On medicine and art - a much needed connection

In 1985 Gabriel Garcia Marquez made a speech in Havana. His words would later be transcribed under the title “Word for a New Millennium” and included in his book “I’m Not Here to Give a Speech”. A notable figure of Latin-American magical realism, Márquez come to state that “The idea that science concerns only scientists is as antiscientific as it is anti-poetic to pretend that poetry concerns only poets.”

I first read this statement many years ago come at a time when I felt overwhelmed by work and had very little time to read, watch movies or visit exhibitions. I lived surrounded by people that dedicated themselves exclusively to science. Time dedicated to other activities, including art, was scarce and considered superfluous. Influenced by this notion, I became increasingly immersed in the world that I had chosen as my profession and eventually accepted the idea that scientists should concern themselves with science, leaving poetry to actual poets. And, as one would expect this thought anguished me deeply.

It felt as if an invisible wall separated science from art to keep the former from being contaminated by the imaginative character of the latter. Oliver Sacks, a British writer and neurologist, conveyed just this feeling in his autobiography when describing his first trimester in medical school:

“There was a physical and social separation (…) Spending a lot of time studying neuropsychology was fun and even exciting but I increasingly felt as if something was missing in my life.”

At a certain point during my academic path I was invited to choose one of three paths: “science”, “arts” or “humanities”, as they were colloquially called. Following the path of science seemed to require renegading art or even renouncing the notion of humanity. I was expected to follow the “path of science”. We are were taught that at the far end of this path lay true intelligence, intellect, progress. Society requires scientific advancement and the community specialized technicians in different areas. Where did literature, sculpture, philosophy or painting fit in modern society? I learned physics, chemistry, biology, geology and math; along the way I memorized countless formulas, laws and layers that I can no longer recite. To many, philosophy was a bore and Portuguese an unnecessary duty.

Oliver Sacks writing

When I started studying and, some time later, practicing Medicine I felt that I would have to forget art forever. Medicine felt a complex science, filled with its own laws and formulas. There was always something left to learn and someone who just knew a bit more and left one feeling like a failure.

The digestive system was a whole interactive universe of organs, histological layers and difficult pathological processes. Above all, I feared saying something that was unforgivably wrong, afraid of mispronouncing a scientific term, of using the English nomenclature where the French would be more appropriate. Reading for pleasure was considered a luxury, a superfluous pleasure one could (and should) ignore.

What did change, then? Perhaps in my intimate thoughts I secretly knew it would be impossible for me to leave art for good. Even if medical encyclopedias and surgical videos had taken the place of fiction books and Malick, Bergman and Nolan’s films, something must have laid dormant inside, waiting. Thankfully, I was lucky enough to meet two people who allowed me to shift back my perspective.

On my fifth year of medical school I faced one of the most complex and demanding specialties: Internal Medicine. The mere mention of Internal Medicine seemed to evoke a subtle and persistent chill. If Medicine were Geography, Internal Medicine would be a conglomerate of countries with an impossibly vast area that was extremely difficult to explore, let alone conquer. All I could imagine were hospital corridors filled with old people, bodies filled to the brim with problems and illnesses. I In my mind, specialists in this area were grim elders who served as a distant goalpost that students should aim for – it was with this mental image that I first entered the office of my Internal Medicine professor. It was an old office, just like I had imagined. Its walls, covered with shelves of thick, worn out books, surrounded his wooden desk. On it laid scribbles and pens of various colors that had been used to explain complex clinical processes. After arriving, our professor asked us to sit down, a request to which we promptly complied. His face seemed friendly but by this time we had learned to be suspicious of initial impressions. “So, do any of you know the history behind this room we find ourselves in?”, he asked. A wave of reflection passed us by: this was probably a loaded question, one with a trick answer that we couldn’t figure out. “Nothing? Let me tell you about it.” He then proceeded to transmit us stories that culminated in important scientific breakthroughs, real or fictional, he spoke of books, people, clinical cases that he had witnessed. That semester was soon over but I will never forget the excitement of those sessions.

Years later, just after finishing college, I spent a year in a small city in the north of Portugal completing a mandatory medical internship. In that city, I spent three months on a primary health care center located right next to one of the most beautiful Portuguese rivers. At that time, I believed my future would include becoming a hospital specialist, but those months would eventually convince to become a family doctor. And I did so because of my tutor at the time, who taught me something very difficult to apprehend just by reading or attending classes: the power of stories, of active listening, of empathy. Even if I didn’t know it at the time, his words demonstrated his holistic understanding of patients. During breaks, we would discuss art, stories and travelling; I’d listen closely to him and in turn he would care about my objectives, dreams and experiences. His listening skills, empathic responses and storytelling ability helped me make a final decision to become a primary care physician and for that I’ll always be thankful to him.

The importance of stories is a fundamental building block of human beings and, by extension, of healthcare professionals. It is easy to forget that everyone has a life story, especially in everyday situations where time is scarce. Art taught me to interpret and getting in touch with different ways of thinking and feeling. We’re all afraid of feeling – I believe art helps us not only to feel but also to comprehend. Active understanding and empathy are traits that one develops under the guidance of art. All different art forms – photography, painting, literature or cinema – forces us to contact realities different from one’s own and to develop our emphatic understanding. Roger Ebert, a film critic, once expressed that:

“For me, the movies are like a machine that generates empathy. If it’s a great movie, it lets you understand a little bit more about what it’s like to be a different gender, a different race, a different age, a different economic class, a different nationality, a different profession, different hopes, aspirations, dreams and fears.”

My internal medicine professor taught me the value of stories. With his serene and paused voice, he taught me that behind great scientific discoveries and medical progress lay people, contexts and sometimes chance. My general practice tutor taught me the same in a closer interaction with patients; he taught me the importance of interacting with people and validating their emotions. Without knowing it, they both helped understand the value of Art in Medicine.

When I started to work, I found myself inside a consultation room, surrounded by white walls and accompanied by a few objects sitting on my desk: a computer screen, a mouse, keyboard and a blood pressure meter. And in front of me lay a more intimidating object: an empty chair. Many people would come to sit upon that chair with an endless possibility of symptoms, complaints and reasons to seek help.

It’s difficult to convey how lonely it is to work in a consultation room. Health professionals work in a team and primary healthcare is no exception; and yet most of our work is spent inside a room alone with a patient and sometimes his family. I soon discovered that what motivated many consultations was not directly related to physical or psychological complaints. Rather, they involved familial, financial or social issues. I still remember the fear I felt when I performed my first consultations alone – fear of breaking bad news or dealing with strong emotions like sadness, anger, anguish.

Every time I’m asked how art has helped me to understand certain topics related to medicine, science or the interaction between medical professionals and patients, I’m always reminded of certain books, movies or even music albums. Literature has always had a special place in my life and certain pieces have made a big impression in my thinking.  “Beware of Pity”, written in 1939 by Stefan Zweig, served as a great way to distinguish empathy, pity and compassion. Similarly, “The Death of Ivan Ilyich”, the famous literary piece of fiction by Tólstoi, is relevant to doctors, given its approach to medical paternalism and how illness is experienced by the individual. Its story revolves around the life and death of Ivan Ilyich, a famous Russian judge that tries to maintain his status amidst a competitive society. Life takes its normal course until the moment the protagonist suffers a fall while fixing his curtains, which results in a minor back injury. Most characters surrounding Ivan are oblivious to his feelings: his fragility, pain, powerlessness and fear of dying. This miscomprehension on their part lead to his isolation and development of frustration, sadness and discouragement. His family made constant negative remarks and doctors frequently made judgements about his symptoms (“patients sometimes dream up this sort of nonsense; but we have to forgive them”) and quickly changed the subject to avoid facing his suffering. All, except for his son and his servant Guerassime, ignored the suffering that the illness inflicted in him.

No matter the art form, they all help me overcome the loneliness inherent to my work. After a particularly challenging appointment, I often feel the need to be in silence and fully absorb the emotions that were expressed. However, this is often impossible due to time constraints and art serves as a sort of reflection, a kind of self-analysis that I’m not allowed at my workplace.

The importance of narrative medicine is increasingly mentioned. While not exactly a new concept, it attempts to improve the recognition of suffering and its interpretation. João Lobo Antunes, a famous Portuguese neurosurgeon, repeatedly advocated the importance of this subject:

“A new breeze soothes a body that believes itself to be solid in knowledge and skills. I’m referring to Narrative Medicine, an area that I gladly welcomed due to its ideas and principles, which I’ve long defended and taught. Many of my writings, which I modestly designated as essays, are filled with stories that distill examples of what is singularly human in the artform of treating. These are the building blocks with which I keep building my hidden curriculum and that enhance the fictional treasure trove that I’ve accumulated since my childhood.”

Today still, art helps me. I frequently come back to stories - both fiction and non-fiction. It  gives me great joy knowing Gabriel García Márquez was not alone in exploring the relationship between science and art. Fernando Pessoa, a Portuguese writer, wrote that “Science describe things as they are; art as they are felt, as one feels that they are.” Other scientists have made their remarks about this subject. Carl Sagan, an American astrophysicist that died in 1996, defended the power of imagination in science and Albert Einstein stated that “When I examine myself and my methods of thought, I come to the conclusion that the gift of fantasy has meant more to me than any talent for abstract, positive thinking.”

In science, proof is always required. It’s necessary to be sure that a certain intervention is beneficial both for patients and medical professionals alike. Some studies have tried to demonstrate that artistic interventions could bring a positive impact to certain conditions and improve communication with patients by transmitting facilitating the transmission of empathy. Regardless, it feels urgent to cultivate humanity and empathy. And art is the tool that will allow us to accomplish that. They’re not independent entities but rather complementary. I can imagine both areas as two old friend arguing at the end of a long day, as they observe light prolonging through eternity. 

On depression - five books that portray living with mental illness

There are words that we find common. We hear them almost everyday and often start to devalue them. For the last years, the word “depression” started to seem an ordinary word, just as “food” or “sleep”. If we think about it, we use it everywhere and every-time: we are depressed because we had a bad day, we are depressed because our favorite sports team lost a match. We are depressed because we are momentously sad. 

I first acknowledged the true meaning of the word “depression” when I was fourteen years old and one of my closest relatives was diagnosed with major depressive disorder and anxiety disorder. I cannot recall exactly what happened then, but I clearly remember what followed in subsequent years. Later, this person was diagnosed with psychotic depression, a severe form of depression where people experience the common symptoms of depression, plus delusions and hallucinations. Her depression was severe, and she would also have intrusive and morbid thoughts which scared her. 

I want to say that I fully understood her pain and always remained calm by her side. However, I would be lying. Although I always tried to be supportive, I would lose my temper whenever she didn’t want to take her medications and I rarely asked why she didn’t. I assumed she had to endure the terrible nausea and dizziness associated with her medication. I would shout if she said she didn’t want to gain weight again. I would sigh if she called me and said she had seen a new psychiatrist again. I rarely actively listened. Instead, I would tell her “you have to be strong, this is not the end of the world.”

But what does that mean? And what if it really was the end of her world?

Despite thinking for a long time that I was a horrible person, I now understand I was worried about her and simply didn’t know how to deal with her disease. I was afraid of losing her, of slowly watching her wither away. For almost 15 years, I was by her side as she cried, was hospitalized and had mood swings. It was difficult understanding she was not being stubborn or pessimistic but rather that she was sick. Even now, after treating and caring for so many different people with this disease, I have to actively remind myself that this person is just like those patients.

Being understanding and empathetic with people who suffer from mental diseases is not an easy task, especially for those closest to them. I only understood that when my relative went through the darkest period of her life. For that reason, I decided to write an article about books that address depression and some mental diseases that feature depressive episodes or symptoms. Professional books about these topics abound in libraries, but I will only talk about specific books that I found important in helping me understand people who suffer from this mental illness.

Portuguese cover of The Bell Jar (A Campânula de Vidro)

Several authors addressed depression in their works: Virginia Woolf, Andrew Solomon, and David Foster Wallace are some popular examples. But Sylvia Plath's experience of depression is so deeply a part of her work that it's hard not to mention her. “The Bell Jar” is a novel that  perfectly describes a patient’s experience with depression. We follow the main character’s struggles and her descending path through the disease, which ultimately lead to her hospitalization in a psychiatry yard. The novel itself is a semi-autobiographical book, because the protagonist's descent into mental illness parallels Sylvia Plath’s, an American novelist and poet who experienced serious depression symptoms.

I find some aspects of this book of great importance. First, it helps us understand how depression symptoms start and also the importance of some risk factors, such as lack of support and adverse life events. Esther, the main character of this book, often tells us about her sense of inadequacy and hopelessness. She starts to lose her focus, which eventually prevents her from fulfilling her interests and plans of writing a novel. She describes how she felt oppressed and deeply affected by her disease. One of the most beautiful paragraphs in this book shows exactly what depression may do:

If Mrs. Guinea had given me a ticket to Europe, or a round-the-world cruise, it wouldn't have made one scrap of difference to me, because wherever I sat – on the deck of a ship or at a street cafe in Paris or Bangkok – I would be sitting under the same glass bell jar, stewing in my own sour air. ― The Bell Jar, Sylvia Plath

Sylvia Plath uses the bell jar as a symbol to capture how Esther felt trapped and isolated from the rest of the world. People often think they can just cheer up someone by buying them stuff and stating “don’t be sad”. Although supporting people with mental diseases is a crucial aspect of the treatment, it is also important to understand that sometimes depression is so severe that people won’t be able to appreciate and enjoy these things until they are medically treated. Sylvia Plath addresses some condescending attitudes  and disbeliefs regarding her disease, especially her mother:

My mother smiled. “I knew my baby girl wasn’t like that.”

I looked at her. “Like what?”

“Like those awful people. Those awful dead people at that hospital.” She paused. “I knew you’d decide to be all right again.

― The Bell Jar, Sylvia Plath

Another important aspect of this book is Esther’s experiences with doctors and several treatments. Esther eventually sees a psychiatrist called Dr Gordon. She immediately feels he is not interested in her as a person, and he often makes pointless comments. Under Dr Gordon’s care, Esther receives electroconvulsive therapy, also known as ECT. Nowadays, ECT is a safe procedure, done under anesthesia, which can be very helpful especially in treatment-resistant depression. In this book, Sylvia Plath describes ECT as a painful procedure, which might be explained because it used to be administered without anesthesia, leading to serious side effects. More than the stigma attached to ECT or how painful it was, I was startled by how no one told Esther about this treatment, its side effects and how it was done. “The Bell Jar” shows just how poorly healthcare professionals and mental patients communicated. Fortunately, she receives better treatments and care by another consultant called Dr Nolan, a female psychiatrist who treats her with respect. 

Sylvia Plath

Besides the social criticism present in this book, “The Bell Jar” is an essential work in understanding how a patient’s point of view about depression and its treatments are essential to recovery. Unfortunately, Sylvia Plath did not escape the fate that Esther fears by the end of the novel, when she wonders about her future after being discharged from the hospital, wondering if the bell jar would descend upon her again.

“The Bell Jar” is an important book which portraits many crucial aspects of depression. Moreover, I always find personal memoirs useful in understanding people’s points of view and experiences with mental diseases. 

In the last years, we have been following many famous people struggling with depression and mental diseases. In fact, almost every year we hear in the news that a famous actor / singer / artist died by suicide. Usually, these news strike us and leave us in disbelief. How could someone as funny as Robin Williams do that? How could someone as talented as Chris Cornell die by suicide? It seems incomprehensible that a famous and rich person would take his or her life. And when we hear they were deeply depressed, we are astonished: they seemed so happy, they had everything we will never have. How can such a disease do that?

William Styron was an American novelist. He wrote “Sophie’s Choice” and “Lie Down in Darkness” and won many literary awards for his work. He was married, had a big family and a successful life and career. It might seem odd that Styron would suffer from a severe depression, which almost cost his life. Why?, would someone wonder. Why would Styron feel so depressed that he would isolate himself and attempt to commit suicide?

In “Darkness Visible: A Memoir of Madness”, William Styron addresses some of these questions. But above all, Styron explains he does not have a simple answer for them. This is a small but powerful book that portraits Styron’s journey through depression, his inability to comprehend his disease and its profound impact on his life. Before experiencing depression symptoms himself, William Styron could not understand how someone would not recover from this “state of mind”, as he says. He adds:

“Romain told me that Jean was being treated for the disorder that afflicted him, and mentioned something about antidepressant medications, but none of this registered very strongly, and also meant little. This memory of my relative indifference demonstrates powerfully the outsider’s inability to grasp the essence of the illness. Camus’s depression and now Romain Gary’s - and certainly Jean’s - were abstract ailments to me, in spite of my sympathy, and I hadn’t an inkling of its true contours or the nature of the pain so many victims experience as the mind continues in its insidious meltdown.” ― Darkness Visible, William Styron

Note the use of “sympathy” instead of “empathy”. In fact, these are different concepts, which might help us understanding Styron’s words. Styron felt sorry for his friend (sympathy), but could not fully understand him. He could not imagine his pain, nor his wife’s (empathy). As he also states: “but even then I was unable to comprehend the nature of his anguish.” He also explains that the inability of healthy people to imagine “a form of torment so alien to everyday experience” might be the reason why it is so difficult for a regular person to understand someone who suffers from depression.

“Darkness Visible” - first page

Later, he would experience the same pain. His words helps us to understand how impactful his depression was, preventing him from enjoying parties, prize awards and social gatherings. His words even resemble Sylvia Path’s regarding her bell jar: “For myself, the pain is most closely connected to drowning or suffocation.”

“Darkness Visible” is an essential memoir who shows the progress of untreated depression, but also the recovery that medical treatment can sometimes provid. Styron talks about psychotherapy and medical treatment, and how important their combination is to recovery. This is also addressed in another important memoir called “Un Unquiet Mind: a Memoir of Moods and Madness”, one of my favorite books about depression and bipolar disorder. 

This is a somewhat different book, since it follows Kay Redfield Jamison’s experiences with bipolar illness. Formerly called manic depression or manic-depressive illness, bipolar disorder is defined by depressive and maniac episodes or symptoms. Dr Kay Redfield Jamison was diagnosed with type I bipolar disorder, in which patients experience manic episodes and nearly always major depressive episodes. A maniac episode is marked by an unusually good or high mood, which may be accompanied by expansiveness, disinhibition (for instance, wearing garish clothes or disrobing in public), increased energy and a sense of wellbeing and self-confidence. As it might seem, it is a devastating disease because patients often struggle to maintain employment and interpersonal relationships, as it frequently disrupts mood, energy, activity, sleep, cognition, and behavior:

“It took me far too long to realize that lost years and relationships cannot be recovered. That damage done to oneself and others cannot always be put right again.” ― An Unquiet Mind, Kay Redfield Jamison

The author tells us about her unique experiences regarding her maniac episodes, but also her devastating and serious depressive ones. She presents an unique perspective both as a patient and a clinical psychologist whose work is focused in this disease. It is a helpful and singular view, because she experienced many doubts and barriers across her life: the social stigma of having a mental disease, the resistance she offered being medicated and also the despair and fear she felt about losing control of herself. 

An Unquiet Mind, by Kay Redfield Jamison

Many people are afraid of taking medications for mental illnesses, and depression is no exception. Everyday, I face many concerns about side effects of antidepressants. People often fear they’ll have to take their pills forever and become “addicted” to them. Dr Jamison also addresses these concerns, as she felt them too. After her diagnosis, she took her prescribed medications reluctantly. But eventually she began understanding the importance of antidepressants and also psychoteraphy:

“No pill can help me deal with the problem of not wanting to take pills; likewise, no amount of psychotherapy alone can prevent my manias and depressions. I need both. It is an odd thing, owing life to pills, one's own quirks and tenacities, and this unique, strange, and ultimately profound relationship called psychotherapy.” ― An Unquiet Mind, Kay Redfield Jamison

She explains major depression is an illness as any other, stating it should be considered “malpractice to treat it without medication”, but also highlights the role of an understanding doctor in tackling these issue in a partnership with the patient.

I think picture books are amazing, not only for children, but also for every adult who loves to read. One of my favorite picture books was written by a Portuguese author called Joana Estrela. Unfortunately, you won’t be able to find it in english, but I will recommend it anyway, hoping someday you’ll have an English translation.

“A Rainha do Norte” (“The Queen of the North”) is a recreation of a popular Portuguese legend called “Legend of the Almond Trees”. In this legend, a young prince met and married a Nordic princess. They lived in Portugal, an European country with a sunny and warm weather. As time went by, the princess began missing her hometown, especially the snow. She yearned for the snow covered mountains, the cold weather and everything that reminded her home. Her prince was saddened to see his wife pining away and tried everything in his power to make her happy - including jewels and presents - but still her heart ached. He eventually came up with a plan, which involved almond trees - but I won’t reveal too much. 

In Joana Estrela’s book, the story is similar, but instead of giving the queen presents, the king decided to bring some famous doctors in order to cure her. Unfortunately, no one could do anything for her strange illness, as they could not understand why she was so sad. She started to get worse, and eventually she even refused to eat and exit her room. The doctors gave her a bunch of random treatments, but nothing worked.

“The Queen of the North” is a beautiful book which shows us that sometimes is difficult to understand someone’s pain. We have to put ourselves in their shoes in order to understand and help them. In this story, a man eventually arrives at the kingdom and talks to the queen. He listens to her, showing an empathic attitude, and finally understands the reason why the queen was feeling so depressed. He explains everything to the king, and with his support, the queen slowly begins to improve.

This is a wonderful small book which portraits how depression may have a huge impact in someone’s life. It also proves how sometimes depression is hard to understand by everyone around us. Although everyone has heard about it, no one is fully prepared to help someone who struggles with this diagnosis. I wasn’t prepared for doing that when I was younger, and even today I have to remind myself that my relative isn’t being stubborn or reckless. She is struggling with a powerful and strong disease. And although I am an healthcare professional, although I have studied depression and its symptoms, sometimes it is very hard for me - as it is for her - to understand and help her. Getting professional help is also important for people who support someone with depression, because support is a crucial aspect of depression’s treatment. 

At last, there is “Micheal Rosen’s Sad Book”. Every time I read this beautiful picture book I cannot help but feel a great sense of bittersweetness. This is a somehow different work, as it talks about depressive symptoms that followed the death of his son Eddie. But besides grief, it tells us about sadness: 

“Sad is a place 

that is deep and dark

like the space under the bed”

― Micheal Rosen’s Sad Book, Micheal Rosen

The main reason why I love “Micheal Rosen’s Sad Book” so much is because he tells us about so many important things in just a few pages and in few words. He tells us about his strategies to escape his negative thoughts, about loss and grief, about being sad and confused, angry and happy. He shows us that even in our darkest periods we are allowed to have happy thoughts without having to feel guilty. 

All of these superb books are amazing vehicles for better understanding how someone with depression feels. I’m sharing them in the hope that they’ll help you cope with the mental health issues faced either by yourself or by someone you care about.

If you have any other book suggestions, feel free to use the comment section below.