“Last in a Long Line of Literary

Kleptomaniacs”: Intertextuality in
Sarah Kane’s 4.48 Psychosis

antje diedrich

In February 1999, playwright Sarah Kane committed suicide at the age of

twenty-eight. Only days earlier, she had completed 4.48 Psychosis, a play
engaging with the subject matter of depression, psychosis, and suicide.
Kane discussed a draft of the play with her agent Mel Kenyon shortly before
she died and left the revised version of 4.48 Psychosis in a package prior to
committing suicide (Saunders, Love Me 153). Little is known about Kane’s
personal life. Kane suffered from depression and admitted herself volunta-
rily to the Royal Maudsley Hospital in south London for treatment in 1997
(Saunders, About Kane 10). One may speculate that her personal experience
of depression and of suicidal thoughts informed the play. But those close to
her were anxious to safeguard the play from being read in purely autobio-
graphical terms. “What she wanted to leave behind was her work. That’s all
Sarah was interested in people seeing, rather than a fairly uninteresting
story of her life,” explained Simon Kane, Kane’s brother and the executor of
her estate, in an article in the Guardian published in the wake of the stage
premiere of 4.48 Psychosis in June/July 2000 (qtd. in Hattenstone). James
Mcdonald, who directed the premiere, argued along similar lines: “I want
people to see the play without thinking of her life” (qtd. in Hattenstone).
Mel Kenyon, Kane’s agent, expressed her anxiety that the work could be re-
garded as “more symptomatic of a psychological illness” or as “more pro-
found because she committed suicide” (qtd. in Hattenstone, Part 2). And,
as if justifying that anxiety, Mary Luckhurst proposed, some years later, that
Kane’s suicide formed “the beginning of her iconisation,” which elevated
her status to that of a “‘great’ writer” and authenticated the seriousness of
her dramatic work (120).
Indeed, in the immediate aftermath of the premiere of 4.48 Psychosis,
many critics were unable to separate the author from her work, calling the
play “an acutely painful, manifestly personal study of despair,” “an extended

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 Intertextuality in Sarah Kane’s 4.48 Psychosis

suicide note,” or “Kane’s most nakedly autobiographical work” (Bassett;

Coveney; Clapp). This trend of intertwining reality and fiction has continued
in critical writing that affirms the autobiographical dimension of the text. In
response, some critics are eager to dissociate the author from her work by
foregrounding the non-representational, non-signifying, and – in a perfor-
mance context – experiential nature of 4.48 Psychosis, which allows for an
associative and visceral engagement with the text and forestalls interpreta-
tive closure.1 Both interpretative approaches ultimately raise the question of
the status of the author to her work. Whereas the first approach foregrounds
the author’s “presence” in the text, the latter lays emphasis on the author’s
strategies for doing away with authorial “presence,” referring to post-struc-
turalist ideas about the absence of the author from a purely textual universe:
“4.48 Psychosis constitutes a ‘death-of-the-author’ play in that it does away
with setting, authorial voice, narrative voice, and character voice in concen-
trically hierarchical rings” (Fordyce 112).
Kane herself playfully and self-reflectively ponders the relationship
between the author and her/his writing in 4.48 Psychosis, when the speak-
ing I, repeatedly identified as writer/dramatist, reflects on the relationship
between artistic production and personal anguish. Suffering is seen as an
obstacle to artistic production (“How can I return to form / now my formal
thought has gone?”), though the I assumes that the public will read the
work in the light of personal suffering (“They will love me for that which de-
stroys me”). The I dismisses such reading (“They know nothing – / I have
always walked free”) and ironically refers to her/himself as “[l]ast in a long
line of literary kleptomaniacs / (a time honoured tradition),” championing
literary theft as key in the process of aesthetic production: “Theft is the holy
act / On a twisted path to expression” (213). Kane seems to intimate that
the text may owe more to plagiarism than to personal experience.
The I’s reflections on the author’s relationship to her writing echo T.S.
Eliot’s notion of the poet’s stance toward her work as impersonal and
detached, of writing as an escape from personality and subjective emotion.
In “Tradition and the Individual Talent,” Eliot suggests that the poet ought
to create emotion through an assemblage of found feelings, phrases, and
images: “The poet’s mind is in fact a receptacle for seizing and storing up
numberless feelings, phrases, images, which remain there until all the parti-
cles which can unite to form a new compound are present together” (77).
Eliot also renounces romantic notions of the writer’s originality, replacing
them with the writer’s ability to align herself with literary tradition, not as
something past and complete, but as something that still exerts influence
on her consciousness in the present:

[T]he historical sense compels a man to write not merely with his own generation
in his bones, but with a feeling that the whole of the literature of Europe from

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Homer and within it the whole of the literature of his own country has a
simultaneous existence and composes a simultaneous order. This historical sense,
which is a sense of the timeless as well as of the temporal and of the timeless and
of the temporal together, is what makes a writer traditional. And it is at the same
time what makes a writer most acutely conscious of his place in time, of his own
contemporaneity. (74)

Kane clearly aligned herself with the European literary tradition, openly
acknowledging her engagement with Shakespeare, Büchner, Ibsen, Bulga-
kov, Kafka, Eliot, Camus, Artaud, Huxley, Beckett, Pinter, Bond, Barker, and
Crimp (Saunders, About Kane 38–49). Not only did their works exert an
unconscious influence on her; she always consciously used particular
works or writers as points of reference in the process of writing – for exam-
ple, King Lear for Blasted, Woyzeck for Cleansed, The Waste Land for Crave,
and the works of Antonin Artaud for 4.48 Psychosis (Saunders, About Kane
38–39). Kane’s reference to “literary kleptomania” in 4.48 Psychosis may
refer to the writer’s alignment with the tradition of European literature as a
whole or may specifically point to the extensive use of cultural and literary
quotation and allusion in modernist poetry, particularly in the works of T.S.
Eliot and Ezra Pound. Not surprisingly, critics have discussed Kane’s formal
experimentations in Crave and 4.48 Psychosis in terms of a breakdown of
dramatic form and a movement toward poetry. “Poetic drama,” “free-verse
dramatic poem,” and “poetic meditations” are some of the terms applied to
her later work (Saunders, About Kane 32; Innes 534; Barnett 21). Critical re-
sponses emphasize the plays’ use of poetic devices, such as sound, rhythm,
repetition, alliteration, and silence and, in the case of 4.48 Psychosis, its
unusual layout on the page, “the visuality of the text” (Watson 196), which
suggests “shapes, pauses, lacunae, and probably a host of other modula-
tions” (Barnett 21).
In the present article, I want to replace the notion of autobiography with
that of authorship and discuss intertextuality as a conscious dramaturgical
strategy in the composition of this “dramatic poem.” I investigate how the
writer stored up “numberless feelings, phrases, images,” and how these
were finally arranged to form a new compound (the play). My approach is
inspired by Jörg Helbig’s structuralist hermeneutic notion of Markierung
von Intertextualität [intertextual marking]. Helbig refers to those instances
when an author implicitly or explicitly marks a reference to another text,
when she consciously embeds in a manifest text (the text the author pro-
duces) intertextual traces or inscriptions from a referent text (the text the
author borrows from).
The idea that the reader will eventually recognize the referent text and
that this will in some way inform the process of reception forms the basis of
most of Helbig’s argument. But this is slightly problematic in the case of 4.48

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 Intertextuality in Sarah Kane’s 4.48 Psychosis

Psychosis. Kane drew from texts that would probably remain elusive to the
reader/spectator. These include specialist literature on suicide, medical
questionnaires, children’s fiction, and an eighteenth-century German novel.
Kane did not mark intertextual inscriptions explicitly, and she did not openly
acknowledge her referent texts. There is, however, a degree of implicit mark-
ing in Kane’s writing – quantitatively through frequent contamination and
repetition and qualitatively through linguistic code changes – that makes the
reader aware of the existence of referent texts, even if they are unidentifiable.
The fact that Kane does not reveal any of her sources and implies in-
stances of literary theft suggests that 4.48 Psychosis falls into the category of
“pla(y)giarism”, a term Helbig borrows from Raymond Federman (Helbig
165–66). Pla(y)giarism refers to literature that employs intertextual marking
but in which the identification of the referent text does not necessarily aid
an exegesis of the manifest text. Pla(y)giarism destabilizes the notion of the
author as the originator of meaning and invites the reader to playfully
engage with and extend chains of references present in the text. Some
critics characterize this as the “linguistic turn” in Kane’s work (Voigts-
Virchow 204), the creation of a “theatre of language” (Barnett 21) that defies
interpretative closure and is often associated with the paradigm of post-
dramatic theatre. Indeed, in 4.48 Psychosis Kane does away with dramatic
devices such as plot, character, and setting. The twenty-four scenes, con-
veying the thoughts and feelings of a severely depressed and suicidal per-
son (with some fragments of dialogue between a doctor and a patient), are
laid out in different arrangements on the page and separated by five
dashes. Thus, on the surface, the I’s internal monologue appears fragmen-
ted, disjointed, and at times incoherent.
My intention is not to refute this reading of the play but to complement it
with an approach that considers the possibility of an authorial subjectivity
beyond the narrow confines of autobiography. 4.48 Psychosis – I argue – is
constructed from and refers to a significant number of texts outside itself,
and Kane’s engagement with depression, psychosis, and suicide is
mediated through ideas and structures that she adapts from a range of
sources. Each of these frames and re-frames the experience of individual
suffering explored in the text, and together, they chart the I’s journey from
depression to psychosis to suicide. In addition, my analysis will show not
only that the referent texts detectable in 4.48 Psychosis situate the author in
her culture but that their appropriation is imbued with a political charge
and represents a form of cultural intervention. This intervention extends
beyond the political dimension assigned to the fragmentation of dramatic
form and dramatic subjectivity attributed to the text (Gritzner 335). Kane
deliberately plays poetic discourses on the subject of mental illness and sui-
cide against psycho-medical discourses, with the artist/author resisting a
disempowering process of medicalization.

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Kane’s critique of psychiatric care and practice needs to be viewed in the

context of the radical paradigm shift that the discipline of psychiatry under-
went during the 1970s and that culminated in the publication of the Diag-
nostic and Statistical Manual of Mental Disorders (DSM-III) by the
American Psychiatric Association in 1980. DSM-III (and later DSM-IV) re-
placed the until then prevalent psychodynamic model that considered psy-
chological problems to be the result of repressed intra-psychic experiences,
with a biomedical model that categorized mental illnesses – like organic
diseases – into discrete natural entities, clearly identifiable by clusters of
symptoms. This biomedical conceptualization placed greater emphasis on
chemical imbalances in the brain (i.e., biological as opposed to psychologi-
cal or social factors), with psychopharmacological drugs as the preferred
method of treatment. Sociologist Allan H. Horwitz argues that this shift to
what he calls “diagnostic psychiatry” was – in a US context – not so much
based on scientific fact as on a number of professional, economic, and
political factors, such as the interests of clinicians and drug companies, the
need to justify treatment to health insurers, a growing governmental con-
servatism that withdrew funding from psychiatric intervention based on
the alleviation of social and economic problems in communities, and the
advocacy of lay groups wanting to de-stigmatize mental illness (Horwitz
55–82). Horwitz is particularly critical of DSM-III’s almost exclusive focus
on symptoms as supposed “objective” evidence for diagnosis, disregarding
the origins of the symptoms as well as the context in which they occur. In
his view, only a few, severe mental illnesses are based on organic dysfunc-
tions; most other conditions form expectable responses to stressful social
and economic conditions. The publication of DSM-III, and particularly the
severing of symptoms from their causes, resulted in the creation of a range
of new, previously unknown mental illnesses and in a proliferation of men-
tal health problems and their treatment.
Rogers and Pilgrim outline similar developments in British psychiatry,
where the administration of psychopharmacological drugs is mostly pre-
ferred to other forms of therapy. The authors identify a number of factors
contributing to this development, among others the biological emphasis
placed on the medicalization of psychological abnormality in the nine-
teenth century, the alignment of psychiatry with mainstream medicine in
the 1960s to raise the profile and credibility of the profession, the profit
motive of drug companies, the relatively cheap cost of drug treatment, and
the “illusion that biodeterminism has been proven” once psychopharmaco-
logical drugs have been patented and marketed, even though the effective-
ness of the drugs is limited and some of their side effects are severely
debilitating (143–49). Aspects of this shift toward a biomedical conceptual-
ization of mental health problems are clearly reflected in the I’s experience
as patient throughout the play.

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THE SUICIDAL MIND

Almost half way through the play the I laments the impossibility of finding
love, considering death as a possible response to her/his predicament: “I
can fill my space / fill my time / but nothing can fill this void in my heart /
The vital need for which I would die” (219), a thought s/he returns to only
moments before her/his death: “the vital need for which I would die / to be
loved” (242–43).
Kane borrows the concept of the “vital need” from Edwin S. Shneid-
man’s book The Suicidal Mind. Shneidman, a specialist in suicidology, sug-
gests that suicide is predominantly psychological in nature and is played
out in the suicidal person’s mind; it “is chiefly a drama in the mind” (4). He
regards most cases of suicide in the western world as caused by intense psy-
chological pain, which he terms “psychache (sīk-āk)” (4). The primary
source of intense psychache is frustrated psychological needs.
Shneidman works from a model of the human psyche that relates most of
our behaviour and actions to the pursuit of psychological needs. Once our
fundamental biological needs “for oxygen, for food, for water, and for a livable
temperature” have been met, “our actions are motivated by our need to
reduce inner tensions by satisfying an array of psychological needs” (18).
Shneidman adopts these ideas from Henry A. Murray, who, in his book Ex-
plorations in Personality (1938), defines and discusses psychological needs as
the dynamic elements of our personality. Shneidman differentiates between
modal needs, needs that characterize our ongoing functioning personality
and that we simply live with on an everyday basis, and vital needs, needs an
individual focuses on when suffering mental pain or when under duress. In
the mind of a suicidal person, the focus shifts from modal to frustrated or
thwarted vital needs, whose lack of fulfilment is perceived as “threat, failure,
duress, pain, emergency – the psychological needs deemed by that individual
as vital for continued living” (24). Such fixation on thwarted vital needs causes
psychache, and suicide is considered as a possible escape from emotional
hurt. A suicidal person will undergo a process of psychological constriction, in
which she begins to narrow her focus on two options – life or death – at the
expense of all other possibilities. Shneidman uses the analogy of film:

In suicide, the diaphragm of the mind narrows and focuses on the single goal of
escape to the exclusion of all else – parents, spouse, children. Those other persons
in the life are not forgotten; they are simply not within the narrow focus of the
suicidal lens. (60)

Thought processes in the suicidal mind limit themselves to the question of

“yes or no,” life or death: “In the camera of the mind, the suicidal film is
limited to stark black and white” (61).

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Kane adopts Shneidman’s metaphor for psychological constriction. Prior

to committing suicide, the I speaks of “a black and white film of yes or no
yes or no yes or no yes or no yes or no yes or no” (240). Kane activates
Shneidman’s key concept of suicide as a response to intense psychache
caused by frustrated psychological needs that has led to a process of psy-
chological constriction. The thwarted vital need is the need to be loved – in
Shneidman/Murray’s terminology the need for affiliation.
Kane deliberately renders the identity and existence of a lover ambigu-
ous. (As Kenyon notes, it is remarkable “how oblique and obscure she
[Kane] could afford to be and still render the play meaningful” [qtd. in
Saunders, Love Me 153]). Whereas, early on in the play, the lover is identi-
fied as “he” (“I am jealous of my sleeping lover and covet his induced un-
consciousness / When he wakes” [208]) and as a doctor (“the only doctor
who ever touched me voluntarily . . . I trusted you, I loved you” [209–10]),
the love object becomes more abstract as the play progresses; it turns into
“a person who does not exist” (215) and is later identified as “a woman who
was never born” (218). The increasing focus on the impossibility of finding
love and the ensuing anger, hopelessness, and loneliness culminate in the
utterance, “[t]he vital need for which I would die,” followed by “[b]reak-
down,” indicating a sudden ceasing of the person’s functioning (219).
The motif of unfulfilled love only resurfaces shortly before the end of the
play, in a scene consisting of a long list of infinitives referring to goals or
achievements (233–35). Kane has taken nearly all items on this list verbatim
from Murray’s list of psychological needs, which Shneidman cites exten-
sively throughout his book. In The Suicidal Mind, each psychological need
is broken down into a list of infinitives that further define that need, e.g.
“Defendance The need to defend the self against assault, criticism, blame;
to conceal or justify a misdeed, failure, or humiliation; to vindicate the ego”
(180; emphasis in original).
Shneidman proposes that most cases of suicide fall into one of five clus-
ters of psychological needs. They are

• Thwarted love, acceptance, and belonging – related to frustrated needs for suc-
corance and affiliation.
• Fractured control, predictability, and arrangement – related to frustrated needs
for achievement, autonomy, order, and understanding.
• Assaulted self-image and the avoidance of shame, defeat, humiliation, and dis-
grace – related to frustrated needs for affiliation, defendance, and shame-
avoidance.
• Ruptured key relationships and the attendant grief and bereftness – related to
frustrated needs for affiliation and nurturance.
• Excessive anger, rage, and hostility – related to frustrated needs for dominance,
aggression, and counteraction. (25; emphasis in original)

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On close inspection, Kane’s list reflects most of the frustrated needs

closely associated with suicide, beginning with achievement, aggression,
dominance, defendance, autonomy, shame-avoidance, and counteraction.
The focus shifts in the last third of the list to the needs for affiliation, nur-
turance, and succorance. The list not only reflects the psychological need-
profile of a suicidal person; it also moves toward and focuses in on needs
closely associated with the need to be loved. Thus, it reflects the overall
movement of the text toward a fixation on a thwarted vital need, leading to
psychological constriction and suicide.
Shneidman is critical about the medicalization of suicide in psychiatry
and refrains from labelling suicidal patients as mentally ill. Although diag-
nosis with the DSM and the prescription of drugs may help temporarily, in
Shneidman’s view, the therapist must eventually attempt to understand the
suicidal patient’s “mental landscape” in order to save her/his life (151).
This requires the therapist to reduce the pain and relieve the constriction;
that is, to make apparent choices other than life or death and to pursue the
long-term goal of “re-examining and altering the patient’s life-threatening
needs themselves” (140). In this process, there will most likely be a degree
of positive transference (a “shift or flow of [the patient’s] feelings of trust
and warmth and benign expectation” [147]) onto the therapist, and the pa-
tient’s transference needs to be met with a modicum of positive counter-
transference; the therapist needs to like the patient and genuinely want to
help her/him (146–51).
In The Suicidal Mind, Shneidman presents the case of Castro Reyes, a
failed suicide, who appeals for help in a letter to his therapist: “Help me. I
have no answers. I have no one else to turn to who understands me, who
knows what I’ve been through. Please respond soon. I must regain control
and find the solution. R.S.V.P.” (120). Reyes’s words echo in the short and
enigmatic “RSVP ASAP” in 4.48 Psychosis, as a patient’s cry for help and
her/his positive transference onto the therapist (214). Earlier in the play the
I reminisces about feelings of love and trust toward a doctor, who seemed
to show genuine care and concern (“the only doctor who ever touched me
voluntarily, who looked me in the eye”), but whose behaviour was ulti-
mately dismissed as false and dishonest and as a betrayal of her/his trust
(209–10). Significantly, the penultimate scene of the play revolves around
the patient’s request for friendship (“You’re my last hope”) and the doctor’s
refusal of that request: “You don’t need a friend you need a doctor” (236).
And the play opens with the doctor’s argument in defence of this position:
“But you have friends” (205). The I makes reference to another of the doc-
tor’s arguments (“I feel your pain but I cannot hold your life in my hands”
[237])) in the moment prior to suicide: “[Y]ou will always have a piece of
me / because you held my life in your hands / those brutal hands / this will
end me” (238).

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There is a clear sense in the play that the medical establishment has not
lessened the pain, responded to the voice’s life-threatening needs, or
shown genuine care and concern. The experience of staying in a psychiatric
care unit has caused overwhelming feelings of shame and anger, thus rein-
forcing, not lessening, some of the life-threatening vital needs of the sui-
cidal person. Close to death, the I, echoing Artaud, intones, “Despair
propels me to suicide / Anguish for which doctors can find no cure / No
care to understand” (239).2

BECK DEPRESSION INVENTORY AND SERIAL SEVENS

The diagnosis of depression is usually made in tandem with questionnaires
that measure the existence and severity of depression and that can be used
to monitor the success of treatment. One of the most widely used question-
naires is the Beck Depression Inventory (BDI), which was developed by
Aaron T. Beck, the father of cognitive therapy (often referred to as cognitive
behavioural therapy). The BDI is a self-administered multiple-choice ques-
tionnaire, consisting of twenty-one groups of statements that relate to
symptoms of depression. In each group, the patient has to tick the state-
ment that most accurately describes how she has been feeling over the past
two weeks. Each statement is assigned a numerical score, and scores are
added up and measured against a key that determines the severity of
depression. Beck published the original BDI in 1961 (Beck et al.); today
health professionals work with a revised version (BDI-II) published in 1996
(Beck, Steer, and Brown).
The third scene of 4.48 Psychosis consists of a list of statements about
the I’s thoughts, feelings, and state of mind. The list borrows and adapts
statements from the BDI (there is larger congruence with the original BDI
than with BDI-II), revealing the speaking I as suffering from severe depres-
sion. The first nine statements (pertaining to mood, pessimism, sense of
failure, lack of satisfaction, self-punitive wishes, crying spells, social with-
drawal, and indecisiveness) are either cited verbatim or are very close to
the original source. The following statements revolve around questions in
relation to other symptoms of depression (loss of appetite, sleep distur-
bance, work, body image, and libido), although the I no longer adheres to
the script and eventually breaks the endless litany of “I am” or “I can’t/can-
not.” Liberated from the prescriptive language of the questionnaire, the I,
time and time again, returns to the question of suicide, which the BDI re-
fers to in only one of the twenty-one questions.
Kane consciously explodes the restrictive, formulaic design of this diag-
nostic tool, turning the reader’s attention back to suicidal thoughts and
pain: “Some will know the simple fact of pain / This is becoming my nor-
mality,” concludes the I (208). Kane’s intertextual inscriptions reveal the

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scene as a moment of diagnosis, in which – in the context of diagnostic psy-

chiatry – the I’s experience is framed as mental illness. The I resists the
diagnostic method as an inadequate means of reflecting individual experi-
ence. This critical stance toward psychiatric discourse and practice corre-
sponds with the I’s persistent rejection of the label “ill” and her/his rebuff
of the doctor’s insistent textbook response that self-harm “relieves the ten-
sion” (216–17). Ariel Watson suggests that silence is another tool of the I’s
resistance to “the scriptedness of the therapeutic encounter, its inability to
deviate from the expectations of depression and illness or from the pre-
scriptions of cure” (194). Cast in the role of the patient and object, the I
tries to assert her/his individuality.
The scene that follows consists of numbers scattered on the page, start-
ing at “100” and counting down to “7” in irregular intervals (208). Towards
the end of the play, another scene consists of a similar list of numbers, this
time arranged in an orderly straight column, starting from “100” and count-
ing down in sevens to the number “2” (232). Here, Kane alludes to another
method of psychiatric testing, Serial Sevens, which is part of the Mini-Men-
tal State Examination (MMSE), a questionnaire test to determine cognitive
impairment, often used in the diagnosis of dementia but also applied to
test a patient’s momentary cognitive faculties (Folstein, Folstein, and
McHugh). In Serial Sevens, the patient is asked to count down from one
hundred in sevens. The I’s inability to perform the test in the earlier scene
suggests a state of cognitive impairment and identifies the scene as another
moment of diagnosis, marking the beginning of a process of medical inter-
vention.

DRUG TREATMENT
A critical stance toward diagnostic psychiatry is most pronounced in a
scene that makes reference to the discourse of medical case notes and par-
ticularly to the administration of psychopharmacological drugs and their
side effects (223–25). On first reading, the scene simply emphasizes the lim-
itations of drug therapy as it charts a number of treatments that were dis-
continued, mostly due to severe side effects. On closer inspection, the
scene also outlines a narrative: symptoms, diagnosis, treatment as an out-
patient, hospitalization, argument with a junior doctor, shaving of the head
and self-harm, discharge into care in the community, a gradual refusal of
further treatments, a failed suicide attempt. On even closer inspection, the
patient is treated with a range of psychopharmacological drugs: tricyclic
anti-depressants (Lofepramine), anti-depressants of the selective serotonin
re-uptake inhibitors (SSRI) type (Sertraline, Citalopram, Fluoxetine, and
Seroxat) and of the serotonin and noradrenaline re-uptake inhibitor (SNRI)
type (Venlafaxine), as well as hypnotics (Zopiclone), and antipsychotics

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(Melleril and Thorazine) (British National Formulary 56). There comes a

point when it is unclear whether the patient’s symptoms are caused by her/
his illness or by the drugs’ side effects or by discontinuation symptoms.
Curiously, the patient responds well to antipsychotic drugs, whereas most
anti-depressants bring little signs of improvement.
Kane dramatizes the unreliability of drug treatment and the potentially
severe debilitating side effects. As with the Beck Depression Inventory,
Kane gradually appropriates and personalizes the objective and objectifying
medical discourse and allows the patient’s subjective thoughts and feelings
to surface. This appropriation and personalization occurs after the patient’s
discharge from hospital. Suffering from severe side effects, the I begins to
develop severe “side affects” (sic), feelings of anger and rage, in response to
the failure of drug therapy: “homicidal thoughts towards several doctors
and drug manufacturers . . . / Mood: Fucking angry. / Affect: very angry”
(224).
Earlier in the play, the patient had resisted the idea of drug treatment
(“I am terrified of medication” [207]), fearing that it would impede her/
his ability to write, but had finally given in to the doctor’s argument that
“[n]othing will interfere with your work like suicide” (221). Ironically, the
medical notes conclude with self-medication, a suicide attempt as a “safer”
form of treatment with no side a/effects: “100 aspirin and one bottle of Bul-
garian Cabernet Sauvignon, 1986. Patient woke in a pool of vomit and said
‘Sleep with a dog and rise full of fleas.’ Severe stomach pain. No other reac-
tion” (225). The possibilities of medical intervention appear to have been
exhausted, at this point.

THE SILVER CHAIR

From here the play moves into a cluster of scenes that appear closely con-
nected with the state of psychosis. I say so because most of these scenes
contain references to the image complex established as psychotic visions at
the beginning of the play: the ceiling of a mind, the cockroaches, the shaft
of light (later referred to as “hatch opens / stark light”), and the appeal to
“[r]emember the light and believe the light” (205–6). It is as if the I now
transgresses the confines of rational psychiatric discourse, refusing to be
framed as an object and mentally ill, and finds her/his subject position,
her/his authentic self in psychosis. The play can be read

as the attempt of the “ego” to extricate itself from positions or manners to which it
is socio-culturally-historically assigned (from the position of object, of the ill
person, of the prison of rationality or alienation from the symbolic order). The
means of this rebellion is the “subversive” poetic language which disturbs the
symbolic order and its alienation. But the subversive language of poetic

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imaginings does not lead to freeing the authentic subject (which is imprisoned by
symbolism, reason, etc.), rather to the “tyranny of madness.” (Chrz and Čermák
73)

Vladimír Chrz and Ivo Čermák, referring to research by Kateřina Zábrodská

here, emphasize the destructive potential of madness. Accordingly, the I ex-
periences ambivalent feelings and fears at the onset of psychosis: “I beg
you to save me from this madness that eats me / a sub-intentional death”
(226). Kane employs Shneidman’s notions of “indirect suicide” and “subin-
tentioned deaths” (emphasis in original), actions not directly suicidal but
indirectly and unconsciously contributing to the shortening of one’s life.
Shneidman refers to Karl Menninger, who classifies psychosis as a form of
“chronic suicide,” self-harm as a form of “focal suicide” (qtd. in Shneidman
63; emphasis in original).
But ultimately, the I refuses to act as patient-object in the therapeutic
setting and demands that the doctor avert her/his gaze: “I REFUSE I
REFUSE I REFUSE LOOK AWAY FROM ME” (227). S/he erupts in prophetic
visions proclaiming the reign of insanity – “We are anathema / the pariahs
of reason” – in language that echoes the language of the prophets in the
Old Testament (228). The I concludes that the abjects can find sanity if they
“[e]mbrace beautiful lies – / the chronic insanity of the sane / the wrench-
ing begins” (229). Kane marks the wrenching, the twisting around of our
understanding of what constitutes madness and sanity.
In one of the scenes, the I describes to the doctor how s/he experiences
clarity, sanity, unity of body and mind (for most of the play, the I refers to
her/himself as suffering from a debilitating split between mind and body),
and a sense of being in touch with her/his essential self during the early
hours of the morning. But this is also the time when, from an external point
of view, psychosis appears at its most intense:

At 4.48
when sanity visits
for one hour and twelve minutes I am in my right mind.
When it has passed I shall be gone again,
a fragmented puppet, a grotesque fool.
Now I am here I can see myself
but when I am charmed by vile delusions of happiness,
the foul magic of this engine of sorcery,

I cannot touch my essential self.

Why do you believe me then and not now?

Remember the light and believe the light.

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 ANTJE DIEDRICH

Nothing matters more.

Stop judging by appearances and make a right judgement. (229)

Here, Kane uses a number of intertextual inscriptions from C.S. Lewis’s

fantasy novel The Silver Chair (1953). In the novel, the lion Aslan entrusts
the children Jill and Eustace with the mission of finding the missing Prince
Rilian of Narnia. Aslan gives Jill four signs they will have to follow on their
quest; his appeal to her that she “[r]emember the signs and believe the
signs. Nothing else matters” (27) is echoed in Kane’s “Remember the light
and believe the light. /Nothing matters more” (206, 228–29). On their travels
with the marsh-wiggle Puddleglum, the children descend into the kingdom
of the Queen of Underland and meet a young knight in her castle. He tells
them that he is under a spell and that every night he suffers from a terrible
fit of fury that takes possession of his mind and body and lasts for one
hour. For his own safety and the safety of others, he is chained to a silver
chair until the fit has passed. The companions witness the knight’s transfor-
mation. To their surprise, he insists that he is sane for that one hour but be-
witched for the rest of the day:

It is at this hour that I am in my right mind: it is all the rest of the day that I am
enchanted . . . Believe me . . . Now you can save me; when this hour has passed, I
shall be witless again – the toy and lap-dog, nay, more likely the pawn and tool, of
the most devilish sorceress that ever planned the woe of men. (132; emphasis in
original)

But only when he appeals to them in the name of Aslan (the last of the
signs given to Jill by Aslan), do they release him. The knight takes his sword
and breaks the silver chair: “‘Lie there, vile engine of sorcery’, he said, ‘lest
your mistress should ever use you for another victim’” (135). The knight re-
veals himself to be Prince Rilian, who, under the spell, had forgotten his true
identity: “‘[W]hile I was enchanted I could not remember my true self’”
(136).
The novel is easily mapped onto the play: the doctor takes the role of the
Queen/witch, the patient of the enchanted prince; psychiatry becomes
the engine of sorcery symbolized by the shackles of the silver chair. In the
novel, the witch returns to the castle and tries to bring the liberated Prince
Rilian and the three companions under her spell. “There is no Narnia, no
Overworld, no sky, no sun, no Aslan. And now, to bed all. And let us begin a
wiser life tomorrow,” she says, trying to charm them (144).
The I of 4.48 Psychosis, after asserting her identity as an autonomous and
authentic self in psychosis, engages in the act of self-harm (another form of
“subintentioned death”), unifying “Victim. Perpetrator. Bystander” in one

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 Intertextuality in Sarah Kane’s 4.48 Psychosis

person and inflicting “beautiful pain / that says I exist” on her/himself.

While doing so, s/he is aware of the transience of this moment (“the morn-
ing brings defeat”), already adopting the witch’s/psychiatrist’s voice of rea-
son that will rule her/his life with the onset of dawn “and a saner life
tomorrow” (231–32). The “spell” of psychosis is coming to an end. In com-
mand of her/his cognitive faculties again, the I performs the Serial Sevens
test with ease (232).
Kane overlays these scenes with a cluster of themes that further call into
question fixed demarcations of normalcy and madness: the scenes contain
references to extreme violence and genocide (as the I, Christ-like, takes on
the sins of the world – “I gassed the Jews, I killed the Kurds, I bombed the
Arabs” [227]), allusions to religious beliefs and prophecy (Kane quotes Eze-
kiel: “I saw visions of God” [Ezek. 1.1 (AV); qtd. 228]), and evocations of our
willingness to surrender rational thought to the world of fantasy novels.
Kane polemically suggests that psychiatry makes perfectly “normal” peo-
ple adjust to a “mad” world, and she challenges our notions of madness
and normalcy, echoing social-constructionist conceptualizations of mental
illness that view definitions of psychiatric disorders as contingent on chan-
ging social systems of meaning – particularly, on changing cultural rules
that define what is normal and abnormal (Horwitz 5). Kane commented on
this “inversion of values” (Rebellato 37) in relation to the life and work of
Antonin Artaud:

I think to a certain degree you have to deaden your ability to feel and perceive. In
order to function you have to cut out at least one part of your mind. Otherwise,
you’d be chronically sane in a society which is chronically insane. I mean, look at
Artaud. That’s your choice: Go mad and die, or function but be insane (qtd. in
Saunders, Love Me 114).

ANTONIN ARTAUD: SELECTED WRITINGS

Kane made the preceding comment on Artaud in a February 1998 interview
in which she also acknowledged that she had read and re-read Artaud’s
writings while working on a new play (Tabert 19). Not surprisingly, 4.48 Psy-
chosis contains a significant number of intertextual references to the works
of Artaud. More specifically, these refer to Antonin Artaud: Selected Writings
(1976), an anthology edited by Susan Sontag and translated by Helen
Weaver. Most can be traced back to the early poetry and prose and to the
book Van Gogh: The Man Suicided by Society (1947).
Artaud wrote the latter in response to an article by a psychiatrist describ-
ing van Gogh’s paintings as symptomatic of his psychiatric disorder; the
article had prompted Artaud to visit the great van Gogh exhibition at the

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 ANTJE DIEDRICH

Orangerie in Paris in early February 1947 (Barber 139–40). Artaud, who suf-
fered from various mental health conditions and a life-long drug addiction,
had only been released from nine successive years of internment in five dif-
ferent mental institutions (during which he had undergone 51 electroshock
treatments) in late May 1946. Stephen Barber suggests that, in Van Gogh:
The Man Suicided by Society, Artaud reconstructs the life of van Gogh in
parallel to his own, launching a bitter attack on psychiatry; rejecting any
psychiatrically constructed notion of madness; condemning psychiatry as a
means of social exclusion, suppression, and silencing; and declaring “his
belief in the ‘authentic madman’,” the man who prefers being “mad” to ad-
justing to an insane world (140–41).
Indeed, Artaud praises the painter’s creative force, originality, and vision
while railing, simultaneously, against society and psychiatry. In his view,
psychiatry declared the painter insane because his work did not conform to
accepted aesthetic norms, presented a threat to social institutions, and ex-
pressed intolerable truths. Artaud celebrates the drama and myth van Gogh
was able to find in the everyday, his ability “to imbue nature and objects
with so much passion . . . A candlestick on a chair, an armchair of braided
green straw, / a book on the armchair, / and there the drama is revealed”
(Van Gogh 490). This concern for expressing heightened emotion and
drama through simple means is echoed in 4.48 Psychosis: “A glut of excla-
mation marks spells impending nervous breakdown / Just a word on the
page and there is the drama” (Kane 213). Artaud suggests that the cause of
van Gogh’s death was not suicide but was the direct result of the treatment
he had received from his psychiatrist:

I think that he died at thirty-seven because he had, alas, reached the end of his
dismal and revolting story of a man strangled by an evil spirit.

For it was not because of himself, because of the disease of his own madness, that
van Gogh abandoned life.

It was under the pressure of the evil influence, two days before his death, of Dr.
Gachet, a so-called psychiatrist, which was the direct, effective and sufficient
cause of his death. (Van Gogh 492)

“I have reached the end of this dreary and repugnant tale of a sense in-
terned in an alien carcass and lumpen by the malignant spirit of the moral
majority” (214), concludes the I, her/his reflections on the relationship
between personal anguish and artistic creation marking her/his position as
that of a non-conformist artist, rejected by society and hence close to sui-
cide. “I have been dead for a long time,” the I continues (214); “I suffer hid-
eously from life. There is no state that I can attain. And it is certain that I

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 Intertextuality in Sarah Kane’s 4.48 Psychosis

have been dead for a long time, I have already committed suicide. They
have suicided me, so to speak,” reflects Artaud on his personal suffering, in
the short prose text “Inquiry . . . Is Suicide a Solution?” He concludes, “I
have no appetite for death, I have an appetite for not existing” (103; empha-
sis in original), expressing his dismay at having to live with his weak and
“crippled” self and body, for having been thrown into an impossible exis-
tence. “I have no desire for death / no suicide ever had,” the I says only mo-
ments before her/his death (Kane 244).
Artaud did not side-line his “madness”; it became an integral part of his
writing, something he consciously incorporated into his work, albeit with
great difficulty. He eloquently articulates this struggle in his correspon-
dence with Jacques Rivière, the then editor of La Nouvelle Revue Française,
to whom he had sent poems for publication. (Rivière rejected the poems,
because – in his view – Artaud had not succeeded “in creating a sufficient
unity of impression,” something “coherent and harmonious” [Artaud “Cor-
respondence with Jacques Rivière” 33].) Artaud describes how a “horrible
sickness of the mind” affects him when writing (31), how he struggles to
find form for his thoughts and how he is unable to externalize feelings and
images in words, phrases, and sentences, causing him pain and suffering:

[T]o have within oneself the inseparable reality and the physical clarity of a
feeling, to have it to such a degree that it is impossible for it not to be expressed,
to have a wealth of words, of acquired turns of phrase capable of joining the
dance, coming into play; and the moment the soul is preparing to organize its
wealth, its discoveries, this revelation, at that unconscious moment when the
thing is on the point of coming forth, a superior and evil will attacks the soul like a
poison, attacks the mass consisting of word and image, attacks the mass of feeling,
and leaves me panting as if at the very door of life. (“Correspondence with Jacques
Rivière” 45)

Hence, he grasps a form as soon as it presents itself “for fear of losing the
whole thought” (31), aware that he cannot achieve harmonious coherence
but can only write in fragments. Nonetheless, Artaud defends his creative
efforts; their lack of perfection, he argues, may be redeemed by the power-
ful and beautiful images and feelings they contain: “Do you think that one
can allow less literary authenticity and effectiveness to a poem which is
imperfect but filled with powerful and beautiful things than to a poem
which is perfect but without much internal reverberation?” (32). But most
importantly, to him writing is a means of saving himself from extinction, a
way of manifesting his existence: unable to give form to his thoughts, Ar-
taud experiences himself as not being in the world, as living in a state of
“nonexistence” (44). And so, he defends his right to express himself in prose

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 ANTJE DIEDRICH

and poetry, his right to give expression to this reality, even if he can only
express himself in fragments:

A man possesses himself in flashes, and even when he possesses himself, he does
not reach himself completely. He does not realize that constant cohesion of his
forces without which all true creation is impossible. Nevertheless, this man exists.
I mean to say that he has a distinct reality which redeems him. Should he be
condemned to oblivion simply because he can give only fragments of himself? (43)

In “Manifesto in Clear Language,” Artaud, who has become a member of

the Surrealist group centred around André Breton, more confidently pro-
claims his desire to investigate the laws of the mind that exist outside the
realm of reason (a mind that is directly connected to the body, the nerves,
the flesh) and that will allow for the discovery of a “new Meaning” (108).
Within the realm of this bodily mind, images become their own substance,
cannot be deduced by logic. Artaud describes this activity of the mind as an
“immediate teeming . . . a multiform and dazzling insinuation of animals.
This insensible and thinking dust is organized according to laws which it
derives from within itself, outside the domain of clear reason or of thwarted
consciousness or reason” (109; emphasis in original).
The second scene of 4.48 Psychosis opens with an accumulation of
images with no discernible sentence structure:

a consolidated consciousness resides in a darkened banqueting hall near the

ceiling of a mind whose floor shifts as ten thousand cockroaches when a shaft of
light enters as all thoughts unite in an instant of accord body no longer expellent
as the cockroaches comprise a truth which no one ever utters. (205)

These words – I would argue – are Artaud’s “insensible and thinking

dust” that captures workings of the mind outside “the domain of clear rea-
son”; “the ten thousand cockroaches” echo Artaud’s account of the mind as
a “dazzling insinuation of animals,” and Kane borrows the images of “the
ceiling of a mind” and of the “banquet” from Artaud’s poem “Love” (6). The
I experiences this moment as a revelation, a moment in which “new Mean-
ing” emerges: “I had a night when everything was revealed to me. How can
I speak again? (206)”
In a later scene, in which the I erupts into prophetic visions, Kane
equally employs intertextual references to Artaud. “[T]he pariahs of reason”
(228) echoes “the pariahs of Thought [sic]” of Artaud’s “The Activity of the
Surrealist Research Bureau,” a declaration of the bankruptcy of logic (107).
“Sanity is found in the mountain of the Lord’s house on the horizon of the
soul that eternally recedes” (229) has similarities to a passage from Artaud’s
description of André Masson’s surrealist painting, L’Homme: “The

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 Intertextuality in Sarah Kane’s 4.48 Psychosis

mountain has its own place in the soul. It is the horizon of something that
constantly recedes. It gives the feeling of an eternal horizon” (“A Slender
Belly” 67). Finally, Kane adapts Artaud’s notion of the “chronic insanity of
the sane” (4.48 Psychosis 229): “And this . . . is how modern life maintains
its old atmosphere of debauchery, anarchy, disorder, delirium, derange-
ment, chronic insanity, bourgeois inertia, psychic anomaly” (Van Gogh
483).
Some of the unusual formal characteristics of Kane’s play – the breaking
up of sentences, the lack of punctuation, the fragmentation of language, the
unusual layout on the page (particularly, the indenting of phrases or lists of
words) – were inspired not so much by poetry as by those of Artaud’s works
that were written after his release from internment; for example, Artaud Le
Mômo, Here Lies, and the radio play To Have Done with the Judgement of God.
Many of the themes pertinent to Artaud’s writings resonate through 4.48
Psychosis: the pain and suffering caused by mental illness; the way it inter-
feres with the process of artistic creation; the failures of medicine and of
psychiatry; the “inversion of values,” of what constitutes madness and san-
ity; and the mind operating outside the confines of rational thought and
language. Kane, it appears, used Artaud’s works as a key reference point in
her dramatic exploration of the state of psychosis and in her representation
of the thoughts and feelings of the mentally ill and suicidal artist.

THE SORROWS OF YOUNG WERTHER

“[P]lease open the curtains,” reads the last line of 4.48 Psychosis, almost cer-
tainly a meta-theatrical reference to the moment of performance (245). But
there is a curious paradox here: the opening of the curtains belongs at the
beginning of a play, not its end.
Only days before his death, Werther, the young hero of Johann Wolfgang
von Goethe’s novel The Sorrows of Young Werther ponders the possibility of
suicide:

To lift the curtain and step behind it! That is all! And why with fear and trembling?
Because no one knows what one may see there? Or because one cannot return? Or
because it is, after all, a peculiarity of our mind to apprehend that confusion and
darkness exist in places of which we know nothing definite? (135–36)

Over a year earlier, Werther has experienced the onset of a long-lasting

spell of melancholy “as if a curtain has been drawn away from my soul, and
the scene of unending life is transformed before my eyes into the pit of the
forever-open grave” (66). The drawing or lifting of the curtain signifies the
protagonist’s transition from one state to another; it represents a physical

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and emotional “scene change.” In suicide, the curtain lifts to reveal death
and, with death, the long-desired end of emotional pain.
In the summer of 1998, Kane was approached by Nick Philippou, then
artistic director of the Actors Touring Company (ATC), to write a piece of
drama inspired by Goethe’s novel The Sorrows of Young Werther. This was
in line with ATC’s artistic policy at the time of presenting classic works of
drama and literature to contemporary dramatists as starting points for new
pieces. Philippou sent Kane a copy of the novel (in the translation by Eliza-
beth Mayer and Louise Bogan) and, according to him, Kane phoned up a
few weeks later to accept the commission, suggesting the working title 4.48
Psychosis (Philippou). Contracts were not drafted until January 1999, and
their formal exchange was forestalled by Kane’s death in February. To this
day, Philippou believes that 4.48 Psychosis is ATC’s commission, an asser-
tion adamantly contested by Kane’s agent, Mel Kenyon, who firmly believes
that the play has nothing to do with the novel. Kenyon maintains that Kane
had already been working on the play for several months when contracts
were drafted and that she had even received a small grant to finish it, which
was in no way linked to ATC’s commission (Kenyon). Indeed, Kane men-
tioned as early as February 1998 that she had started work on a play about
the subject of madness and the split between body and consciousness (qtd.
in Tabert 10). Kane commented on the play, again, in an interview in
November 1998, in which she identified the subject matter of the play as “a
psychotic breakdown” (Kane, “Interview” 19), though this does not neces-
sarily preclude the possibility that she merged the subject matter of psycho-
sis with that of unrequited love, depression, and suicide. It is, however,
certain that Kane read The Sorrows of Young Werther in the process of writ-
ing 4.48 Psychosis, and it is, therefore, worthwhile examining the play in
relation to the novel.
Written in the form of a novel in letters, The Sorrows of Young Werther
reveals the intimate thoughts and feelings of its young hero, who kills him-
self for unrequited love. Werther’s highly subjective confessions represent
one of the finest literary works of the German Sturm und Drang period,
with its emphasis on individuality, emotion, sensitivity, personal freedom,
and the artist as genius. But the novel not only draws the reader into the
subjective world of its hero’s Empfindsamkeit (“sentimentalism”); it also
portrays Werther’s demise as the result of his inability, as a young middle-
class intellectual, to find a place and identity in a society still dominated by
social rank and feudalism.
Goethe’s suicide novel and Kane’s suicide drama have little in common,
formally or linguistically, but both are highly subjective accounts that
revolve around the same thematic complexes. Werther’s encounter with a
young woman called Lotte sends him into amorous euphoria. The arrival of
Albert, her fiancé, and the realization that she is unobtainable makes him

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 Intertextuality in Sarah Kane’s 4.48 Psychosis

sink into deep melancholy, feelings of listlessness, hopelessness, and

despair. He escapes from her presence and takes up state employment with
an ambassador in another town, only to find that his employer, the greed
for rank in the society around him, and the snobbery of the aristocracy are
unbearable. He returns to be near Lotte, who, in the meantime, has married
Albert. Werther slowly loses his senses, gets fixated on and obsessed with
Lotte. A series of dramatic events leads to Lotte’s removing herself from her
friend’s company. Werther shoots himself.
Werther’s subjective account of events moves from euphoria, to depres-
sion, to a fixation on unrequited love, to madness (although Werther does
not develop psychosis himself but, instead, empathizes with his mad “alter
ego,” Heinrich), to suicide, framed by the overall sense that the young hero,
subject to intense swings in moods and emotions, is incapable of fitting
into the fabric of society. There is no such linear progression of narrative in
4.48 Psychosis. Nonetheless, the movement toward suicide, expressed as
the result of unrequited love (the need to be loved), the ensuing depression
and psychosis, the sense that the suffering I feels alienated from the world
around her/him, echoes throughout Kane’s text. Both texts chart the move-
ment of a person toward suicide, including her/his fixation on a vital need
followed by psychological constriction.
But whereas Werther addresses himself to his friend Wilhelm in writing,
directs his amorous desires to Lotte, and sees his moods, feelings, and
thoughts reflected in nature, the I, in 4.48 Psychosis, talks predominantly to
her/himself, conducting a conversation in the mind. In a pre-psychiatric
age, Werther’s condition of melancholy had not been classified as patholog-
ical; on the contrary, his contemporaries perceived his sentimentality as a
fashionable ideal. The publication of the novel triggered Werther-fever all
over Europe: young men dressed like Werther; people made pilgrimages to
the places described in the novel; and there was a flurry of Werther poems,
plays, operas, songs, china, jewellery, perfume, gloves, and fans (Hulse 11–
17). In the late twentieth century, the age of diagnostic psychiatry, the mel-
ancholic hero would be diagnosed as clinically depressed. In the world of
4.48 Psychosis, there is no nature, there are no friends (although the I has
friends, they never appear), there is not even a lover – only references to a
psychiatric care unit. “Oh this void, this terrifying void I feel in my breast! I
often think: if you could once, once only, press her to your heart, this void
would be filled,” weeps Werther (Goethe 111). “I can fill my space / fill my
time / but nothing can fill this void in my heart / The vital need for which I
would die,” laments the I in 4.48 Psychosis (219).

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CONCLUSION
The present discussion of intertextuality as conscious dramaturgical strat-
egy in 4.48 Psychosis has identified a significant number of instances of “in-
tertextual marking” that draw attention to connections between manifest
text and referent text and enable us to detect themes, ideas, images, and
structuring principles that the author adopted in the process of writing the
play. The analysis discredits any notion of the play’s being predominantly
an expression of the author’s personal experience and demonstrates how
Kane drew inspiration from source material connected to the subject mat-
ter of depression, psychosis, and suicide and wove “stor[ed] up feelings,
phrases, images” (Eliot 77) into the fabric of the play.
4.48 Psychosis clearly reflects Shneidman’s notion of suicide as “a drama
in the mind” with the self focusing in on a thwarted vital need and moving
to psychological constriction and suicide. Within this drama in the mind,
the world of psychiatry is represented in negative terms, not responding to
but worsening the I’s psychache and suicidal intentions. Kane’s appropria-
tion of psychiatric questionnaires, her mimicking of medical case notes on
the inefficacy of drug treatment, and her references to the therapeutic situ-
ation contain a critique of diagnostic psychiatry, particularly its scripted-
ness, the failure of the biomedical model to account for the patient’s
emotional pain, and the potentially life-threatening absence of care and
concern in those dealing with suicidal patients. But mostly, Kane critiques
the way diagnostic psychiatry places the patient in a position of hetero-
nomy, dependence, and otherness. In addition, many of the thoughts, opi-
nions, and experiences the I expresses in the play resemble those
articulated in the writings of Antonin Artaud: the difficulty of giving form to
thought in the process of writing – “How can I return to form / now my for-
mal thought has gone,” the I declares (213); the notion of the artist’s being
rejected and suicided by society; the idea of being dead while alive, of living
in a state of non-existence, in which the self can only grasp itself in frag-
ments; the vitriolic attack on psychiatry coupled with a rejection of socially
constructed conceptions of mental illness (which are also explored through
intertextual references to C.S. Lewis’s The Silver Chair); and the striving to
express the operations of the mind outside language and reason. As De Vos
puts it, “What Kane and Artaud share is not just a predilection for violence
onstage but the presentation of a motherly, pre-oedipal world that has not
been corrupted by the Symbolic Order” (128). In addition, the I’s suffering
from unrequited love and her/his drive to suicide is close to that of
Goethe’s Werther, who experiences the absence of love as a void and fore-
sees the taking of his life as the lifting of a curtain from his soul.
The positioning of the self in the play also reflects a wider trend in culture,
which the sociologist Frank Furedi has termed “therapy culture.” Furedi

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charts the pervasive influence therapeutic discourse and thought have ex-
erted on Anglo-American culture since the 1970s. Possibly as a response to
the fragmentation of social relations, to the decline of tradition, of religion
and shared moral norms, the demise of political ideologies, and the sense
that we are subject to forces outside our control (such as globalization and
environmental disasters), culture and public institutions have re-orientated
themselves toward the self and its quest for self-realization and self-expression.
Therapeutic ideas provide a shared system of meaning through which peo-
ple can interpret their personal experience. Furedi argues that this cultural
shift has produced a problematic reconceptualization of the self as vulnera-
ble, at risk, and in need of professional intervention. In therapy culture, he
claims, the self has almost lost any sense of self-determination and agency.
In addition, therapy culture has recast social, economic and political pro-
blems – such as poverty or exploitation at the workplace – as problems of
the self. His argument echoes Horwitz’s critique of diagnostic psychiatry as
a discipline that has severed symptoms from their social and environmental
causes. Furedi is particularly critical of therapy culture’s stigmatization of
close relationships, such as family and love relationships, as the source of
potentially irreversibly emotional damage and of the way it puts the achieve-
ment of self-realization before the forging of secure relationships. This, ac-
cording to Furedi, distances the self from others and opens the private
sphere to therapeutic management by the government and other institu-
tions, with potentially authoritarian implications. The self in 4.48 Psychosis,
alienated from nature and from meaningful social relationships, has, in Fur-
edi’s sense, become an “asocial self” (25).
Throughout the play, the I resists the therapeutic subject position, re-
fuses the label “ill,” and insists, instead, that s/he is angry. By identifying
the I as a writer/dramatist, by introducing poetic (counter) discourses that
reveal mental illness as constructed and contingent on changing social and
cultural perceptions and practices, and by equating “madness” with a state
of lucidity in an insane world, Kane places art and the artist in a position to
magnify, resist, and challenge hegemonic discourses. The I is Kane’s answer
to a world that conceptualizes sadness and anger as illness and the self as
vulnerable and in need of (heteronomous) therapeutic intervention, to an
age obsessed with the idea that the ills of the world lie within the self and
not within the world itself.

NOTES
1 For critics who emphasize the autobiographical, see e.g., Innes 535; Kaplan 125;
Ward 146; for those who focus, instead, on the non-representational and perfor-
mative, see e.g., Barnett; Campbell; Tycer; Voigts-Virchow.

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 ANTJE DIEDRICH

2 Cf. “Anguish which drives men mad. / Anguish which drives men to suicide. /
Anguish which condemns them to hell. / Anguish which medicine does not
know. / Anguish which your doctor does not understand” (Artaud, “Letter” 70).

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ABSTRACT: The article examines intertextuality as conscious dramaturgical strategy in the

composition of Sarah Kane’s 4.48 Psychosis. Inspired by Jörg Helbig’s notion of intertextual
marking, the analysis identifies intertextual inscriptions in the play and examines the rela-
tionship between manifest text (the text the author produces) and referent text (the text
the author borrows from). Kane’s engagement with depression, psychosis, and suicide is
mediated through ideas and structures that she adapts from a range of sources. Each of
these frames and re-frames the experience of individual suffering explored in the text, and
together, they chart the I’s journey from depression to psychosis to suicide. Moreover, the
play contains a critique of diagnostic psychiatry and plays out medical discourses against
poetic (counter) discourses that reveal mental illness as constructed and contingent on
changing social and cultural perceptions and practices.
KEYWORDS: Sarah Kane, 4.48 Psychosis, Intertextuality, Artaud, British Drama

ANTJE DIEDRICH is Lecturer in Contemporary Theatre and Practice at Middlesex

University, London. Her work has previously been published in New Theatre Quarterly,
Beckett Today/Beckett Aujourd’hui, and Performance Research.

398 Modern Drama, 56:3 (Fall 2013)

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