Psychiatrists Explore Their Inner Hemingway

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After a long and fulfilling psychiatric career, which included pioneering work in the development of computerized cognitive-behavioral therapy (CBT), Jesse Wright, M.D., Ph.D., was ready to try something different.

As an academic, Wright was familiar with publishing, having put forth eight textbooks and over 50 research articles; he also had experience creating dozens of informational CBT videos. But he wanted to share a more personal story of mental health based partially on the experiences of his father and uncle, both of whom fought in World War II and came home from that trauma to suffer in silence. He decided to write a novel.

It ended up being an arduous process. “I had some naiveté in how fiction gets published,” Wright told Psychiatric News. But with the support of some colleagues who had been down this same path, he successfully released his first novel, A Stream to Follow, in 2022.

Essential Elements of Fiction Found in Clinical Encounter

The ambition to write a novel is hardly unique to psychiatrists. Yet as Wright and other successful psychiatrists who have written fictional books will attest, psychiatrists possess skills that are key to good fiction writing, as well as a wealth of stories that deserve a louder voice. Anton Chekhov, one of the most celebrated authors of the 19th century, was a physician who parlayed his interest in mental illness to develop stories with a profound psychological impact.

“To be a good psychiatrist requires strong clinical knowledge, empathy, and creativity,” said Monica Starkman, M.D., a consultation-liaison psychiatrist and an active emerita professor of psychiatry at the University of Michigan Medical School. “You need to bring all of this to bear when writing a novel.” Starkman authored the 2016 novel The End of Miracles.

Starkman noted that psychiatrists’ clinical experience is valuable for developing accurate and compelling stories involving mental health and illness—a trove of fascinating story ideas. Her novel, for instance, centers around a woman with a rare condition known as pseudocyesis, or false pregnancy. It is a somatic disorder in which women experience classic symptoms of pregnancy—such as loss of menstruation, breast tenderness, and even abdominal distention—without being pregnant.

“I became fascinated with the biology and psychology of the condition when I provided psychiatric consultation and treatment for two such women,” said Starkman, who specializes in psycho-endocrinology. “The prospect of inventing a story involving pseudocyesis was intriguing to me,” she said. She then worked on the book over the course of a decade during her academic career, writing more than 20 drafts during the process.

The End of Miracles is about a woman whose seemingly miraculous pregnancy following years of battling infertility ends in a late miscarriage; she subsequently develops pseudocyesis, which provides relief from her all-consuming grief. When this false belief inevitably clashes with ultrasound reality, she falls into a deep depression and develops a new fantasy that propels her to commit a crime, setting off a suspenseful chain of events.

Along the way, Starkman aims to convey the personal shame and social stigma of someone dealing with a mental illness, building empathy for a character that eventually finds the road to recovery with the help of inpatient and outpatient care.

“As a psychiatrist, your job is to listen to people’s private thoughts and try to imagine life from their perspective,” noted Wright, who credited his years of practicing and researching CBT with helping him to craft his story. A Stream to Follow tells the story of a young World War II battlefield surgeon who returns to his small Pennsylvania town with what would now be recognized as posttraumatic stress disorder to begin a journey of healing, reconnection, and recovery.

Though inspired by family history, the fictional characters in A Stream to Follow also take elements from many of the patients Wright has seen over the years, he explained. Many psychiatrists are likely familiar with creating such character amalgams when developing case studies for medical books or presentations. “You try to provide details to make the subject interesting and emotionally resonating,” he said.

“Good fiction should be humanizing, even to the bad guys,” said psychiatrist and author Daniel Mason, M.D., a professor at Stanford University who has published multiple novels. “As a physician, you don’t portray your patients in black and white terms, and the same goes for a storyteller.”

Mason’s path differs from those of Wright and Starkman in that he wrote his first novel, The Piano Tuner, while in medical school. The story explores life in 19th century colonial Burma as an English piano tuner travels to the region to repair a grand piano made unplayable by the region’s humidity. Mason was inspired by his own trip to the border of Myanmar and Thailand to conduct malaria research, during which time he became fascinated by the local culture.

The success of The Piano Tuner led Mason to transition to full-time writing after completing medical school. He published two more novels and was researching materials for his fourth book—set in a World War I hospital that was treating soldiers for “shell shock”—when he realized he missed medicine. He then completed a residency in psychiatry at Stanford while continuing his novel on the side.

Having now spent years as a novelist and a psychiatrist, Mason said he is amazed at how much overlap there is in the mindset of both professions. “I’ve noticed that the questions residents will ask me about patients (such as ‘Why did this event happen now?’ or ‘What role is the person’s family playing in this situation?’) are the exact same questions my editor asks me about my books.”

One of the areas where fictional writing and the practice of psychiatry differ is in how much information you share with your “audience,” Mason continued. When describing clinical observations to patients and their families as well as other clinicians, clarity is of the utmost importance, Mason emphasized. “The more they understand, the more we can help,” he said. In fiction, however, it is usually better to pull the curtain back slowly for storytelling purposes. “When writing, I’m often tempted to explain all these character details based on the rules I’ve come to learn from medicine, but then I tell myself I need to keep some mystery.”

Before You Start Writing

The psychiatrists/writers who spoke with Psychiatric News agreed that there is no right or wrong way to enter the world of fiction writing; authors can be early career or retired psychiatrists, engaging in writing part time or full time. As Starkman pointed out, many psychiatrists have extensive writing duties already—papers, grants, textbooks, forensic reports, and more—so the skill and discipline are there.

“Writing good fiction can be stimulating, but also demanding,” Wright said. “There are days you hit that brick wall, which can be extremely frustrating.”

Writing—particularly full-time writing—can also be lonely business, and Wright stressed the value of making time to be social. “I was fortunate to be able to recruit a coach who would meet with me for an hour every few weeks to discuss my ideas and give me feedback on characters and plot; sort of like writing therapy,” he said. In lieu of a writing coach, he suggested writers could meet with friends and colleagues to share drafts or exchange ideas.

Finding an agent can also prove challenging, Wright said, but there are online services such as QueryTracker that compile agent data. The site includes such information as agents’ success rates, what genres they work in, and what they expect in a query (the opening letter to an agent in which writers make their pitch).

“Most publishing houses still require you to have an agent, so this is an important step,” Wright noted. However, the publishing options in today’s market have expanded. In addition to traditional publishers who take on all the production costs, hybrid publishers are emerging as a popular alternative. In a hybrid model, the author puts in a deposit to cover some production costs (rather than receiving an advance) but gets higher sales royalties. “You have to put some skin in the game, but since some costs are offset, hybrid publishers are more willing to take on nonestablished authors,” he said.

If all else fails, self-publishing is always an option (paying for your own printing and selling on places like Amazon), but Wright noted that self-published novels rarely receive reviews or placement in a bookstore.

“Most novelists don’t make a lot of money anyway, so don’t factor that in when deciding how to publish,” Wright noted.

Starkman agreed. “My goal was to try and move people emotionally and tell a good story about our profession.” She noted that while some popular fiction negatively portrays patients and psychiatrists, she looked for ways to highlight the field in a more nuanced way.

Stigma is a big theme of Wright’s follow-up novel, A Dance in the Madhouse, which is already in the works. This title takes the reader back to 1905 and follows a young doctor who is institutionalized following typhoid-induced psychosis. “It’s styled as a mystery thriller, but I hope to highlight the poor conditions mental patients have faced through much of history.”

Starkman is also ready to get back to writing again. “I admit I still felt some imposter syndrome right after publishing, but when some positive professional reviews came in, I felt validated,” she said. She has started to work on a memoir, which she notes is a different challenge. “It won’t be quite as much creative fun, since I already know the plot of this story.” ■