Ten books

Books are an enduring passion, and yet considering which are the Top Ten in relation to my professional life is surprisingly difficult. Is it the most used-looking on my bedroom bookshelf, or in my study or hospital office? Or do I in fact never again look at the books of great influence after the contents have seeped in or conveyed one great idea? In the end, only a sample is possible, and choices repeatedly popular with others have been eliminated.

ON DENMARK HILL

As a start, I feel forced into a bit of psychogeography and psychohistory. I was brought up on Denmark Hill – just a bit up the road from the Maudsley and just as close to the wonderful Carnegie Library, for which my father procured me access to the adult collection and the entire works of Jung. The number 176 bus then, as now, went to Charing Cross Road – bookshop territory – where, aged 11, I bought Freud's (1900) The Interpretation of Dreams. However, my early exposure to the psychoanalysts left little visible trace. The school library was good, too – and offered hours of real education when not doing my formal A-level classes of Latin, Greek and History. I remember we were all asked by a forward-looking headmistress what careers we planned. My answer of ‘psychiatrist’ was greeted with laughter by the class and, from the headmistress, the disapproving remark that ‘I hope there will be no need for such things by the time you grow up’. She was too late – the die was cast.

The initial influence – The Psychology of Insanity by Bernard Hart, first published in 1912 – was from my parents’ book-shelves and I have now re-located the copy and re-looked at it after all this time. It is a wonderful little book, clearly written, and very much ‘it does what it says on the label’. We are given an outline of the scientific method: (a) assemble facts; (b) organise them; and (c) think of an underlying principle and test it. For the last, Hart suggests that for the scientific study of mental disorder there are two main principles – the ‘physiological concept’ and the ‘psychological concept’ – which are both useful, corresponding as they do to brain and mind, but they should not be mixed:

‘The psychological conception is based on the view that mental processes can be directly studied without any reference to the accompanying changes which are presumed to take place in the brain’ (Hart, 1912: p. 9).

He then describes the main phenomena of mental disorder, which I remember finding intriguing, and suggests that the states of dementia and mental deficiency, which display a ‘quantitative defect’ are best addressed using the ‘physiological concept’. Of course, by this time, the gross anatomical defects of the brain were well-known, using the available technology, but this line of study had come to something of a dead end for the time being. Other phenomena, such as hallucinations, delusions, excitement, withdrawal and compulsive behaviour, Hart groups together as being better understood by the psychological concept. His explanatory theory is based mainly on the work of Janet and Freud, especially deploying the ideas of dissociation, repression and conflict, which he applies to a number of characteristic symptoms such as hand-washing or conviction of being poisoned – with which we are familiar – and to phenomena such as automatic writing, which are of less current interest. He viewed conflict as ‘a fundamental factor in the causation of insanity’ (p. ), but did not accept Freud's idea that sex is the sole primary instinct concerned. He concluded that

‘It is possible that insanity, or a part of insanity, will prove to be less dependent on defects of the individual than on the conditions in which he has to live’ (p. ).

The debate still goes on.

Insofar as I was aware of the Maudsley influence it was from Eysenck – probably both because of his popular writing and because he also lived further along the road. So I became aware of this aspect of psychiatric debate, especially how Little Hans may or may not have developed his horse phobia, and whether or not psychoanalytic treatment was effective. However, I'll omit these also from the Top Ten, fairly or unfairly.

CHILDREN

My mother, medically qualified, did local baby and school clinics, to which I sometimes accompanied her. The excitement of the time was the clarification of the developmental stages of the child, being taught and disseminated by Mary Sheridan, who was based at Guy's Hospital. Later, I was a fan of Illingworth's The Development of the Infant and Young Child: Normal and Abnormal, first published in 1960 and also still in use – presumably in an updated version. My babies had their reflexes exhaustively tested, but survived. I was very impressed by what we would now call the qualitative research of John and Elizabeth Newson, who wrote about systematic interviews with parents in Nottingham in the 1950s and 1960s. The first in the series was Patterns of Infant Care in the Urban Community (1963). In it one learned what parents actually did rather than what they should or should not do – for instance, as bottle-feeding and even dummy use were nearly always instituted before the age of 1, the ‘weaning trauma’ did not really occur, even though advice booklets were simultaneously being sold on the subject. Smacking and allowing children to sleep in the parents’ bed were also clearly normal, whether or not desirable. Class differences were very evident, but not as extreme as might have been supposed. For example, middle-class parents were more likely than social class IV and V parents to put their infants to bed early and without the help of a bottle or dummy, but did not leave them to cry longer. If they did use a dummy, they were secretive about it. Much of the observation now takes on a period flavour, such as the description of ‘high tea’, and some differences, such as the age of mothers by class, are presumably now even greater.

I studied psychology while my own children were small, taking a break from medicine. The development of language was a point of hot debate, with Skinner's behaviourist approach on one side and Chomsky's innate grammar on the other. That was the time (the late 1960s) when great efforts were put into teaching chimpanzees to communicate in order to test the issues. Of the psychology books of the time I think I'll choose Albert Bandura's (1969) Principles of Behaviour Modification – whose social-learning theory was both balanced and based on humans as well as animals. For instance, a little girl with a fear of dogs became less apprehensive after watching a film showing a fearless peer coping with threatening dogs – an example of successful modelling.

Moving on to child psychiatry specifically, the great Isle of Wight study Education, Health and Behaviour by Rutter, Tizard and Whitmore (1970) was a major influence and was stolen from my book-shelves, a sign of high desirability. This served as an introduction to epidemiology and a reminder that what one sees in the clinic is not necessarily a representative sample of what is ‘out there’. They found that among 10-year-olds 6–7% had a ‘clinical-level’ psychiatric disorder, of which about one-third were neurotic emotional disorders and two-thirds mixed or conduct disorders. Of course, working in Brixton, as I did, it was not surprising to discover from the later studies that rates of disorder in the inner city were much higher.

I also liked Temperament and Behaviour Disorders in Children (1968) by Alexander Thomas, Stella Chess and Herbert G. Birch, which derived from a New York longitudinal study. It is very helpful, when hearing the history of a difficult child, to try to tease out what their temperament was like – in terms, say, of adaptability and regularity. The cluster of characteristics that typified the difficult child were irregularity, slow adaptability, withdrawal and negative mood of high intensity. However, it was evident that effective handling by the parent could overcome these difficulties and, contrarily, that even a placid child could become disturbed by a succession of adverse events. Discussion with parents about the temperament of their child is a non-blaming approach and individual differences between the way children behave, even from birth, is easily recognised.

WOMEN AND MENTAL HEALTH

Although (or perhaps because) there were no women consultant psychiatrists on the staff at the Maudsley in the early 1970s, it was possible to have a few feminist thoughts, and I now have full bookshelves on the topic relating to mental health. I have chosen two books which are more indirect but served as ‘consciousness raisers’. In Marina Warner's book Monuments and Maidens: The Allegory of the Female Form (1985) we are invited to look around us at how women, especially in statues, are portrayed not as individuals (unlike men) but as fixed embodiments of virtue such as justice, mercy, temperance and so forth or of national aspirations such as Marianne or Boadicea. The Statue of Liberty combines the two. Why was this so fashionable in the 19th century, when women had very little liberty and were never regarded as being formally able to dispense justice, although they were regarded as ‘naturally’ more virtuous and beautiful than men? There is a link with the gender of the nouns concerned, which in Latin, for instance, are female. The early Greeks also personalised madness in female form – for example Ate (Delusion) was a daughter of Zeus and Mania was the mother of Lares. However, I notice that Cibber's Raving and Melancholy Madness statues above the gates of the old Bethlem hospital are muscular men, and are not entitled ‘Mania’ and ‘Melancholia’. Athene was a popular figure, especially in the Victorian era, but Warner speculates that as the rights of women increased, the popularity of the warlike maiden decreased. You may recall that Athene, in support of the patriarchal mode of generation, sprang in full armour from her father Zeus’ forehead, and in return for winning the patronage of the city of Athens, votes for women were lost. Warner quotes an observation on Freud by ‘H.D.’:

“‘This is my favourite” Freud said. He held the object towards me.... It was a little bronze statue, helmeted, clothed to the foot in carved robe with the upper incised chiton or peplum. One hand was extended as if holding a staff or rod. “She is perfect,” he said. “Only she has lost her spear.” I did not say anything.’ (Warner, 1985: p. 104)

The Madwoman in the Attic: The Woman Writer and the Nineteenth Century Literary Imagination, by Sandra Gilbert and Susan Gubar and published in 1979, reflected on the position of women writers. The ‘madwoman’ referred to is Bertha, Mr Rochester's first wife, immured upstairs, who died in the fire that crippled the hero but made him available for Jane Eyre. She is taken as the type for the 19th-century woman authors who had to hide behind masculine names or take to their sickbeds in order to write. One might include Florence Nightingale here. Creativity was alleged, for instance by Gerard Manley Hopkins, to be a special quality of men – but ‘If the pen is a metaphorical penis, with what organ can women generate texts?’ (Gilbert & Gubar, 1979: p. 7). Being ‘lady-like’ required acquiescence, silence and not engaging in productive work; expressing independent views appeared monstrous and mad, but their repression could lead to other ‘hysterical’ signs. The equating of ‘femaleness’, ‘hysteria’ and ‘madness’ was a theme for later authors such as Phyllis Chesler and Elaine Showalter. In my view, this is still a necessary part of the dialectic, rather than a permanently revealed truth, and unfortunately adoption by the over-politically correct lobby is off-putting and can lead to a backlash.

LESSONS FROM OTHER WORLDS

While perhaps Kafka's novels cast some light on my experiences with National Health Service management, even more commonly I can derive comfort from the thoughts of Lewis Carroll (1872), especially as expressed in Through the Looking-Glass and What Alice Found There. The world through the mirror looks familiar and yet...Alice tries to read a book that contains the strange poem ‘Jabberwocky’. She notes ‘Somehow it fills my head with ideas – only I don't know exactly what they are!’ She identifies an objective (the top of the hill) and so takes a path which apparently leads straight there, but actually only goes round in circles. You run faster and faster – but remain exactly where you were. Your first management meeting (in which you are the only doctor) comprises a strange group of a Gentleman in White Paper, a Goat, a Beetle and an Insect. They all think in chorus and blame you for not having a ticket. This leads directly on to wandering in the Wood Where Things Have No Names and you are in a full-blown identity crisis. The White Queen is a very subtle manager: ‘The rule is, jam tomorrow, jam yesterday – but never jam today’ – I think she could be talking about the child and adolescent mental health services information system. She also advises screaming loudly before rather than after the pin actually pricks. Doctors know this one – it is called ‘shroud-waving’ – and we can proudly relabel it ‘risk identification’. Humpty Dumpty is clearly a Minister of Health doing a ‘cascade briefing’ and he asserts ‘When I use a word it means just what I choose it to mean – neither more nor less’. This helps explain a curious experience I had recently on attending a ‘workshop’ on ‘leadership’ to find the only definition offered was ‘doing what you are told’. Of course, any manager worth their salt, including medical ones, soon takes to this methodology as it is very helpful in meeting performance targets.

I recommend Samuel Butler's (1872) Erewhon (an anagram of ‘nowhere’) to those involved with contemplating the new Mental Health Bill. Butler's fictional land was found by his hero in a country resembling New Zealand and much of its culture appears topsy-turvy to the traveller, including many of the names. For instance ill-health is regarded as the grave fault of the individual and, rather than incurring sympathy, is subject to the full rigours of legal process with trial and punishment. This to some extent helps to prevent spread, but as a result people do what they can to hide any illness. Antisocial and criminal behaviour, however, are seen as a matter for commiseration. The traveller's host Mr Nosnibor has recently been engaged in major embezzlement and has had to send for a ‘straightener’. The latter takes a moral family history and leaves a prescription of a fine to the State, a diet of bread and water, and 12 floggings. The alternative would be admission to hospital. Although he may privately note signs of physical indisposition it would be regarded by both parties as indelicate to consider openly. His victims are regarded as being blameworthy for incurring misfortune. The straightener's training is of interest: he must practise each vice in turn in order to overcome them personally, and some of those training to become specialists actually ‘died as martyrs to the drink, or gluttony’. Erewhon has been described as a satire that does not go far enough – perhaps even for its day. However, the role of a psychiatrist has a lot of similarities to that of the ‘straightener’, even though flogging is not available as a prescription option.

CONCLUSION

I hear that to be a psychiatrist one requires ‘tolerance of ambiguity’ (of government instructions as well as patients’ states of mind), so Carroll and Butler have helped with that, and perhaps related is the enjoyment of the clash and debate of ideas – nature v. nurture, madness or badness, the evils of patriarchy. In contrast, it is also quite soothing that there can be consistent methodologies – of epidemiological study, for instance – and that the child's development usually still unfolds in a predictable way, even though the correct deployment of a tiny tea-set must be culture-bound. Although ‘one can never step into the same river twice’, looking again at my books has proved a fascinating experience and a reminder of the many as yet unread riches – Emily Dickinson perhaps, or more Virginia Woolf, or even Janet.