Abstract

The apparent maturing of the teenage novel has been controversial. At issue is the potential impact of the novel's content on the well-being of the reader. A grassroots revolt against what is perceived as an increasingly nihilistic form of realism is emerging. In Sydney's Child, an article describes a parent's horror at the content of a Marsden novel: "Can we trust John Marsden with our children's minds?".⁷ In The Australian Magazine, Kate Legge asks "is the nihilistic trend in children's literature out of control?".⁸ The foci of these critics' discontent are no longer books about sex and rule-breaking, but books which showcase severe psychiatric illness and suicide (eg, Shoovy Jed,⁹ Care factor zero² and Dear Miffy¹⁰). The complaint is that the vividness of the contemporary teenage novel has gone beyond the honest to the offensive: "Young adult fiction is carving up the literary nature strip and hanging wheelies on the hard-baked bitumen of realism and it is not just nostalgic fogies and Christian Fundamentalists wrinkling their noses at the smell of burnt rubber."⁸

At a time of growing alarm at the high youth suicide rate,¹¹ increasing awareness of the psychiatric problems confronting our adolescents,¹² and concern about the effects of television, movies and video games on young people,¹³ it is worth ascertaining what we can learn from teenage literature. What attitudes to mental health issues are expressed in this literature and what impact might this literature have on the well-being of its readers? We aimed to explore these issues by systematic examination of a sample of Australian teenage novels.

Sample

Tools

Statistical analysis

The works as a whole

There was reference to psychiatric illness, institutions, treatments or mental health professionals in 69% of the books. In 9% of those, the reference was "slight" (eg, a one-line reference to Freudian psychoanalysis). In 75%, the reference was "significant" (eg, a refugee child suffers a post-traumatic stress disorder which strongly influences the story line). In the remaining 15%, the reference was "major" (ie, the work was about a character with a severe psychiatric illness or a child's experience of a parent with major psychiatric illness).

Among works which refer to psychiatry, there were very few positive portrayals (6%); the depiction of psychiatry was usually negative (51%) or mixed (43%). A typical "negative" portrayal is one in which the sufferer of psychiatric illness is stigmatised, or there is futility expressed about seeking help from mental health professionals and institutions, or the mental health professional is depicted as emotionally abusive and the endpoint of mental illness is suicide.

The characters

Sixty-four per cent of characters experienced a "severe" stressor (eg, rape, sustained physical abuse, a life-threatening motor vehicle accident, or becoming a refugee from war). Having suffered a major loss (eg, death of family member or close friend, loss of home or homeland) affected 78% of characters. Fifty-seven per cent were distressed in some way. Specific psychiatric symptoms were identified in most characters and 41% met DSM-IV diagnostic criteria for a psychiatric diagnosis (Box 1). Most of these (63%) had one diagnosis; 31% had two (31%) and 6% had more than two.

Of the 180 characters who were distressed, experienced psychiatric symptoms and/or had a psychiatric diagnosis, 73% received help (Box 2). The attitude of the 180 characters to seeking help was ambivalent (48%), negative (22%) and positive (24%), with no clear attitude described for the remaining characters.

The 38 characters who sought help from mental health professionals accessed cognitive behavioural therapy (45%), hospitalisation in a psychiatric unit (37%), psychotropic medication (31%), family therapy (16%), dynamic psychotherapy (1%) and treatment in a therapeutic community (0.5%). Treatment outcomes varied: in 55% there was no change in symptoms; in 32% there was clear benefit, while in the remaining 13% mental health intervention had a negative effect.

Twenty-six characters (10%) had suicidal thoughts; 22 of these characters had a psychiatric disorder. Twenty-one manifested suicidal behaviour and 10 actually killed themselves, a very high rate of completion. The psychiatric profile and means of suicide are shown in Box 3.

Comparison of characters with and without a psychiatric diagnosis

A limitation of our study is that we have no data on the instruments' reliability and validity. For instance, we do not know whether the assessments of the rater (a senior trainee in child psychiatry) about issues such as "humour" would concur with those of a teenage reader.

Despite these shortcomings, this report describes how contemporary writers (and those who selected the books) view growing up in Australia at the end of the 20th century. What image of the times do these books project? The past decade appears to have been a time of trauma and loss for youth, unrelieved by humour or hope. Young people in these books experienced high levels of mental distress, but professional help was seldom obtained for mental health problems (only 38 out of 111 characters with a psychiatric condition accessed mental health services) and few patients actually benefited from the contact (only 12 of the 38 youths).

Characters who met criteria for a psychiatric diagnosis were more likely to have been abused, traumatised and to have suffered a loss. They were less attractive, worse academically, and social failures. And for characters with a psychotic illness the outlook was even more grim (over half killing themselves).

Considering this image of our times we may well ponder whether the genre has crossed the threshold from realism into nihilism. Yet, in some respects, the depiction of mental illness in teenage fiction can be applauded. Acknowledging mental illness is a first step towards understanding and the removal of prejudice. Many of the portrayals are so authentic that the teenage novel can be used to educate both general readers and students of psychiatry. However, we have concerns about some aspects of psychiatry's representation in these novels.

Detailed speculation about the effect of literature on young people's behaviour is outside the scope of this article. Nevertheless, many questions arise. How will books that are scathing of mental health professionals influence the preparedness of young people to seek or accept treatment?

As soon as she'd revealed a weakness, the shrink had gone for the jugular. To reveal that you were weak, scared or confused gave them power. And once they had the power, they could manipulate you, control you -- Who the hell did they think they were anyway, trying to pry into your soul: God? (Care factor zero, p. 106).²

What is the impact of books which feature psychiatric illness on vulnerable teenagers or those who either suffer a psychiatric illness or have a family member affected? For example, how can one safely expose a teenager with a psychiatric illness to a book in which the principal character (who also has a psychiatric illness) is bad/mad, consummately devilish and incurable,¹⁷ or to a book in which a teenage boy with schizophrenia is hounded to his death by the ignorance and cruelty of his peers, the abject failure of psychiatric help and the urgings of his hallucinations?¹⁸ Both these books are wonderfully crafted and educative, but at whose expense are we "doing wheelies on the hard baked bitumen of realism"? Similarly, will a character's decision that suicide is the best or only option tip the scales for teenagers going through a rough patch? Although data are lacking on the effects of reading literature on psychopathology and suicide, there are suggestions that other media -- newspapers, television, music -- may have an adverse impact.^13,19,20

Do medical professionals have a valid role in encouraging accurate and therapeutic content in teenage literature, without becoming "thought police" or encroaching upon "artistic freedom"? Do authors feel that responsibility for the well-being of their readers is compatible with the right to such freedom? If so, these two professions should enter into a dialogue and exchange perspectives. A recently published resource kit to assist various media professionals portray mental illness and suicide makes no mention about the possible responsibilities of authors in this matter.²¹ In any case, there seems to be a very wide gap between Karrawingi the emu and Care factor zero. Exploring the reasons for this and its consequences may prove just as helpful for the future of Australian society as many epidemiological and clinical studies.

Book covers reproduced with permission. Clark, M. Care factor zero. Sydney, Random House, 1997. Harnett, S. The devil's latch. Melbourne, Penguin, 1998. Hilton, N. Hothouse flowers. Sydney, HarperCollins, 1997. Marsden J. Checkers. Sydney, Pan Macmillan, 1997. Orr, W. Peeling the onion. Sydney, Allen and Unwin, 1996. Saliba, S. Watching seagulls. Melbourne, Longman, 1997. Walters, C. The killing of mud-eye. Brisbane, UQP, 1997. Winton, T. Lockie Leonard legend. Sydney, Pan Macmillan, 1997.

1. Rees L. Karrawingi the emu. Sydney: John Sands, 1946.
2. Clark M. Care factor zero, Sydney: Random House, 1997.
3. Morell M. Bush cobbers. Sydney: Australasian Publishing, 1948.
4. Phipps J. Good luck to the rider. Sydney: Angus and Robertson, 1953.
5. Pausacker J. What are ya? Sydney: Angus and Robertson, 1987.
6. Marsden J. So much to tell you. Melbourne: McVitty Books, 1987.
7. Bolt A. Do you want your children influenced by the world of John Marsden? Sydney's Child, Dec 1999/Jan 2000: 52.
8. Legge K. Life sucks, Timmy. Australian Magazine, March 8-9 1997: 10-18.
9. Stewart M. Shoovy Jed. Sydney: Random House, 1997.
10. Marsden J. Dear Miffy. Sydney: Pan Macmillan, 1997.
11. Cantor CH, Neulinger K, De Leo D. Australian suicide trends 1964-1997: youth and beyond. Med J Aust 1999; 171: 137-141.
12. Sawyer M, Arney M, Baghurst PA, et al. Child and adolescent component of the national survey of health and well-being. Canberra: AGPS, 2000.
13. Centerwall BS. Television and violence. JAMA 1992; 267: 3059-3063.
14. Children's Book Council of Australia. The Children's Book Council of Australia Awards Booklet. Brisbane: The Council, 1997.
15. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV). Washington, DC: American Psychiatric Association, 1994.
16. Australian Bureau of Statistics. Children, Australia: a social report (1999). Catalogue no. 4119.0 <www.abs.gov.au> Accessed 28 August 2000.
17. Hartnett S. The devil latch. Melbourne: Penguin Books, 1996.
18. Walters C. The killing of Mud-Eye. Brisbane: University of Queensland Press, 1997.
19. Hassan R. Effects of newspaper stories on the incidence of suicide in Australia: a research note. Aust N Z J Psychiatry 1995; 29: 480-483.
20. Martin G, Clarke M, Pearce CM. Adolescent suicide: music preference as an indicator of vulnerability. J Am Acad Child Adolesc Psychiatry 1993; 32: 530-535.
21. National Mental Health Strategy. Achieving the balance: a resource kit for Australian media professionals for the reporting and portrayal of suicide and mental illness. Canberra: Commonwealth Department of Health and Aged Care, 1999.

Authors' details

Department of Psychological Medicine, University of Sydney, Sydney, NSW.
Joseph M Rey, PhD, FRANZCP, Professor of Child and Adolescent Psychiatry, and Director of Child and Adolescent Mental Health Services, Northern Sydney Health, Sydney.

Reprints will not be available from the authors.
Correspondence: Dr G Walter, Rivendell Unit, Hospital Road, Concord West, NSW 2138.
gwalterATmail.usyd.edu.au

©MJA 2000
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