Birmingham Medical School, UK
In the 1930’s classic Tender is the Night, F. Scott Fitzgerald portrays Nicole Diver as “a schizoid – a permanent eccentric” [i]. However, whether the diagnosis is clinically accurate is a question that arises as the novel explores issues of mental illness and the doctor-patient relationship. The evolution of psychiatry and the medical conception of mental illness can be regarded as having begun as early as the fourteenth century, [ii] with the erection of mental asylums continuing into the Victorian era and evolving to modern times. The term ‘schizoid’, as applied to Nicole, was coined by Eugen Blueler in 1910, [iii] referring to an extreme tendency of an individual to fixate on internal life rather than the external world, and early descriptions stress the eccentricity of this so-called ‘schizoid temperament.’ [iv] From the late 1800s, psychiatric treatments were fixated on Weir Mitchell’s ‘rest cure,’ which is satirically portrayed by Fitzgerald and other nineteenth and twentieth century novelists. [v] Charlotte Perkins Gilman and Virginia Woolf, for instance, depict the lack of holistic care and paternalism of the medical profession through their own demeaning representations of Mitchell’s idolised ‘cure.’
In parts, Fitzgerald’s focus on institutionalization shifts to look in more detail at schizoidia. An interesting parallel can be drawn between the novel and Leffel’s 1999 model regarding psychoanalytic treatment, which looks at whether schizophrenia is actually a defense or a deficit. [vi] The latter is a model explicating the qualitative differences between schizophrenics and others, whereas the defence standpoint places schizophrenics on the same continuum as normal people. However, Tender is the Night more acutely corresponds to Leffel’s deficit theory of schizophrenia which dehumanizes the mentally ill by viewing them as incomparable with others. For instance, the author emphasizes the divide between the mentally ill and the mentally sound through capitalization of Nicole’s mental state when Rosemary refers to her as “Out of Her Mind.” Through doing this, Fitzgerald illustrates the deficit model and simultaneously underscores Nicole’s insanity and the stigma associated with it, reducing her to nothing more than an illness, and expounding the habit of society to turn its back on the mentally ill.
Fitzgerald continues to exemplify this stigma through his characterization of “crazy” Nicole and people’s reactions to her. His simile, delineating Nicole as “a broken roly-poly that can’t stand up straight” is a perfect illustration of Corrigan and Watson’s concept of ‘self stigma’[vii] whereby internalization of other people’s beliefs leads to the mentally ill placing prejudice upon themselves. The fact that Rosemary is “somewhat afraid of [Nicole]” goes on to then underline the sister concept of ‘public stigma’ – the negative attitudes held by the general populace. [viii] For Nicole, this leads to “her own withdrawal” and loneliness which Fitzgerald symbolizes through the boxed-in garden she loses herself in “between kaleidoscope peonies massed in pink clouds, black and brown tulips” to the point where she becomes invisible even to Dick “[crossing] the path ahead of her”, the garden thus becoming a metaphorical representation of Nicole’s social withdrawal. Even today, this stigma is an acute problem, and NAMI’s 2008 report suggests that the crisis lies in society’s lack of knowledge regarding mental illness and its treatment processes. [ix]
Fitzgerald also depicts the nineteenth century Freudian concept of ‘transference.’ [x] While believed in the novel by Dr. Franz to be a psychotherapy “of the most fortuitous kind,” the redirection of feelings – specifically emotions experienced during childhood – towards a psychoanalyst [xi] has negative corollaries for both Dick and Nicole. Fitzgerald implies in the novel that Nicole’s rape by her father was the critical event which catalyzed her mental deterioration. Ironically, later in the novel Dick is mistaken for a rapist but openly confesses, despite being innocent, publicly declaring: “I raped a five year old girl. Maybe I did.” In this way, he begins to exhibit schizoid tendencies himself and acts as an extension of Fitzgerald’s psychological metaphor; he takes on the role of the analyst, with Nicole being the patient, and appears to internalize her “transferred” perceptions of her father – who raped her as a young child. He replays her conflict and “[paralyses] his faculties” in the same way the childhood rape paralyzed Nicole’s to some extent, causing the pair of them to “fall into the same dark hole of unconsciousness” [xii] psychiatrist Jung cautioned against in his book on analytical psychology.
However, as transference-focused psychotherapy is an evidence-based treatment for personality disorders, [xiii] it favors Nicole’s diagnosis more towards a multiple personality disorder (MPD) rather than schizophrenia. Also, given that schizophrenia does not clinically involve split personalities, [xiv] nor is it caused by childhood experiences, the reader is led to question whether Fitzgerald is perhaps satirizing the medical profession for their lack of knowledge.
Literature suggests that multiple personality disorder is associated with a high incidence of sexual abuse in childhood [xv] which, along with Fitzgerald’s consistent allusion to Nicole having a “divided personality” suggests MPD as a plausible diagnosis for Nicole. For instance, she qualifies a confession of hers with “not if I were a million girls” and later explains how “sometimes [she is] Doctor Dohmler and one time [she] may even be an aspect of [Tommy Barban]” alluding to multiple sides of herself. Even when she is arguably “well again” at the end of the novel, she tells Tommy that “she’s a whole lot of different simple people” in such a way that undercuts the DSM criteria [xvi] for schizophrenia and reiterates that Nicole may be suffering with some description of multiple personality disorder. Nevertheless, it’s arguable that the knowledge of mental health in 1920s was extremely limited: from the early 1800s to the end of World War II, only seventy-six cases of MPD were diagnosed, [xvii] thus the likelihood of Nicole having been given an accurate medical label was slim.
As award-winning novelist Nathan Filer expounds with regard to writing mental health fiction, it is imperative “to see the person and see the illness as one facet of their character.” [xviii] However, Fitzgerald’s exposition of mental illness is one of ambiguity as he chooses to purposefully blur the boundaries between sanity and insanity, reversing the relationship of his doctor figure and mental patient and undermining societal expectations to capture the true question at hand, which Nicole’s sister astutely voices: “how can anyone tell what’s eccentric and what’s crazy?” Thus, the crux of the novel centers on this difficulty in differentiating between ‘normal’ and ‘abnormal’ states of mind, making the key question for the reader not merely who in ‘Tender’ is insane but, more pertinently, who is more insane than whom?
[i] All quotes from the novel taken from the 2011 kindle edition of ‘Tender is the Night’ by F. Scott Fitzgerald (Numitor Comun Publishing, first edition).
[ii] Bowcott, O. Bedlam Exhibition Traces the Meandering History of Mental Health. The Guardian 2010. [Internet] Available at: http://www.theguardian.com/society/2010/jan/20/bedlam-mental-health-exhibition.
[iii] Ashok, A; Baugh, J; Yeragani, V. Paul Eugen Bleuler and the Origin of the Term Schizophrenia. Indian J Psychiatry. 2012 Jan-Mar; 54(1):95-69.
[iv] Maj, M. Akiskal, H. Mezzich, J. Okasha, A. Personality Disorders. WPA Series. Evidence and Experience in Psychiatry. John Wiley & Sons Ltd, 2005.
[v] Bassuk, E. The Rest Cure: Repetition or Resolution of Victorian Women’s Conflicts. Poetics Today, Vol. 6:1-2 (1985) 245-257.
[vi] Leffel, R.J. Psychotherapy of Schizophrenia (1999). Dissertations and Theses: Widener University, Institute for Graduate Clinical Psychology.
[vii] Corrigan, P. Watson, A. Understanding the Impact of Stigma on People with Mental Illness. World Psychiatry. 2002 Feb; 1(1): 16–20.
[viii] Corrigan, P. Watson, A. Understanding the Impact of Stigma on People with Mental Illness. World Psychiatry. 2002 Feb; 1(1): 16–20.
[ix] NAMI. Schizophrenia: Public Attitudes, Personal Needs. (2008) [Internet] Available at: http://www2.nami.org/SchizophreniaSurvey/SchizeExecSummary.pdf
[x] Wilbur,C. Multiple Personality Disorder and Transference. Dissociation 1:1, 1988.
[xi] R. Howes. A Client’s Guide to Transference. Psychology Today. [Internet] Available at: https://www.psychologytoday.com/blog/in-therapy/201206/clients-guide-transference.
[xii] C. Jung. Analytical Psychology. Vintage Books, 1970.
[xiii] Stoffers JM, Vollm BA, Rucker G, Timmer A, Huband N, Lieb K. Psychological Therapies for People With Borderline Personality Disorder. Cochrane Database of Systematic Reviews 2012, Issue 8.
[xiv] May, A. Schizophrenia Does Not Mean Split Personality. Nature (2008). 451 (127).
[xv] Coons, P. Child Abuse and Mulitple Personality Disorder: Review of the Literature and Suggestions for Treatment. (1986) Child Abuse & Neglect; 10(4).
[xvi] Cold Spring Harbour Laboratory. DSM-IV Criteria for Schizophrenia. [Internet] Available at: http://www.dnalc.org/view/899-DSM-IV-Criteria-for-Schizophrenia.html
[xvii] K. Kruszelnicki. Schizophrenia & Split Personality. [Internet] Available at: http://www.abc.net.au/science/articles/2004/09/16/1200266.htm
[xviii] Brown, M. Nathan Filer Wins Costa First-Novel Award With The Shock of the Fall. Guardian (2014). [Internet] Available online: http://www.theguardian.com/books/2014/jan/06/nathan-filer-costa-award-first-novel.
Jessica Frost is a twenty-year-old medical student at Birmingham University, with a passion for English Literature and medical humanities.
Editorial Note By Jonathan Lewis, MD
In her creative and original analysis of F. Scott Fitzgerald’s lesser-known novel, “Tender is the Night,” Ms. Frost makes two important contributions. First is the notion that one of the main characters, Nicole Diver, may be suffering from that rare condition of ‘multiple personality disorder’ (MPD), a condition that had not been described at the time Fitzgerald published his novel (1934). She adduces evidence for this hypothesis. First, Nicole had been sexually abused by her father during her childhood, child sex abuse being frequently found in the histories of those diagnosed with MPD. Second, Nicole several times refers to herself as having many personalities.
More importantly, however, Ms. Frost says that Fitzgerald writes in his novel of the difficulty in differentiating between the mentally ill and those considered more ‘normal’ or mentally healthy. In the novel, Nicole Diver is the identified Crazy Person, who evolves to become, arguably, healthier than her psychiatrist husband, who at the outset of the story had been her treating psychiatrist. The line between the insane and the ‘normal‘ becomes quite blurred.
I would like to consider this novel from an altogether different point of view, one more akin to literary criticism than psychological analysis. In this approach, I am taking off from another important observation by Ms. Frost, that Fitzgerald is “perhaps satirizing the medical profession for their lack of knowledge.” I submit that the novel is not just a satire, but also a parody, specifically directed at Carl Jung and Jungian psychology. Evidence for this can be found in Part II of the novel. Nicole’s husband, Dr. Dick Diver, son of a retired clergyman in America, comes to Switzerland for psychiatric training. Specifically, he goes to work at a mental hospital in Zurich, where he is supervised by a noted Swiss doctor and treats a young American woman who later in the novel becomes his wife. Is this scenario familiar?
Carl Jung, the son of a minister, was trained at the Burgholzli psychiatric hospital in Zurich by Eugen Bleuler, one of the first to describe and treat schizophrenia. While working at the hospital, Jung was asked to treat an extremely bright but extremely disturbed eighteen-year-old woman from Russia, Sabina Speilrein. Like Nicole, whose illness is never definitively identified, Speilrein recovered in a matter of weeks after starting her treatment in hospital, then was well enough to begin medical training in Zurich. Though she no longer required treatment, Speilrein remained at the Burgholtzli for a time and became an assistant to Carl Jung in his experiments in word association. Jung was one of her medical school professors and a dissertation supervisor. Their association lasts for the duration of her medical training, from 1904 until 1909, when she left Zurich. By that time, Jung and Speilrein had developed an intimate social relationship which some historians believe became sexual in nature.
Whether or not this was the case, Jung’s wife was prompted to write to Sabina’s mother to warn her of the pair’s growing intimacy. This is another convincing piece of evidence that Fitzgerald has taken Jung as his model for Dr. Dick Diver. In the novel, the mother of a mentally ill young woman writes to Nicole, now Dick’s wife, alleging that Dr. Diver had seduced her daughter while she was his patient. While the mother’s accusation is untrue, it is close enough to the events that occurred between Emma Jung and Sabina’s mother, that it could not have been a mere coincidence. There are many other parallels between Dick Diver and Carl Jung, too many to belabor other than to relate the hilarious spoof of psychiatric writing in Dick Diver’s fabulous textbook titled “An Attempt at a Uniform and Pragmatic Classification of the Neuroses and Psychoses Based on an Examination of Fifteen Hundred Pre-Kraeplin and Post-Kraeplin cases as They would be Diagnosed in the Terminology of the Different Contemporary Schools”, a book he had written while working in the Zurich psychiatric hospital. Similarly, Jung had written his text on word association tests while working at Burgholzli. Finally, I shall point out that Dr. Diver’s infidelity with an American actress who we met in the very beginning of the novel mimics Jung’s multiple infidelities, including at least one with a patient other than Sabina (this was Toni Wolff).
So we could say that among the characters in the book, Dr. Dick Diver represents Jung, Nicole Diver takes the part of Sabrina Speilrein, Dr. Dohlmer, Dick’s mentor at the hospital, recreates Eugen Bleuler and so on. Using this reasoning, Nicole could be diagnosed with an hysterical psychosis, just as Sabrina Speilrein was. She is most like the patients Freud and Bleuler describe in their book, “Studies on Hysteria”.
A final note on creative writers; in a letter to Sabina Spielrein, Carl Jung (1908) wrote, “Give me at this moment something back of the love and patience and unselfishness that I was able to give to you during the time of your illness. Now I am the sick one…” What an extraordinary request of a treating psychiatrist to his patient, to reverse their relationship. Jessica Frost writes towards the end of her essay that Fitzgerald blurred the boundary between sane and insane, ‘interposing his doctor figure and mental patient, reversing their relationship…’ I think by now, it is incontestable that Fitzgerald had used Jung and his relationship with Sabina Spielrein as models for Dr. and Mrs. Diver. Many of the details of Jung’s history were widely know at the time that Fitzgerald was writing, yet F. Scott did not have access to the correspondence between Spielrein and Jung, that was not published until the 1990s. So how was he able to intuit this reversal of doctor patient relationship in his novel? Perhaps Jung was correct in conceiving of the ‘collective unconscious’ and there was a congruence between Jung’s and Fitzgerald’s unconscious. I prefer to believe Freud’s contention that the creative writer had uncanny access to his own unconscious and could call forth psychological insights articulated in fictional characters, insights not accessible to the ordinary person. Freud puts this notion most poetically in his 1907 essay, ‘Delusions and Dreams in Jensen’s Gradiva:’
… creative writers are valuable allies and their evidence is to be prized highly, for they are apt to know a whole host of things between heaven and earth of which our philosophy has not yet let us dream. In their knowledge of the mind they are far in advance of us everyday people, for they draw upon sources which we have not yet opened up for science. (p. 8. op. cit.)
If Ms. Frost is correct in her hypothesis that Fitzgerald was describing a ‘multiple personality’ in the character of Nicole Diver, he had indeed preceded the identification of this disorder in psychiatry by several decades.