Choice of novels

We chose two contemporary, award-winning YA fiction novels, How it Feels to Float by Helena Fox and A Monster Calls by Patrick Ness, as case study examples of how sensitively portrayed literary representations of hallucinations and dissociation can promote empathy and reduce stigma associated with these experiences. Both texts offer strikingly nuanced portrayals of adolescent protagonists who experience hallucinatory or dissociative phenomena in the context of trauma and grief. Helena Fox, author of How it Feels to Float, has lived experience of both complex PTSD and dissociative disorder.

Novel summaries

How it Feels to Float is a first-person fictional narrative told by the protagonist, Biz, a 17-year-old living in Wollongong, Australia. In the novel, Biz’s father died ten years previously but she still sees and speaks to an apparition of her father who visits her in her room. As Biz navigates troubles at school and new friendships, she struggles to hold on to her sense of reality, experiencing panic attacks, auditory hallucinations, and dissociative episodes while trying to make sense of her traumatic past.

A Monster Calls is a third-person narrative of Conor O’Malley, a 13-year-old boy living in present-day England. Conor’s mother has cancer. Since her diagnosis he has been tormented by a recurring nightmare while facing isolation and bullying at school. One night Conor is visited by a monster in the form of a yew tree. The monster visits Conor multiple times, tells him three allegorical stories and then asks Conor to reveal a related truth that he has suppressed. That truth is symbolised in his recurrent nightmare. As Conor struggles to understand the usefulness of stories and questions the reality of the monster itself, he finds himself healing in ways he never thought possible.

Both novels concern childhood and adolescent confrontations with the death of a parent. Both tell the story of the social isolation and peer relationship difficulties that can result from such experiences. From A Monster Calls,

In both, the young protagonists experience episodes of dissociation in the context of their personally held and internalised trauma. Both also experience anomalous visual phenomena. Biz sees her dead father.

Conor sees a monster carved from a yew tree.

Literary devices that promote empathy and counteract stigma

We focus on three important literary devices in these novels that promote empathy for the protagonists: 1) emphasising similarity; 2) contextualising emotions; and 3) embracing ambiguity and contradiction. These devices act as a means of challenging stigma associated with hallucinatory and dissociative experiences. Emphasising similarity is a literary strategy shared by both novels where reader and protagonist similarities are emphasised, serving as a foundation from which each novel delves into their protagonist’s unique experience. Contextualising emotions and embracing ambiguity and contradiction were identified as the main devices in each text that encouraged understanding around the protagonists’ experiences. Each device is discussed below.

Emphasising similarity

Emphasising similarity is a device used in both novels. Both consistently present similarities between the protagonists and readers, starting with protagonists who are the same age as each novel’s target audience. Biz and Conor also speak like regular teenagers, using colloquial language and everyday references that young readers would be familiar with (e.g. Netflix, YouTube, and using emojis when texting).

The protagonists also struggle with similar problems to many adolescents, including schoolwork, friendships, bullying and sexuality. When discussing a new assignment given to her class, Biz participates in the ‘collective groan’ and uses first person plural pronouns that include herself in the group:

In A Monster Calls, Conor is the victim of persistent bullying at school. His anger with all he is experiencing is captured in an exchange with his friend Lily, when she gets detention after coming to his defence when he was being bullied.

This highlights another crucial similarity that is centred on the protagonists’ relationships. Like many readers, Biz and Conor have complex relationships; they fall out with old friends, form new friendships, and have a loving but at-times fraught relationship with their parents. For instance, even though Conor is angry at his friend Lily, he still registers her reaction to his outburst against his school bully:

Contextualising emotions: confronting trauma in How it Feels to Float

It is clear that the origin of Biz’s mental health struggles lies outside of her control. By placing her hallucinatory experiences and episodes of dissociation in the context of internal emotional upheaval resulting from trauma, readers may more readily understand Biz’s reaction to her circumstances. Furthermore, the use of evocative imagery gives life to this emotional experience, immersing the reader into Biz’s world so they can better relate to her reactions.

Embracing ambiguity and contradiction: resisting oneness in A Monster Calls

The frequent use of contradiction and ambiguity in A Monster Calls invites readers to resist the notion of a singular way of knowing and to question the very nature of reality. In A Monster Calls ambiguity and contradiction are central to Conor’s experience, starting with the debatable reality of Conor’s monster. Conor himself continuously questions if this monster is real, reflecting the reader’s own doubt around whether this is a fantasy story or a story about a boy experiencing a hallucination. This literary device is further developed when even the monster poses a question about the nature of reality.

It has been pointed out that Conor’s story could be understood as a case study of a young person experiencing a dissociative episode (Ghoshal and Wilkinson Reference Ghoshal and Wilkinson2019). In fact, this ambivalence around the central premise of the novel contributes to the narrative’s insistence that reality is complex and multifaceted. In turn, by accepting that reality is multiform this opens the way for people with ordinary experiences to recognise Conor’s alternative experience as meaningful.

Emphasising similarity

Our observation of similarities between protagonists and the target audience is consistent with existing research where identification has been conceptualised as a way of combating discrimination against stigmatised groups (Chung and Slater Reference Chung and Slater2013; Vezzali et al. Reference Vezzali, Stathi, Giovannini, Capozza and Trifiletti2015; Ferchaud et al. Reference Ferchaud, Seibert, Sellers and Escobar Salazar2020). For example, understanding psychosis as existing on a continuum of shared human experience has been associated with prosocial attitudes and less desire for social distance (Schomerus et al. Reference Schomerus, Matschinger and Angermeyer2013; Peter et al. Reference Peter, Schindler, Sander, Schmidt, Muehlan, McLaren, Tomczyk, Speerforck and Schomerus2021). With regard to young people, presenting characters of a similar age to readers increases identification, leading young people to express greater empathy towards people experiencing emotional or mental distress (Secker et al. Reference Secker, Armstrong and Hill1999). Young people are also less likely to use negative descriptions when others’ behaviour is understood in terms of their own personal experience (Secker et al. Reference Secker, Armstrong and Hill1999; Schulze et al. Reference Schulze, Richter-Werling, Matschinger and Angermeyer2003). The act itself of perspective-taking has been shown to increase empathy (Batson et al. Reference Batson, Eklund, Chermok, Hoyt and Ortiz2007; Stietz et al. Reference Stietz, Jauk, Krach and Kanske2019). In fact, the degree to which adolescents identify with a target outgroup may modulate empathy’s effect on improving mental health-related stigmatising attitudes (Vescio et al. Reference Vescio, Sechrist and Paolucci2003). Therefore, encouraging identification with the protagonists in these texts, who are part of an outgroup, may increase empathy and reduce stigma. Additionally, they offer relatable accounts of dissociation and hallucinations as normative responses to traumatic loss, bullying and exclusion (Martindale Reference Martindale2007; Longden et al. Reference Longden, Madill and Waterman2012; Coughlan and Cannon Reference Coughlan and Cannon2017). In this context, the importance of developing anti-stigma mental health education focused on relatable stories and a shared humanity cannot be underestimated.

Accentuating similarities could simultaneously benefit young people experiencing mental health issues. In interviews with young people who hear voices they reveal that ‘the perceived “normality” of others in contrast to the perceived “difference” of the self was a source of anxiety’ for them (Parry et al. Reference Parry, Loren and Varese2020). Young people have also expressed greater distress around feeling ‘abnormal’ than around experiences of hallucinations and/or delusions in themselves (Coughlan et al. Reference Coughlan, Humphries, Clarke, Healy and Cannon2022). Meanwhile, a recent study highlighted how young people repeatedly attempted to make sense of their experiences of hallucinations or unusual thoughts or beliefs by using culturally acceptable frameworks (Coughlan et al. Reference Coughlan, Healy, Humphries, Clarke, Kelleher and Cannon2020). Moreover, young people who hear voices have expressed a wish for treatment approaches focused on normalising and destigmatising (Newton et al. Reference Newton, Larkin, Melhuish and Wykes2007; Kapur et al. Reference Kapur, Hayes, Waddingham, Hillman, Deighton and Midgley2014). Recent research calling for a broader biopsychosocial framework within which to conceptualise experiences of psychosis echoes this push towards a more holistic understanding of these phenomena (Kelleher and Cannon Reference Kelleher and Cannon2021). Thus, the narrative accounts examined in this study have the potential to both normalise these phenomena for other young people who experience them and to humanise such experiences for young people who don’t.

Contextualising emotions

In How it Feels to Float, Biz’s narrative challenges the widely accepted belief that it is not possible to understand someone experiencing hallucinations, delusions or dissociation (Jaspers Reference Jaspers1963; Walker Reference Walker1991; Kiran and Chaudhury Reference Kiran and Chaudhury2009). Vivid descriptions of emotional upheaval infuse the narrative effectively bringing the reader into Biz’s inner world and rendering it more familiar.

It has been shown that increased familiarity and personal experience reduce stigmatising attitudes towards people with mental health difficulties (Link and Cullen Reference Link and Cullen1986; Corrigan et al. Reference Corrigan, Edwards, Green, Diwan and Penn2001; Pinfold et al. Reference Pinfold, Toulmin, Thornicroft, Huxley, Farmer and Graham2003; Angermeyer et al. Reference Angermeyer, Matschinger and Corrigan2004; Morgan et al. Reference Morgan, Reavley, Ross, San Too and Jorm2018). Further, researchers have found that parasocial contact, referring to the psychological relationship created in the interaction between media users and mass media representations, can reduce stigma towards minority groups (Giles Reference Giles2002; Schiappa et al. Reference Schiappa, Gregg and Hewes2005). With regard to mental health, studies found that exposure to filmed social contact reduced stigma similarly to in-person contact (Clement et al. Reference Clement, Van Nieuwenhuizen, Kassam, Flach, Lazarus, De Castro, McCrone, Norman and Thornicroft2012; Koike et al. Reference Koike, Yamaguchi, Ojio, Ohta, Shimada, Watanabe, Thornicroft and Ando2018). Correspondingly, engaging with a work of fiction is a form of parasocial contact (Schiappa et al. Reference Schiappa, Allen, Gregg, ed., Gayle, Burrell, Allen and Bryant2007). Fiction can be understood as a simulation of the world (Mar and Oatley Reference Mar and Oatley2008), where readers come into contact and empathise with characters, which may have an effect on how readers act (Mar et al. Reference Mar, Oatley and Peterson2009). Biz’s engrossing descriptions allow readers to identify with certain aspects of her inner world, making her foreign experiences of hallucinations and dissociation more understandable since they are happening to someone the reader has already related to. This envelopment into the narrative world promotes perspective-taking on behalf of readers, which is crucial to reduce outgroup perceptions allowing for greater social acceptance (Chung and Slater Reference Chung and Slater2013).

Children’s beliefs about causes of mental health difficulties influence their attitudes and behaviour towards children with mental health struggles (Juvonen Reference Juvonen1991; Giles and Heyman Reference Giles and Heyman2003). More specifically, whether they perceive someone as being responsible for their behaviour significantly shapes negative attitudes (Dolphin and Hennessy Reference Dolphin and Hennessy2014; O’Driscoll et al. Reference O’Driscoll, Heary, Hennessy and McKeague2015). In actuality, childhood trauma is a risk factor for the development of hallucinations and delusions (Janssen et al. Reference Janssen, Krabbendam, Bak, Hanssen, Vollebergh, de Graaf and van Os2004; Arseneault et al. Reference Arseneault, Cannon, Fisher, Polanczyk, Moffitt and Caspi2011; Kelleher et al. Reference Kelleher, Keeley, Corcoran, Ramsay, Wasserman, Carli, Sarchiapone, Hoven, Wasserman and Cannon2013; Coughlan et al. Reference Coughlan, Healy, Ní Sheaghdha, Murray, Humphries, Clarke and Cannon2019; Stanton et al. Reference Stanton, Denietolis, Goodwin and Dvir2020). Contextualising Biz’s struggle within a story of intergenerational trauma that gives prominence to emotional pain may further counteract negative attitudes by evoking powerful emotions on behalf of readers. YA literature has been shown to elicit emotions in students even though they had not been in the same situations as characters (Hébert and Kent Reference Hébert and Kent2000; Govindarajoo and Mukundan Reference Govindarajoo and Mukundan2013), marking the ability of YA literature to foster empathy towards alternative experiences. Moreover, in a study considering how photographs and fiction changed student’s attitudes towards people with HIV, evoking emotions was key to reducing stigma (Teti et al. Reference Teti, Schulhoff, Koegler, Saffran, Bauerband and Shaffer2019). In another study, when asked to come up with less stigmatising descriptions for people with mental health difficulties, students focused on emotions rather than labels (Pinfold et al. Reference Pinfold, Toulmin, Thornicroft, Huxley, Farmer and Graham2003). Importantly, these studies point to the power of eliciting emotion as a way of understanding alternate experiences and reducing stigma.

Embracing ambiguity and contradiction

Ness’s narrative unrelentingly shows readers the ubiquity of ambiguity, thus opening the door to greater empathy and understanding of Conor’s experience. As Hinshaw (Reference Hinshaw2005) notes,

Indeed, studies have shown that people, including children, who believe that experience is flexible rather than fixed did not believe as strongly in stereotypes (Dweck Reference Dweck, ed. and Dweck1998; Levy et al. Reference Levy, Stroessner and Dweck1998; Levy and Dweck Reference Levy and Dweck1999; Corrigan and Watson Reference Corrigan and Watson2007). Conor’s monster brings home the point that there is never a singular way of perceiving human experience and cautions against injustices that arise when assuming there is one correct perspective.

Evidence supports the benefits of addressing ambiguity, contradiction and complexity with young people through the arts. A recent study found that analysing works of art increased students’ tolerance of ambiguity and increased empathy (Bentwich and Gilbey Reference Bentwich and Gilbey2017). The same study provided a theoretical framework to explain the relationship between tolerance of ambiguity and empathy. Acceptance of ambiguity is suggested as a prerequisite for imagining worlds that are outside of the single reality we experience. Imagination is thus posited as a learning tool that allows readers to enter into others’ thinking, leading to greater empathy. A greater tolerance of ambiguity has indeed been linked to empathy (Jones Reference Jones1974). Significantly, there is evidence that empathy is associated with greater acceptance and prosocial behaviour towards outgroups (Batson et al. Reference Batson, Polycarpou, Harmon-Jones, Imhoff, Mitchener, Bednar, Klein and Highberger1997; Malti et al. Reference Malti, Ongley, Dys and Colasante2012; Abrams et al. Reference Abrams, Van de Vyver, Pelletier and Cameron2015). Specifically regarding mental health, greater empathy has been associated with lower stigmatisation in adolescent and adult populations (Hsiao et al. Reference Hsiao, Lu and Tsai2015; Webb et al. Reference Webb, Peterson, Willis, Rodney, Siebert, Carlile and Stinar2016; Silke et al. Reference Silke, Swords and Heary2017). Literature, by its ability to convey nuanced depictions of ambiguity, therefore emerges as a compelling choice for fostering empathy and fighting stigma. An estimated 75% of young people in the U.S. with moderate to severe depressive symptoms have engaged with accounts of other people’s health experiences through blogs, podcasts and videos reflecting young people’s interest in learning from stories (Rideout and Fox Reference Rideout and Fox2018).