Ten books

In the novel Hard Times, Charles Dickens gives his views on education. His character Mr Gradgrind believes in ‘facts’ and is suspicious of the imagination. All we need to know about the world, he maintains, can be reduced to simple facts. Dickens shows that such a philosophy leads to the impoverishment of the mind and to the weakening of ethical reasoning. Today it seems that the descendants of Mr Gradgrind are still in charge. The main psychiatric library where I work has been closed. It is argued that we can obtain all the ‘facts’ we need from the internet. The notion that books might have more to offer than prosaic detail, that they reflect the rich diversity of human experience, seems alien to the modern-day Gradgrinds.

And yet Scotland has a long history of recognising the importance of the humanities. The philosopher George Davie (1961) has characterised the Scottish approach as that of the ‘democratic intellect’, an approach which combines the practical with the philosophical. In his autobiography Wisdom, Madness and Folly, the Scottish psychiatrist R. D. Laing (1985) described working his way from A to Z of the local public library, a project that saw him take in the works of Freud, Huxley, Kierkegaard and Nietzsche. Reading books was for Laing, as it has been for countless others, a means of widening one's intellectual horizons. It has also been a means to escape poverty.

When I went to Glasgow University in the late 1970s, there was a belief that politics mattered. The inequalities in wealth affected the well-being of the people and there was a need for political action to change society and improve the lot of its citizens. Representative of this view was Dave Widgery, a flamboyant London general practitioner, who combined a career in medicine with political action. He also wrote for the music press and set up ‘Rock against Racism’, a campaign to fight prejudice by enlisting the support of popular musicians. All of this made Widgery an appealing figure to many students. His recent biography (Hutt, 2005), however, reveals a deeply troubled man, who was flawed and full of contradictions. Widgery is a good example of the combination of idealism and egotism, social concern and hedonism, which characterised left-wing circles of the time.

A key political battleground during this period was that of mental illness. The works of Laing, Szasz and Goffman were still provoking debate. Peter Sedgwick's Psychopolitics (1982) dissected the antipsychiatric movement from a left-wing perspective, while Anthony Clare's Psychiatry in Dissent (1976) offered an eloquent and good-humoured defence of traditional psychiatry. Such discussions were exciting and dealt with fundamental questions about the nature of madness and the role of psychiatry. As David Healy (2004) has observed, psychiatry once led the rest of medicine in its engagement with ethical issues. The rise of biological psychiatry has been accompanied by a belief, among some, that the neurosciences are value-free and thus altogether unproblematic.

Clinical psychiatry: R. D. Laing

Of all the books that challenged psychiatry at this time, the one that influenced me most was The Divided Self by R. D. Laing (1960). It argued that madness was potentially understandable. In a famous set piece, Laing examined the clinical technique of Emil Kraepelin. In his Lectures on Clinical Psychiatry (Kraepelin, 1905), the German professor had described his interview with a young man conducted in front of a class of students. Kraepelin deemed his patient to be suffering from catatonia and proceeded to demonstrate the clinical signs and symptoms to his audience. Laing felt that Kraepelin was treating the patient as an object rather than a person. He suggested that the young man was not merely a passive presence in the room but that he had his own perspective on the situation. Further, the interview was not a neutral activity – it had an effect on the patient and influenced his behaviour. Laing speculated that the young man's apparently incomprehensible symptoms were a coded protest against being exhibited before a class of students.

Of course, Laing's explanation of what the young man was doing was not necessarily the truth of the matter, but it did emphasise the fact that the patient had a viewpoint, and that clinicians, with their ‘objective’ gaze, often overlooked this simple truth. Laing's quest to find meaning in madness finds an echo in a recent publication in which Glenn Roberts (2006) attempts to redress what he sees as the failure of biological psychiatry to attend to the inner world of the patient. He argues, like Laing, that psychosis is much more understandable than some clinicians allow.

Psychopathology: Karl Jaspers and Eugene Bleuler

I started psychiatric training in Edinburgh at a time when there was an array of talented teachers. For me, reading books does not take place in isolation and I discovered many books through attending the lectures on the MPhil postgraduate course. A trainee in psychiatry is faced with a bewildering variety of models of clinical practice, as Lester Havens pointed out in Approaches to the Mind (1973). Havens identified several different approaches: the objective–descriptive, as exemplified by Kraepelin; the phenomenological, as exemplified by Jaspers; the psychodynamic; the existential; and the social.

Reading Jaspers' General Psychopathology (1963) as a trainee, I was fascinated by the rich descriptions of the mental worlds of the individuals discussed in the book. Here were strange and disturbing personal experiences, which Jaspers accorded time and space to consider. In like vein was Eugene Bleuler's Dementia Praecox (1911), which also contained a wealth of clinical detail. At this early stage I was unaware that some writers were critical of Jaspers' grasp of phenomenological philosophy, or that others held that Bleuler's attempt to incorporate Freudian theory into his account of schizophrenia was misguided. For me, Jaspers and Bleuler demonstrated that making a detailed study of mental symptoms and relating them to a person's life story was not only intriguing but also crucial in trying to understand the patient. Several observers have lamented that the advent of symptom checklists and an exclusively biological conception of mental disturbance have led to a decline in this type of detailed approach.

Psychotherapy: Freudian and existential

Among the commentaries on Freud's work, Paul Roazen's Freud and His Followers (1976) compared psychoanalysts to a fanatical religious sect in which heretics were repeatedly excommunicated. Charles Rycroft provided the invaluable A Critical Dictionary of Psychoanalysis (1972). Although a trained analyst, Rycroft was well aware of the limitations of psychodynamic theory and brought a sceptical and demystifying approach to the subject. But perhaps the best book in the field was Henri Ellenberger's The Discovery of the Unconscious (1970), which placed Freud in his cultural context and served to debunk the myth of him as the lone hero, battling with a hostile world to bring forth ideas of complete originality.

Existential psychotherapy seemed to be an attractive alternative to psychoanalysis. It was critical of the Freudian model of psychic determinism and tried to see the situation from the patient's perspective. A book I read early on was Existence: A New Dimension in Psychiatry and Psychology, edited by May, Angel and Ellenberger (1958). It drew on European philosophers such as Søren Kierkegaard and Friedrich Nietzsche, and it featured the writings of Continental psychiatrists such as Ludwig Binswanger and Eugene Minkowski. Paradoxically, despite the avowed intention to free the patient from objectifying terminology, the actual writing of the European clinicians buried the patient in a ‘tomb of words’, as Laing (1982) put it. One of the reasons for Laing's success was that he transformed potentially difficult ideas into accessible and readable prose.

Religion: William James

Freud was notoriously critical of religion, but a psychologist who had a more sympathetic approach was William James. In 1900 he sailed from America to Europe, where he delivered the Gifford Lectures in Edinburgh. These were subsequently published as The Varieties of Religious Experience (James, 1902), a book which has since become a classic. In it, James adopted an open-minded response to religious experience. He was critical of those he dubbed ‘medical materialists’, who saw all accounts of spiritual experiences as evidence of brain pathology. He was also critical of institutional religion, which he thought turned the individual experience of the divine into rules and ritual. James surveyed a vast selection of accounts by individuals of their spiritual journeys, including people who heard voices and saw visions. For James, the life of religion consisted of ‘the belief that there is an unseen order, and that our supreme good lies in harmoniously adjusting ourselves thereto’ (James, 1902: p. 53).

James had originally trained to be a painter but went on to study medicine instead. However, he disliked clinical work and wondered what he was going to do with the rest of his life before he eventually decided on a career in psychology. Throughout his life, James suffered from recurrent bouts of melancholy and had contemplated suicide on more than one occasion. He used his own case, in disguised form, in The Varieties of Religious Experience. The book also contains James's distinction between the ‘healthy-minded’, who see the positive in everything, and the ‘sick-souls’, who are aware of the essential fragility of human life. James would definitely have counted himself among the ranks of ‘sick-souls’.

The mind–body problem: Karl Popper and John Eccles

A core philosophical question which underpins psychiatry is the relation between mind and body. There are now numerous books on the nature of consciousness and the subject is very much in vogue. When I started in psychiatry there were fewer books, but a good introduction was The Self and its Brain by the philosopher Karl Popper and the neurologist John Eccles (Popper & Eccles, 1977). The book contained a lucid summary of the various theoretical positions concerning the mind–body problem. Popper provided a valuable historical survey of how philosophers down the centuries have responded to the question. The book also contained transcripts of discussions between Popper and Eccles on the implications of adopting particular philosophical solutions to the problem. In the book, Popper outlined his own view that the mental could not be reduced to the physical, but he did not claim that the mind could exist independently. Whether one agreed with Popper or not, and these days many philosophers are critical of his dualist approach, the book very clearly set out the philosophical context of the debate and the problems involved.

Art: Hans Prinzhorn

I have always been interested in art. A book which combined art and psychiatry was Artistry of the Mentally Ill by Hans Prinzhorn (1922), a German psychiatrist who had also trained as an art historian. His book, which originally came out in 1922, intrigued many artists, especially the surrealists and expressionists. Prinzhorn argued that the work of patients, or at least certain patients, had aesthetic value. Their creations should not be inspected for evidence of pathology but should be considered as works of art in their own right. The book contained a great many pictures, which Prinzhorn had collected from asylums throughout Europe. It is the images, often strange, sometimes disquieting, rather than the text, which remain in the memory. Prinzhorn's book played a major role in the process whereby the creations of psychiatric patients came to be viewed not as worthless examples of mental derangement, but as of artistic interest, a process that John MacGregor (1989), an art historian, has called ‘the discovery of the art of the insane’.

History: Roy Porter

The late 1980s and early 1990s saw an outburst of activity in the history of psychiatry. The great figure in all of this was the late Roy Porter, whose personality and writing galvanised the subject. Unlike many academics whose dry-as-dust prose was replete with terminology seemingly employed to deter non-academics from taking an interest in the subject, Porter was a great writer with an engaging and exuberant style. Formidably well-read, he did not parade his erudition to show off, but rather to involve and inform the reader. Porter particularly championed ‘history from below’, which in the case of psychiatry meant attending to the voice of the patient. Historical records have tended to be written by those in positions of power but they tell only one side of the story. In A Social History of Madness, Porter (1987) focused on the individual sufferer. With great humanity and sensitivity he recounted their tales of despair and recovery. Further, in the Faber Book of Madness, Porter (1991) collected a wide range of patient narratives from history and literature. Even psychiatrists who are not particularly interested in history have a lot to learn from accounts by people with mental illnesses: both Porter's perspective on history and the existential approach to psychotherapy have advocated listening to the voice of the patient.

Biography: Samuel Johnson and James Boswell

As psychiatrists we engage in writing ‘biographies’ of our patients. One of the greatest biographies in the English language is The Life of Johnson by James Boswell (Hill & Powell, 1964). Samuel Johnson, essayist, playwright and compiler of The Dictionary, had a life of hardship. Afflicted by scrofula, subject to tics and involuntary utterances – it is suspected that he had Tourette syndrome – Johnson was also prone to bouts of melancholy and the fear that he would lose his reason. His biographer, Boswell, also suffered from low spirits and, in the pages of The Life, we read their conversations about mental disquiet and how to counter it. Johnson adopted a stoical stance, while Boswell preferred to talk endlessly about his woes. A companion work to the biography is Boswell's collected journals, now published in 13 volumes, which represent one of the most extensive records that any human being has left of themselves. In them he sought to record ‘the history of [his] mind’. As well as suffering low spirits, Boswell was also prone to periods of elation. With great frankness, he recorded his mood swings as well as his bouts of alcoholic and sexual excess. We see him repeatedly vowing to mend his ways, and repeatedly failing. Boswell's all-too-human frailty makes him an endearing character.

Literature: Fyodor Dostoyevsky

Even a cursory acquaintance with Dostoyevsky's work reveals that most, if not all, of his characters seem to be on the verge of mental disintegration. As the narrator of A Raw Youth asks: ‘Is everyone mad?’ In Dostoyevsky's novels, characters are afflicted with brain fever, start to rave, announce their personal philosophy, talk about God and the beauty of life, create scandalous scenes, make disturbing confessions, and become offended by slights. There are numerous portrayals of insanity, but also of gambling, alcoholism, epilepsy, sexual abuse, suicide, personality disorder and pathological gambling. Dostoyevsky took a keen interest in psychology and read contemporary medical writers. His novels such as Crime and Punishment and The Brothers Karamazov contain discussions of psychiatric theories. Dostoyevsky was wary of such theories, believing that they could be used to absolve a person of responsibility.

Dostoyevsky's underlying philosophy has resonances with ideas also popular today. He lived at a time when scientific materialism was in the ascendancy. Many of Dostoyevsky's contemporaries believed that the evolution of society obeyed laws which the natural sciences were uncovering. Not only that, but human beings were held to be subject to these laws. A fully defined science of man was considered to be just within reach. While many of his contemporaries welcomed this new materialist philosophy in the conviction that it would usher in a better world, Dostoyevsky looked upon such developments with horror. He did not believe that human beings could or should be approached in this deterministic fashion, but stressed the essential and irreducible uniqueness of each individual. Materialist philosophy turned people into objects, into automatons. Dostoyevsky's Notes from the Underground put forward a powerful critique of positivistic concepts of humanity. He argued in favour of free will and felt that deterministic accounts of man offered a deeply impoverished and essentially false description of what it is to be human.

Childhood: Jacqueline Wilson

Having children has meant that I have read books I probably would not otherwise have read. I am especially glad to have read The Illustrated Mum by Jacqueline Wilson (1999), the award-winning children's author. Her book tells the story of Marigold, a woman with bipolar disorder. She is also a mother, and the story is told through the eyes of her younger daughter. The book brilliantly conveys the impact on children of having a parent who is mentally ill. It does so in a manner that avoids being patronising to the child characters, or giving a romanticised and unrealistic picture of psychiatric illness. It also manages to be humorous and to end on a note of hope.

Because the story is told in the first person by the daughter, we share the child's growing sense of anxiety at her mother's increasingly wayward behaviour. We share her attempts to control her mother's volatile activity and her embarrassment in social encounters when Marigold is acting outrageously. Jacqueline Wilson astutely and economically shows the dynamics of the family, and the shifting allegiances between the mother and her two daughters. All this is conveyed in simple prose and through crisp but convincing dialogue which reveal the emotions of the protagonists.

Both daughters would prefer their mother to be ‘normal’, and the book looks at the conflict between conforming to society and expressing one's individuality. Is Marigold an exciting rebel, or is she a suitable case for treatment? Wilson avoids romanticising mental illness, but she also recognises that difference makes society more interesting.

The book ends on a positive note with Marigold starting to recover and mending her troubled relationship with her daughters. Psychiatrists often become involved only after someone becomes acutely ill. The Illustrated Mum vividly describes what it is like for an individual and their family in the weeks leading up to admission to hospital. It also reminds psychiatrists that their patients often have complex social networks outside the walls of the consulting room.

Concluding remarks

The books I have read counter the philosophy of the modern-day Gradgrinds. In his riposte to the theories of Mr Gradgrind, Dickens championed the world of the imagination, of which books form such an important part. This exercise in looking back at what you were reading at a particular period in your career has brought back many memories. Books, like music, can transport you to earlier times and evoke how you were thinking and feeling at different stages. They embody not only aspects of personal biography, but also the cultural changes that have taken place in psychiatry.