“Magical Realism as a Way to
Reimagine Mental Illness”

Please See Me readers have enjoyed Adam Strassberg’s fiction in past issues, including “The Doctor Behind the Curtains” and “The King of Stories.” His fiction provides both a creative and realistic look at what caring for patients living with mental illness might look like, shaped by a career spent as a psychiatrist. Since retiring from practice, Adam has devoted his writing to stories with a mental health focus. His novella, December on 5C4, brings that same blend to a locked inpatient unit and the two unlikely heroes admitted there. For an issue devoted to rebooting our idea of heroes, it felt like the right conversation to have: about who gets to be the hero of a story, and what a clinician owes the patients he writes about.

Please See Me: You spent your career as a psychiatrist before writing December on 5C4. What made a locked psychiatric ward — rather than any other setting — feel like the right place to stage a story about Jesus and Santa?

Adam Strassberg: There were many stories from my residency years, some apocryphal, some true, of involuntary hospitalizations of various patients with delusions of being either Jesus or Santa. I had always wondered what would happen if a patient with similarities to Jesus were hospitalized at the same time and on the same ward as a patient with similarities to Santa. This became the essential conceit behind December on 5C4.

In the story, Josh, a patient with many similarities to Jesus, is admitted involuntarily to locked psychiatric unit 5C4, concurrently with Nick, a patient with many similarities to Santa. The two figures are so different in entertaining and fundamental ways: young versus old, single versus married, optimist versus pragmatist, socialist versus capitalist. Would the two become friends? enemies? both? And what if they chose to ally together to escape the unit?

A locked psychiatric ward also felt like the right place to stage a story about Jesus and Santa because the presence of the divine, however one might define it, can be felt very strongly there. The patient population is suffering. They are very ill, and frequently, especially in county facilities such as described in the story, also very marginalized, poor and disempowered. I can imagine few other settings in greater need of the spirits of both Jesus and Santa.

Both figures have similar and overlapping messages. Jesus asks us to “love our neighbors”, Santa asks us to “give to our neighbors.” The historical Jesus encourages us to love each other, forgive those who hurt us, care for the poor and the vulnerable, seek forgiveness, and live with humility and compassion. The mythological Santa encourages us to be kind, generous, and thoughtful, to feel wonder, and to share joyful gifts with one another – especially with children and with people who have less.

The setting of the story in a locked unit is very defined and limiting, but as an author, such a setting was very liberating. Within the confines of 5C4, I was able to place two patients Josh and Nick, each somehow very similar to Jesus and Santa respectively. I have them share a unique adventure, but also, through their interactions with other patients and staff, I have them retell and re-enact a vast number of Jewish myths, Christian tales, and Santa legends.

PSM: Josh’s “God voice” starts as comfort and becomes something closer to a burden. As a clinician, how did you think about portraying religious experience and psychosis as genuinely intertwined, rather than choosing one or the other to explain a diagnosis?

AS: This subject demands a great deal of respect from me as both a writer and a psychiatrist because religious experience and psychosis are so very interconnected, both presently and historically. Religious experiences are of course very common. Auditory hallucinations are less so, but they are certainly not rare, with some estimates of about a 10% lifetime prevalence in the general population.

I like to define mental illness as a “dysfunctional set of thoughts, emotions, and/or behaviors which cause harm”. Hearing a “God voice” is certainly not a mental illness, but it can be a symptom of mental illness, to the extent that the experience causes harm to the recipient or to those around them.

At first, Josh finds comfort in hearing the “God voice”, and it is left to the reader’s interpretation as to whether the source of the voice is biological, psychological, divine, or some mix of all three. However, at later stages in his life, Josh is harmed by hearing the “God voice” and thus, at this point, it becomes a valid focus for psychiatric treatment.

An awkward truth is that not all hallucinations and delusions are terrifying, some can be comforting, a few can even be a source of great strength and resilience. Religious experience and mental health are inherently intertwined and exploring this interconnection, either clinically or via fiction, requires enormous humility and compassion.

PSM: The novella balances real weight — involuntary admission, homelessness, medication refusal — with humor and nostalgia, especially in Nick’s riddles. How did you find that balance, and were you ever worried the humor would undercut the seriousness of what Josh is going through?

AS: Nick is a patient with many similarities to Santa, who is canonically “jolly” and so the riddles and puns are an important part of Nick’s characterization. Of the two main characters, Nick is more silly, Josh is more serious, but as the story progresses, the two protagonists grow towards each other and Josh eventually creates a few riddles and puns of his own to share with Nick.

We mental healthcare providers have a notorious reputation for being humorless. We are called upon to evaluate and treat tremendous suffering. The fear is that any joking could invalidate a patient’s pain, but my clinical experience has proven quite the opposite. Humor, when used judiciously and authentically, is an invaluable tool; it is a coping mechanism, a “mature defense,” one which allows us to ease emotional pain. I have never laughed so hard as with some of my sickest patients.

PSM: You’ve described Josh’s ending as an “integration” rather than a cure — he accepts his medication but also finds the God voice replaced by the presence of other people. What were you trying to say about what recovery actually looks like?

AS: Recovery looks boring. Happy, but boring. Recovery is when a chronic medical condition becomes mundane, the treatment just a regular part of a person’s daily self-care. Josh takes his medication and sees his doctor. His symptoms are mostly absent, minimal, and whatever remain are integrated into his daily life. He is too busy with the joyful mundanity of everyday life to focus on listening or not listening to the God voice in his head. It’s enough to just be a human and live an ordinary human life. That is really more than enough. And quite joyful. You don’t have to be special, you just have to be.

Recovery is also about re-integration into the world. And Josh’s world at the end has become so joyously busy. He is connected to others. He has a partner and a child and they are a family. He has a skillset, a career, and a successful small business. He has a sense of control over his life and the world around him. He remembers his past, enjoys his present, and plans for his future. His life may not seem divine to Josh, but it seems divine enough to me.

PSM: December on 5C4 has been called “an intense novella of ideas.” Was there a specific idea or question about faith, mental illness, or identity you were most afraid readers might miss or misinterpret?

AS: December on 5C4 is a ‘multivalent’ work of fiction. This means that it operates simultaneously as adventure, medical fiction, psychological exploration, philosophical inquiry, magical realism, and even faith-based legendarium for Jewish and Christian tales. All of the characters and events have different concurrent meanings depending upon the interpretive level at which the reader considers them.

Is Josh a homeless Jewish man with schizophrenia or is he Jesus Christ? Is Nick a wealthy toy company CEO with a cocaine addiction or is he Santa Claus? Can these characters be both at once? They refuse their medications as they plan their escape. Is this making them increasingly psychotic or are they gaining back more of their Jesus and Santa powers?

And we don’t have to limit this concept of ‘multivalence’ to just fiction, we can also apply it to our understanding of faith, mental illness, and identity. Symptoms of mental illness, particularly psychotic experiences, can have multiple layers of meaning–medical, psychological, interpersonal, phenomenological, and spiritual–all simultaneously. Mental health providers focus on diagnosis and treatment via the bio-psycho-social model, and I believe we are right to do so, but most symptoms of mental illness have much deeper, nuanced and more complex spiritual and religious meanings for our patients.

PSM:You’ve published fiction in Please See Me before, including “The Doctor Behind the Curtains” and “The King of Stories.” What is it about the space PSM occupies — healthcare and human experience together — that keeps you returning to it as a home for your work?

AS: Please See Me focuses on health-related stories from multiple specialties and medical milieus. There is an impressive and respectful balance of moving contributions from both healthcare providers–doctors, nurses and others–and healthcare recipients–patients, family members, and others.

I find reading Please See Me to be very cathartic for me as both a physician, patient, family member, and writer, and I feel quite lucky to have been able to contribute a few of my own short stories to the platform as well.

As a medical practitioner, what I find most appealing about the works presented in Please See Me is the inherent verisimilitude of each piece. The medical settings, details, diagnoses, treatments, and clinical experiences all feel very authentic and believable. The doctors, nurses and patients presented share rich three-dimensional characterizations.

The medical world is used as a setting in so much fiction obviously written by authors who are neither healthcare providers nor regular patients. I find such fiction difficult to enjoy. For the 90% of us who don’t work in healthcare, this fiction works, but for the 10% of us who work in healthcare, it falls flat very quickly and very easily. It’s hard for me to lose myself in fiction based in a medical setting when there are too many errors and misrepresentations. (The irony of course is that I can only wonder at all the errors pervading the police, legal, and military dramas which I regularly enjoy…)

In my own niche, mental health, I’ve discovered very few works of fiction which accurately depict the practice of psychiatry and psychology, psychotherapy and psychopharmacology, in inpatient and outpatient settings. And so I am committed to maximal clinical verisimilitude in my short stories and books. They are works of imagination but the medical settings and situations are depicted as realistically as possible. This was very important to me when I wrote December on 5C4, most of which occurs in the setting of locked inpatient psychiatric unit.

PSM: Writing from inside a psychiatric ward, in a patient’s voice, from a place of real clinical authority — what did you feel you owed to the patients you’d actually cared for over your career, and how did that shape what you were willing to put on the page?

AS: I owe them authentic, realistic, and respectful representation in fiction.

Media portrayals of persons suffering from a mental illness continue to feature so many harmful and ridiculous stereotypes. The stigma is profound. Psychiatric patients are villains or victims, only ever so rarely heroes, and never just normal people. Ironic, as almost 50% of us will experience at least one diagnosable mental disorder at some point in our lives. It is normal (statistically!) to suffer from a mental illness.

However Josh and Nick, the protagonists in December on 5C4, are obviously psychiatric patients who suffer from much more severe mental illness. It is an essential aspect of their characters, but I try very hard to not let it define their characters. They have habits and quirks, hopes and dreams, successes and failures, pasts and futures, all evolving and developing as they journey through their arcs in the story.

My hope is to represent the emotional truth of our patients’ experiences as they journey from suffering to recovery, while doing my best to avoid stigma and stereotype and to embrace authenticity and realism. I owe my patients that much, and more.

PSM: For a reader who’s never spent time on a unit like 5C4, what do you most want your novella to leave them believing about the people who live there?

AS: The patients on 5C4 suffer from very serious mental disorders but they are still just like everybody else. They have hopes, dreams and desires. Each has a past, present and future. All have families. Many have careers. Most have homes.
Their illnesses are tough to treat, and can scare the people around them. But many of these illnesses are indeed quite treatable. Some can recover. They do need to take their medications, much like anyone with a chronic condition, and if they go off their medications, similarly, their symptoms do return.

I have been writing fiction with a mental health focus since my retirement. The stories by necessity need to be interesting and have conflict. But the reality of my professional life before retirement was that 90% of my career was boring in the most satisfying way imaginable. As a writer and a physician I like happy endings. I specialized in psychiatry because it specializes in happy endings–after effective diagnosis and treatment, many patients achieve symptomatic recovery and go on to enjoy joyfully boring daily lives, with family, friends, jobs, groceries, laundry, taxes, vacations, etc.

Craft-wise, December on 5C4 lands as a novella rather than a short story or a full novel. Why did this particular story need that length — what could the novella form hold that a shorter piece would have rushed, or a novel would have padded?

AS: The story began as a short story which grew and grew until it insisted on becoming a novella, at about 40,000 words. As I understand it though, there’s a bit more than just word count to being a novella.

December on 5C4 has two main characters who interact together in a single shared plot, in a limited setting, over a short time span. In the story, Josh, a patient with many similarities to Jesus, and Nick, a patient with many similarities to Santa, are both involuntarily hospitalized on the same locked unit, 5C4, at the same time, and then share an adventure as they work together to escape. The actions and goals are simple, but the themes addressed are complex: chronic mental illness, homelessness, identity, recovery, spiritual transformation, forgiveness, and faith.

Whether or not Josh and Nick are the real Jesus and Santa is left up to the reader’s interpretation, but, either way, each has much to discuss and it is fun to imagine how the two would debate one another. Much of the story focuses on philosophical dialogues between these two legendary figures. It’s at once serious, but also a fun Jesus-Santa buddy story.

December on 5C4 fits so well on all these levels as a novella, but the final length also works perfectly too from a marketing perspective. It is fundamentally a holiday book and the perfect length for re-reading each holiday season. The story retells and reimagines Jewish myths, Christian tales, and Santa legends via Josh and Nick’s adventures. It has general Christmas holiday appeal, and of course a more specific appeal to any adults on your gift list who enjoy the intersection of magical realism, mythology, and psychology.

The second edition of December on 5C4 is available now at www.adamstrassberg.com, bookstores, libraries, and directly via Amazon.

Adam Strassberg is a retired psychiatrist living in Portland, Oregon. He uses the intersection of psychology, religion, mythology and magical realism to explore the human condition through fiction. His short stories have been published in Fiction on the Web, Cafe Lit, Total Quality Reading, Story Sanctum, Please See Me, other online portals, and various print magazines and anthologies. The second edition of his award-winning holiday novella December on 5C4 is available now via his website www.adamstrassberg.com, and also at bookstores, libraries, and directly via Amazon.

Tracy Granzyk is the editor in chief of Please See Me.