This was an essay I wrote last summer, that I’ve wanted to post for a while. I hope to be more regular with my blog during this quarantine period. Enjoy:)
[also the bibliography is a bit long so contact me if you want it]
‘Metamorphosis’, a novella by Franz Kafka, commences as the protagonist Gregor Samsa awakes to find that he has turned into a ‘cockroach’’. A travelling salesman and sole provider for his family, his primary concern isn’t directed towards his transformation. Rather he is desperate to get to work, despite what he absurdly terms ‘an occupational illness of commercial travellers.’ Unfortunately, his condition is not transitory and the novella charts Samosa’s progressively worsening ‘metamorphosis’ as a giant bug amid his family. The novella can be interpreted on many levels, however, in this essay I will explore it experimentally as a case study of schizophrenia, focusing on the manifestations of schizophrenic symptoms in the characterisation and structure of the novella and what we can learn from Samsa’s condition to apply to the treatment of schizophrenia.
Pathophysiology of Schizophrenia
Many people fundamentally misunderstand schizophrenia; it is often associated with a split personality when in actuality it describes a fragmented pattern of thinking. With an understanding of how schizophrenia manifests from a clinical perspective, we will be able to understand the proposed reading of the novella. As a syndrome, schizophrenia is composed of many symptoms which depend on the patient. These can be divided into positive, negative and cognitive categories. Positive symptoms can be physiological, were a normal function which acts abnormally for example tachycardia (very high heart rate), or psychotic symptoms which don’t have a normal physiological counterpart such as hallucinations and disorganised behaviour. Negative symptoms entail removal of normal processes such as loss of interests or decrease in expressed emotions. Finally, cognitive symptoms are more subtle to detect as they affect functions such as learning and understanding. The onset and development of schizophrenia occur in phases (see figure 1). The cause of schizophrenia is currently unknown but investigations into antipsychotic medication suggest Dopamine is involved as dopamine receptors are blocked by the medication (see figure 2 ). However,evidence also points towards the involvement of other neurotransmitters. Twin studies have also suggested a genetic basis for the disease however no specific genes have been found.
Manifestation in ‘Metamorphosis’
‘Metamorphosis’ in literal terms is a sudden change in the form or structure of an organism. Gregor undergoes this change from a travelling salesman to giant bug and this seems to begin his schizophrenic symptoms. Firstly, The fragmented pattern of thinking that characterises schizophrenic patient is amplified by the first-person narrative. We observe Gregor’s absurd fragmented reaction to a surreal situation with increasingly pathetic voyeurism. As the novella progresses along the narrative arch, his symptoms also follow the cycle depicted in figure 2: the prodromal period before meeting his boss, the action upon the enclosure in his room when the tenants arrive and the residual period when he prepares to die (see figure 1 ). Through the form of the novel, Kafka makes us pause and revel in Samsa’s misfortune and inability to control his mind and body in a way in which we would not with a person suffering from schizophrenia (or any chronic illness).
Samsa also demonstrates the ‘flat affect’ (a severe reduction in emotional expression) numerous times in the novella due to his physical transformation into a cockroach. His ability to share his thoughts and requirements with his family is highly impaired. As a result, his ailment deteriorates until Samsa dies unceremoniously, dry and alone surrounded by a further body of text, stripped of his narrative perspective, forgotten and rejected by his family and society, harshly mirroring the fate of patients with severe mental illnesses such as schizophrenia. He also develops positive symptoms through the course of the novel: for example, initially, he commands himself to get out of bed, while at the end of the novel his behaviour becomes catatonic such as when turning his head around he ends up ‘banging it against the floor several times’. Furthermore, Gregor laments losing his speech wishing to ‘only be able to speak to his sister and thank her’, indicating alogia (the poverty of speech) that schizophrenic patients must navigate. The strabismic format of the novel blows up these symptoms which in a real life may be passed off and overlooked.
The family of Gregor Samsa play an important role in the development of his condition. Primarily, it could be interpreted that Samsa’s metamorphosis is due to the vast number of responsibilities he must shoulder as the breadwinner of the family. Furthermore, as his metamorphosis progresses his family undergo their own transformation. His family obtain their own burden in caring for Gregor, with the extended metaphor of being trapped in their abode, they access freedom when Gregor dies and they can leave their apartment. This sense of entrapment is felt by many familial carers and is perhaps what causes the ‘familial metamorphosis’ from acceptance of the patient to apathy towards the individual. The shift in lexicon from the personal address of ‘my unlucky son’ to the othering exclamatory ‘We must get rid of it’ highlights this phenomenon. Through Gregor’s narrative perspective, the behaviour of the family seems crass and antagonistic. The behaviour of his family is a documented phenomenon. The ‘Patient Rejection Scale’ measures the extent of the rejection of an individual by their family, the consequences of which can be devastating.
The role of a family in shaping the course and outcome of schizophrenic patient is profound; studies have shown that families ranking high on the patient rejection scale, will be more likely to readmit their ward to the hospital. In Metamorphosis it all goes wrong, from the rejection of the family to the high levels of ‘expressed emotion’, Samsa’scondition is worsened by the treatment from his mother, father and sister. As mentioned previously, the family members undergo their own metamorphosis and it is useful to think about the care of schizophrenic patients by their family members of occurring in two stages: pre metamorphosis and post metamorphosis. At first his sister brings him food and cleans up after him (premetamorphosis), there is an exerted effort to help the patient. However this responsibility becomes overwhelming leading to rejection and by the end of the novella the family abandon their ward(postmetamorphosis). This occurs for many patients suffering with chronic conditions which jeopardises their recovery evident in higher rates of relapse and readmission, and perhaps- as in Gregor’s case- complete eviction from society. This seems like a paradoxical response from family members, hence is difficult to detect. Psychiatrists may find their treatments undermined if they don’t spot the familial metamorphosis. If the physician detects the signs of pre metamorphosis in time, they can prevent the more devastating effects of the following stage. Hence the importance of a therapeutic alliance between the patient’s family and the doctor becomes clear (see figure 3).
 Further research into this would aim to answer questions such as Why do some families reject their wards quicker than others? Is there a critical point of rejection?
The therapeutic alliance is a relationship usually between a healthcare professional and their patient. Interestingly, Metamorphosis can be interpreted to depict the importance of such a relationship between the patient’s family and the physician for those suffering with chronic illnesses such as schizophrenia. In a clinical setting this cooperation takes the form of a clear, empathetic mode of communication, to allow the physician to gain a better understanding of the patient’s symptoms. Without this approach the psychiatrist may be prone to ‘objectifying’ the search for tangible signs of the syndrome without penetrating the concealment of non-tangible signs by the patient. Whilst also aiding in arriving to the correct diagnosis, a therapeutic alliance with the patient may also improve their prognosis.  This is evidenced by a 2011 studied which found that ’the client–therapist alliance is a reliable predictor of positive clinical outcome independent of the variety of psychotherapy approaches and outcome measures.’ When working with the carers of a patient suffering with schizophrenia, the physician is privy to the aspects of the patients condition that they would not normally have access to, which offers them more information to provide an effective treatment plan for the individual.
 Jung observed ‘the meeting of two personalities is like contact of two chemical substances. If there is any reaction, both are transformed.’ He counter’s Freuds postulate that a therapist should keep their patient at an arms length
However, it should be noted that in the novella, the family don’t attempt to seek help, instead they closet Gregor in the confines of his room. There is much to be said about the stigma of schizophrenia. Gregor is both literally and metaphorically spurned from society to live inside the body of a cockroach stuck within his room- a prison within confinement. Kafka himself had a chronic illness when writing this book hence in my view providing a critical perspective of his society’s (and one could argue even our society’s) treatment of those with such conditions. Metamorphosis shows us the humanity of ‘societal vermin’, which could be used to educate the populace and health professionals alike in the personal intricacies of the syndrome.
Perhaps Kafka didn’t write ‘Metamorphosis’ with the intent of charting schizophrenia. However, he wrote from his own experience, as an individual facing chronic illness, shunned by his family and society. The reading proposed in this essay of his novella Metamorphosis, though experimental, aids us, the public,in empathising with schizophrenic patients. It helps health professionals understand the social manifestations of the syndrome. I see the novella as a bridge between Art and Medicine, allows us to see the patient from their perspective as we look out into Gregor’s world with him.