Should psychiatrists read fiction?

Should psychiatrists read fiction? Recent trends suggest that the answer is yes. There has been the publication of the journal, Medical Humanities; the rise of narrative-based medicine, with its insistence that reading literature can help doctors better understand the ‘narratives’ of their patients; the creation of an Arts and Medicine faculty at Durham University; and the proposal to set up an Arts and Psychiatry Special Interest group in the Royal College of Psychiatrists. Such developments spring from the belief that it is beneficial for doctors to be exposed to the arts; that somehow it makes them better clinicians. In contrast, others maintain that doctors should focus on medical science and that the arts are an irrelevance and a distraction. Here I examine the argument, especially as it applies to psychiatry.

In an influential lecture, C. P. Snow (1959), the physicist and writer, contended that society was divided into ‘two cultures’, the scientific and the artistic. He maintained that this split was destructive and warned that ‘Closing the gap between our cultures is a necessity in the most abstract intellectual sense, as well as the most practical’. More recently, David Lodge dramatised this conflict in his novel, Thinks, in which a cognitive scientist and a novelist argue over whether science or imaginative literature offers the best way of unlocking the mysteries of the mind. By the end of the novel, it is clear that both perspectives are valuable, and that to be restricted to only one is limiting.

In medicine, the humanities were formerly considered to be an important part of medical education. In the 18th century it was held that the doctor should be a man (it was invariably a man) of culture, and should be well versed in the humanities. This would confer wisdom on his clinical practice. Rousseau (1986) has maintained that the value that clinicians attach to the humanities has waned in modern times and that doctors increasingly see themselves as scientists and biotechnicians. However, Neve (1993) has argued that, despite the prevailing technological culture, many doctors have maintained an interest in the arts.

ARGUMENTS IN FAVOUR OF READING LITERATURE

1. (a) T. S. Eliot (1948) observed that ‘we read many books, because we cannot know enough people’. We can explore the lives and inner worlds of a wide variety of individuals by imaginatively engaging with them in novels.

2. (b) A purely bioscientific model offers a limited view of human beings. Doctors need a deeper understanding of their patients that takes account of emotional and existential aspects. Literature offers such a perspective (Downie, 1994). The recent changes in medical education outlined in Tomorrow's Doctors (General Medical Council, 1993) recommend that students are exposed to the humanities as well as the biosciences. There is some evidence that medical students who have a background in the humanities and science, rather than science alone, go on to perform better in important areas of practice (Rolfe et al, 1995). In relation to psychiatry, Cawley (1993) has argued that medical science does not provide a complete picture of human beings and advocates the complementary study of the humanities.

3. (c) Reading literature helps to develop empathy. One can see the world from another person's viewpoint. This is especially applicable to literary accounts of illness and suffering. For example, Iain Crichton Smith's novel, In the Middle of the Wood, depicts his own psychotic breakdown; Evelyn Waugh's The Ordeal of Gilbert Pinfold describes drug-induced hallucinosis; Bernard MacLaverty's Grace Notes deals with postnatal depression; Ian McEwan's Enduring Love is concerned with de Clérambault's syndrome; and practically all of Dostoyevsky's novels feature characters with mental disturbances.

4. (d) Some commentators have made the distinction between ‘aesthetic’ and ‘ethical’ approaches to the medical study of literature (McLellan & Jones, 1996). The former approach leads to the development of complex interpretive skills. Narrative-based medicine is particularly concerned with this area (Greenhalgh & Hurwitz, 1998). The techniques involved in understanding and analysing a novel can be applied to the understanding of patient discourse. One can become more sensitive to the nuances and subtexts of a patient's communication.

   Several literary devices have clinical resonances. For example, the concept of the ‘unreliable narrator’ is especially applicable to the understanding of a patient's history. This refers to the situation where the character telling the story might give, either by design or unwittingly, a misleading or distorted account of events. For example, in The Diary of a Nobody by George and Weedon Grossmith, the narrator, Charles Pooter, attempts to present himself as a man of dignity, but his account of himself and his encounters with others reveals that he is a figure of fun. A similar phenomenon can occur clinically when a patient's story suggests to the psychiatrist a different picture than was intended.

5. (e) The ‘ethical’ approach teaches ethical reflection and how to approach moral quandaries and decision-making. For example, William Carlos Williams' short story ‘The Use of Force’ raises the question as to whether it is ever justifiable to medically intervene against a patient's will. Brian McCabe's story ‘Full Moon’ examines the feelings engendered in a therapist when he is mistaken for a patient. Gene Brewer's novel K-Pax explores the dilemma facing the psychiatrist in deciding whether a patient is describing real events or delusions.

6. (f) Theoreticians have also discussed the difference between an ‘additive’ and an ‘integrated’ approach to the subject (Evans & Greaves, 1999). The former sees the arts as adding on to an existing biomedical knowledge base, whereas the latter attempts to refocus the whole of medicine to an understanding of what it is to be fully human. Richard Smith (1999) has observed, ‘The additive view is that medicine can be “softened” by exposing its practitioners to the humanities; the integrated view is more ambitious, aiming to shape the nature, goals and knowledge base itself’.

ARGUMENTS AGAINST READING LITERATURE

1. (a) The arts are simply irrelevant to the practice of medicine. One should concentrate on acquiring clinical skills and learning the basic facts. Anything else is a distraction. Wassersug (1987), has declared: ‘real medical progress has not been made by humanitarians but by doctors equipped with microscopes, scalpels, dyes, catheters, rays, test tubes, and culture plates’. Similarly, psychiatry should be seen as a branch of the natural sciences. Human beings are essentially no different from other constituents of the physical world, and all we need to know about them will be revealed by the neurosciences. The arts, therefore, have nothing to offer.

2. (b) Imaginative writers are attempting to do crudely and unsystematically what modern psychologists do in a sophisticated and rigorous manner. According to Downie & Charlton (1992) it is enough to state this proposition to recognise the absurdity of it, but there are those who agree with it. Certainly the cognitive scientist in Lodge's Thinks makes this claim, dismissing imaginative literature as ‘folk psychology’.

3. (c) Harold Bloom (2000), a distinguished literary critic, asserts that reading does not make us better, more-caring people. It is essentially a selfish activity. It can expand an individual's intellectual horizons but it does not engender altruism or increased sensitivity to others. In his book Newton's Sleep, the physician Raymond Tallis (1995) goes to great lengths to argue that an acquaintance with the arts does not make individuals more caring; in fact, it might make them less so. He quotes Tolstoy's tale of an aristocratic woman weeping in the theatre at the imaginary tragedy enacted on the stage, while outside a real tragedy is taking place as her faithful coachman freezes to death. Here art serves to deceive the woman that she is sensitive, when she is actually inconsiderate.

   More generally, George Steiner (1971) has repeatedly questioned the assumption that exposure to the arts leads to more-civilised behaviour, citing the example of Nazi Germany where high culture coexisted alongside concentration camps. As McManus (1995) has pointed out, the semantic kinship between the terms humane and the humanities suggests a causal relationship, but there may, in fact, be none.

4. (d) Reading is not a substitute for experience. The great French novelist, Marcel Proust, who immersed himself in literature, recognised this. As he wrote:

   • • ‘To make [reading] into a discipline is to give too large a role to what is only an incitement. Reading is on the threshold of the spiritual life; it can introduce us to it: it does not constitute it’ (de Botton, 1997).

   An exclusively bookish life can lead to an estrangement from the rest of humanity. In an amusing historical survey entitled ‘Reading: A Health Warning’, Roy Porter (1999) charted the many voices, including physicians and psychiatrists, who have advised that excessive reading can bring about mental and physical decline.

5. (e) Many doctors simply do not read books, whether through lack of inclination, aptitude or time.

6. (f) From the artistic point of view, several commentators object to the whole notion of approaching a work of literature with the pre-determined aim of extracting something that may be clinically ‘useful’ (Bamforth, 2001). Imaginative writing should produce varied and unpredictable responses in its readers. It is inappropriate to trawl through literature for references to doctors and disease, as this implies that the reader is not open to the aesthetic potential of the work. Oscar Wilde famously declared, ‘All art is quite useless’, and resisted any suggestion that it was educational or morally uplifting.

DISCUSSION

Psychiatrists who read fiction evidently see value in it; those who do not might be unmoved by arguments in its favour. Those who argue against the benefits of reading are surely right to question the assumption that exposure to literature automatically brings about greater sensitivity and empathy in the reader. However, although even the most fervent enthusiast for the arts would not claim that all doctors should read books, there is a growing acknowledgement of the value of the humanities in medical education, and perhaps this is part of a wider trend that recognises the limitations of a purely biotechnological approach to patient care. In a critique of evidence-based medicine, Williams & Garner (2002) conclude that it ‘must be underpinned by the need to understand and respond empathically to the illness in accord with the patient's experiential perspective’, and they go on to underline the importance of engaging with the humanities as part of professional development.

If one does accept that it is of benefit to psychiatrists to read, should there be a canon of improving texts? Several canons have indeed been proposed (Greenhalgh & Hurwitz, 1998). However, there is a danger that they are approached as didactic texts. They can then become a chore to read. Furthermore, if the aim is to develop interpretive skills, it surely does not matter what books are read; they do not have to be about medicine, psychiatry or mental illness.

However, one of the claims in favour of reading is the notion that books about illness and suffering help doctors better understand the inner experience of their patients and, as a consequence, develop greater empathy. It is here that a suggested reading list may be of value, and I have already mentioned a number of novels in this genre. It is important that such reading lists are offered in the spirit of suggestion rather than as compulsory texts. It will then be left to the individual psychiatrist to decide whether they are worth exploring. A medical culture that takes a positive approach to the humanities will greatly encourage such explorations.