How psychiatry works in fiction

What is it with madness and writing? Are the two inextricably linked? Are writers predisposed to madness? And how exactly do novelists portray it in their work? It's really only with twentieth-century fiction, long after the rise of psychiatric institutions, lunatic asylums and so on, that the scientific treatment of mental states has been depicted in novels. I'm interested in this because it's the focus of my own historical novel, Unfashioned Creatures (due out in November) - I didn't research other novels that depicted psychiatric treatments for my own book, although I had read a few before I started it (how to avoid them?). But now I've finished, I'm curious about how other writers have used this subject in fiction, and how well it works.

Because there really couldn't be any greater divide in approaches. It seems to suit historical and contemporary fiction, literary and 'romantic', semi-confessional and thoroughly invented. When F Scott Fitzgerald used his wife Zelda's own experiences of madness and her treatment in various sanitaria for his 1934 novel Tender is the Night, about a psychoanalyst Dick Diver and his wife and patient, Nicole, another question arose - whose experiences do these belong to, and can the novelist simply appropriate them for his/her own? Are they suitable for novelisation? Scott was already furious that Zelda had used elements of their marriage for her novel, Save Me the Waltz, even though he had done exactly that for his previous novels. He had no qualms about detailing what she had gone through (which horrified her when she found out).

So as I say, I'd already read four very different novels that dealt with mental issues and psychiatric treatment of them by the time I started to plot my own:  Sylvia Plath's 1963 semi-autobiographical The Bell Jar, Antonia White's superb and chilling1954 novel Beyond the Glass, Olive Higgins Prouty's 1941 bestseller Now, Voyager and, more recently, Adam Foulds' historical treatment of John Clare and Alfred Tennyson,  The Quickening Maze (2009). I've never read probably the most famous novelistic account, Ken Kesey's 1962 novel, One Flew over the Cuckoo's Nest, and Patrick McGrath's 1997 Asylum was recommended to me, but I was too frightened to read it in case it had ideas like my own and put me off, so I've still got that one to check! I did make a quick perusal of Margaret Atwood's Alias Grace, also published in 1997 but soon put it aside for similar reasons. But I'm hugely looking forward to John Harwood's forthcoming historical novel, The Aslyum, due out this June.

All of these novelistic treatments are very different, of course, with their own particular depictions of madness and the institutions that respond to it. The nineteenth century saw the rise of the lunatic asylum, hence any historical novel that looks at madness during this period pretty much has to take account of it (the 'madwoman in the attic' has become a cliche, even though, for just as many people during this period, care at home was also popular, so it's a situation I think novelists today would probably want to avoid using in their fiction). But few novels looked at it at the time (any suggestions welcome!).

In the twentieth century, Plath's and White's books come out of the authors' own experiences, needless to say (White had even spent a spell in the notorious Bethlem hospital, which of course gave its name to 'bedlam'), and are harrowing accounts. Yet Prouty's novel also reflected the treatment that the author had for her own breakdown, and is much more encouraging (incidentally, Prouty was also Plath's 'mentor' and financial backer of sorts). She is perhaps best known for her novel, Stella Dallas, and both her books were made into hugely successful films. She was very interested in Freud and psychoanalysis, and her depiction of Now,Voyager's heroine, Charlotte Vale, in a very friendly and relaxed sanitarium, was a superb advert for the profession.

There are some common tropes in most of these novels - the psychiatrists are nearly always male (certainly in a historical novel they would have to be), and the patients often female, leading to a power battle that also reflects the 'battle of the sexes', and more - the battle between reason (traditionally viewed as 'masculine') and intuition (traditionally viewed as 'feminine'). In some cases, like The Bell Jar, a female doctor is involved, and of course, one of the most famous psychiatric nurses is Nurse Ratched; in some cases, as with The Quickening Maze, the patient is male. But the power relations remain.

That exercising of power takes various forms: writing is often forbidden by doctors in asylums (it took Zelda Fitzgerald a long time to persuade her doctors that writing would help her progress, not hinder it), and perhaps that means that inevitably, novelists would on the whole prefer to portray medical treatment in a negative light. There is often a sense of the doctor as jailer, of the asylum as a prison. The patient becomes a sort of freedom-fighter. Suited, bearded, often inscrutable, the psychiatrists themselves are even frightening figures, out to terrorise and victimise their patients (although, again, perhaps it's a woman who's scariest, in the form of Nurse Ratched).

So what can a novelist do with these tropes? Subvert them? Employ them happily enough? In my own, I wanted my (male) doctor to be just as vulnerable and damaged as my (female) patients, so that I could at least play with the power relations as they existed at the time (my novel is set in 1823). But a woman does sneak in writing paper to another female patient, an important act for the plot. And as for reason versus intuition - well, you'll just have to get the book in November and see!