against negative symptoms. Moreover, they offer a lower movement disorder burden than do conventional drugs, a critical clinical advantage, and arguably better overall tolerability. (Kane, 3)

Mad in America, however, has another history to tell:

One of the enduring staples in mad medicine has been the rise and fall of cures. Rarely has psychiatry been totally without a remedy advertised as effective. Whether it be whipping the mentally ill, bleeding them, making them vomit, feeding them sheep thyroids, putting them in continuous baths, stunning them with shock therapies, or severing their frontal lobes - all such therapies "worked" at one time, and then, when a new therapy came along, they were suddenly seen in a new light, and their shortcomings revealed. In the 1990s, this repeating theme in mad medicine occurred once again. New "atypical" drugs for schizophrenia were brought to market amid much fanfare, hailed as "breakthrough" treatments, while old standard neuroleptics were suddenly seen as flawed drugs, indeed. (253-254)

He goes on to describe the development and marketing of atypicals in a larger and more critical historical perspective than the one provided so commonly in the medical literature. It need not go unstated here that both the efficacy of atypical antipsychotics and the damaging side effects of these same medications have been chronicled and witnessed in the clinic, both anecdotally and in well-controlled studies. One does not necessarily have to agree with all of Whitaker's critiques, however, to be shocked by how different his version is to what is often thought of clinically as common knowledge. What he has to say is hardly consistent with the history of atypicals in the medical literature, which has been repeated so frequently in that literature that it requires no further citation. But, one has to go back to Whitaker's original question: why are people with schizophrenia doing so poorly if psychiatry has such good pharmaceuticals? Or are these part of the problem? As Whitaker says, after reporting on the outrageous shenanigans involved in the introduction of atypicals into the American market, 'Madness is clearly afoot in American psychiatry, and bad science - as so often has been the case in mad medicine - has helped it on its way.' (Whitaker, 286) Like Michel Houellebecq's novel, Mad in America sheds significant doubt on the very notion of progress, which is an integral part of any medical narrative.
Homelessness; substance abuse and the incarceration of substance abusers; mental illness in prison populations; repressed memory and child abuse; maternal infanticide; the disenfranchisement of people with mental illness and some 30,000 suicides annually in the United States - these are public health problems, even public health disasters, that face mental health practitioners and health care providers. Psychiatry and psychoanalysis cannot resolve these problems alone, even with the best of intentions; the extent to which psychiatry, psychoanalysis and public health interventions fail, and more bitingly, the extent to which they actually contribute to these problems, is chronicled not in the journals and textbooks but in these resistant and defiant narratives. They need to be studied.

Resistance and defiance as concepts can also find a place in other fields of medicine. Of immediate importance and with significant clinical impact, compliance and noncompliance can be the bane of the treating physician: elucidating the elements of resistance and defiance in noncompliance may be a more useful, although more time-consuming, way of figuring out what 'noncompliance' really is. Such a perspective would undoubtedly complicate the dispirited refrain, "Why is that patient so noncompliant?" by reminding the speaker that this is not merely a rhetorical question.
Counter-narratives based on resistance and defiance exist throughout medicine. The conflicts in The Spirit Catches You and You Fall Down can be parsed as culturally-inflected resistance and defiance. Would a better understanding of resistance and defiance shed a modicum of light on racial and cultural disparities in the provision of health care? The vigorous feminist counter-narrative to the medicalisation and 'treatment' of menopause was vindicated with recent studies published in major medical journals; in her regular column for The Nation, Katha Pollit, championing feminist victories in 2003, includes the following: 'Hormone replacement therapy was further debunked'.
And as one more example, on a slightly different tact, the so-called alternative or complementary medicine often consciously constructs itself as a counter-narrative to so-called Western medicine (a term, often used disparagingly and often used by detractors of whatever it is that constitutes 'Western medicine', and which frankly excludes the innumerable contributions of 'non-Western' scientists and doctors). But is this 'counter-narrative' actually informed by a powerful resistance to insight, preventing the manufacturers of these products from placing the products under the scrutiny of double-blind, placebo controlled studies? Or, is their 'defiance' of so-called Western medicine a calculated attempt to protect a multi-million dollar 'alternative' industry?
The roles of resistance and defiance would benefit from further scrutiny.

VI. Resistance is not futile

Counter-narratives are ultimately uncertain because we are unsure what to do with them: where do they fit, given that they insist upon not fitting? Is there a way to view them legitimately when they dispute the legitimacy of the viewer's perspective?
In some extreme cases, the answer will always be no. There are points of impasse - some of the claims made by the church of scientology are simply not reconcilable with modern psychiatry; the snake-oil salesman only has a role in modern medicine as a character to disdain, and the feeling may well be mutual.
In the majority of cases, though, there is a complex negotiation that must take place. After all, there is always the risk that appropriation of counter-narratives into the medical education curriculum sanitises the texts, renders them clinical, the equivalent of pathological specimens floating in amber formaldehyde. Counter-narratives are regenerated in the medical school curriculum as narratives, when students and doctors search for the Axis I pathology or the hidden history of an arrhythmia in the patient's description of his or her experience with illness; the medical reader continues to categorise, nodding over the text with a mixture of rose-tinted empathy and glass-sharp clinical acumen. This happened to me with A Confederacy of Dunces.
To see how this happens, one might look at a counter-narrative. The artists and activists at Adbusters have a masterful grasp of context; one might say that context is the new counter-narrative. Rather like antifascist editors thinking it parody enough simply to reprint Nazi propaganda as it was (Carey, 3), Adbusters dryly reproduces the advertisements for Zoloft, which pose a set of questions that would define Panic Disorder by DSM-IV criteria. Suddenly, shifted out of the 'clinic' into the critical framework of the magasine, the questions about being afraid of dying, shortness of breath, and sweating levels become lethally mundane, desperately everyday. Does one really need medicine for this? Who wouldn't qualify for a trial of Zoloft?
Adbusters' seeks to question the influencing role of advertising, and so another question follows: what sort of complicity is at work when an advertisement reproduces a physician's diagnostic questioning - or, is the physician's diagnostic questioning actually a reproduction of an advertiser's intent to sell?
The resistant and defiant texts demand that the narratives be understood contextually for their sociological, anthropological, economical and cultural as well as their psychological dimensions. To do so, they need to have their distance respected if they are to elucidate and educate. Space can be left for defiance, for the life lived outside of the regressions of psychoanalysis, a life private, unpathologised, unapologised, the result of myriad experiences both known and unfaced. In fact, space must be left for defiance, because along with the genetics of development comes the fury of social experience. It is the latter that compels James Tilly Matthews and Ignatius Reilly; it is the latter that Michel Houellebecq's characters fear.
Ultimately, one way to understand these practically within the medical humanities and narrative medicine is to understand that resistance is an obstacle to insight and defiance an obstacle to abuse. The uncertainty that will remain with this conviction is that resistance is textured with defiance and defiance co-produced with resistance; the uncertainty that pecks at the edges of resistance and defiance, the overdetermination of each, makes both slightly composed of the other.
One might turn again to that often frustrating text, Dora, to where Freud writes, "We shall not be far from solving [how Dora fell in love with someone whom 'her beloved friend' had condemned] when we realize that thoughts in the unconscious live very comfortably side by side, and even contraries get on together without disputes - a state of things which persists often enough even in the conscious." (54, italics added)
It is something of a compromise to suggest that there can be both resistance and defiance, that both can contained in the same monosyllabic "no" - but such a compromise may ultimately be necessary. As we are hardly any closer to "solving" the "problem" of mind-brain dualism, let alone who really won the 2000 Presidential election, perhaps we should heed Freud and become comfortable with, even awed by, the uncertainty.
And Narrative Medicine, as it constructs its history, celebrates its incorporation into the medical thinking process and from a position of strength sets up its heroes and derides its detractors, might do well to set an example for the rest of medicine, and learn how to appreciate the defiance and analyze the resistance.

Bibliography
Adbusters No. 41; May/June 2002.
Adbusters No. 51; January/February 2004.
Carey, John. A Review of Appropriating Shakespeare. The Sunday Times. August 7, 1994;Book Review:3.
Casey, Daniel E. Introduction. Optimizing Treatment for Patients with Schizophrenia: Targeting Positive Outcomes. CNS Spectrums 2003;8(11). Pg 4.
Freud, Sigmund. Dora: An Analysis of a Case of Hysteria New York: Touchstone;1963.
Freud, Sigmund. Introductory Lectures on Psycho-analysis London: W. W. Norton and Company;1989.
Gabbard, Glen O. Psychodynamic Psychiatry in Clinical Practice Third Edition American Psychiatric Press: Washington, DC. 2000.
Holland, N. (1993) Psychoanalysis and Literature - Past and Present. Contemporary Psychoanalysis, 29:5-21.
Houellebecq, Michel. Atomised London: Vintage; 2001.
Houellebecq, Michel. Platform London: William Heinemann;2002.
Jay, Mike. The Air Loom Gang: The Strange and True Story of James Tilly Matthews and his Visionary Madness. London:Bantam;2003.
Kane, John M. Ziprasidone in Schizophrenia: From Acute Treatment to Long-Term Management Journal of Clinical Psychiatry 2003;64. Pg 3.
Laurance, Jeremy. Pure Madness: How Fear Drives the Mental Health System. London:Routledge;2003.
National Alliance for the Mentally Ill. Available at: <http://www.nami.org>. Accessed January 10, 2004.
Pollitt, Katha. Good News For Women. The Nation, December 24, 2003. Available at: <http://www.thenation.com/doc.mhtml?i=20040112&s=pollitt> Accessed January 4, 2004.
Shakespeare, William. Hamlet London:Methuen;1982.
Toole, John Kennedy. A Confederacy of Dunces New York:Grove Weidenfeld;1980.
Vonnegut, Mark. The Eden Express New York:Praeger Publishers;1975.
Wallant, Edward Lewis The Tenants of Moonbloom. New York:New York Review Books;2003.
Whitaker, Robert. Mad in America: Bad Science, Bad Medicine and the Enduring Mistreatment of the Mentally Ill. Cambridge, MA:Perseus Publishing;2002.