It is my great honor and pleasure as a psychiatric educator to teach many excellent medical students and residents. These young and not-so-young men and women are by and large diligent, highly professional, and caring. Most trainees have a good grasp of diagnostic criteria and a solid working knowledge of psychopharmacology; many also have a variety of psychotherapeutic skills. My only real criticism and concern is that they often do not have the benefit of a liberal education. To put it more baldly: they don't read.
This is not so much their own fault, but that of the school systems in which they were educated. Even those residents whose college major was not in the physical or biological sciences were compelled by their aspirations to become physicians to memorize and regurgitate facts, to master the game of multiple-choice test taking, to write for communication and read for practical utility. This criticism applies equally to their attending physicians—and here we also see the effect of the modeling of mentoring—most of whom also never developed a lifetime habit of reading broadly and widely for personal growth and intellectual stimulation.
The lesson we too frequently pass on to our students, mostly through the formal but certainly through the hidden curriculum,1 is that scholarly success in psychiatry is to speak the language of multiple regression statistics, to decipher the increasingly revelatory patterns of positron emission tomography scans, and to continually educate oneself in the second messengers and beyond of psychopharmacology. Much has recently been made (and rightly so) of psychodynamic psychotherapists as a rapidly endangered species,2 but almost no attention has been given to the near extinction of the humanistic scholar-clinician. When the likes of our esteemed editor at Psychiatric Times, Ronald Pies, MD, are gone, who will bridge the worlds of Aristotle and bipolar disorder?3
To read, or not to read?
I expect that many people reading this column would say, "Well, someone like Dr Pies or the Pulitzer Prize winning Robert Coles4 are wonderful writers to read on a leisurely Sunday afternoon when, and only when, I have trudged through the stack of neuroscience articles that have been waiting for me." I would counter that actually, there should be 2 collections of "to be read" articles and texts—one of contemporary, peer-reviewed literature and the other of the great books of the ages. In the more eloquent words of Sidney Block in one of the few recent papers on psychiatry and the humanities: "I contend that the means by which we can accomplish the goal of relating empathically and compassionately to our patients and their families is by regarding the humanities and sciences as (a) of equal importance and (b) as complementary."4
Delving into that repository of biomedical knowledge, PubMed, with the probes of "psychiatry and the humanities," identifies only a small number of articles, mostly written in the 1970s, from the psychoanalytic tradition, and many in European languages, underscoring the greater salience of the Western cultural heritage outside America.5 These articles have made important contributions to thinking outside the biological box, but their intentionality is more focused than I am advocating here. To read Shakespeare or Euripides through a Freudian lens is fascinating and valuable, but it is still nourishing an essentially psychoanalytic vision and not the open and unstructured foray into ideas that most liberates the mind.
If a draconian chair of psychiatry were to demand that I take a seat in one or the other of Tanya Luhrmann's famous camps,6 my interests and abilities would compel me to sit on the biological side. Yet, if an earnest house officer asked me which of my multifarious and diverse academic experiences had most prepared me to practice psychiatry, I would be forced to say it was no formal training in medicine or psychiatry, no passing of board exams, and no disciplined study of the core textbooks and seminal articles on neuropsychiatry. Paradoxically, it was dropping out of high school at age 16—before I failed out—and spending a year lying in a hammock under the South Texas sun reading 10 hours a day. I read everything that anyone of note said was worth the time—history, psychology, literature, religion, philosophy—with no purpose except to understand what far greater minds than mine had thought was the meaning of life. So now, decades later, when I come to the distressed individual at the core of any clinical encounter, I call on not simply my own meager and damaged internal resources but the insights of Doystoevsky on suffering, of George Elliot on empathy, of Kier-kegaard on subjectivity, and of so many other gifted thinkers. The spiritual companionship of the great minds of history can safeguard a psychiatrist from several of the most insidious and pervasive intellectual faux pas of modern clinical practice.
The first and most common error is ahistoricism, an affliction to which the young and bright are especially prone. I begin all my lectures on posttraumatic stress disorder (PTSD) with this quotation:
What profit have I had from all that I have gone through and all the dangers of these wars. So I have watched out many a sleepless night before many a bloody day of battle, fighting against people who were only fighting to keep their women safe.7
I then ask the residents to name the source. Usually only if they have read the work of Jonathan Shay8 do they correctly attribute the citation to Homer. The point of this little exercise is to reinforce that PTSD was neither discovered nor manifested when it appeared in DSM-III in 1980, but is an ancient, perhaps inevitable, consequence of mortals in combat.
Hippocrates and Galen, not to mention Burton and Kraepelin, described almost all the primary psychiatric diagnoses, albeit in very different frameworks and terms.
Acquaintance with these learned men of old endows the 21st century psychiatrist with the neglected virtue of humility as he or she acknowledges that these giants grasped the fundamental mental illnesses without neuroimaging or epidemiology.
The second astigmatism the refraction of the humanities can correct is reductionism. Which more fully and truly illuminates the ambivalence and angst of suicidality: the quote below from Hamlet or the empirical evidence that a low serotonin level is related to violent suicide?9
1. Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med. 1994;69:861-871.
2. Plakun EM. Finding psychodynamic psychiatry's lost generation. J Am Acad Psychoanal Dyn Psychiatry. 2006;34:135-150.
3. Pies R. The historical roots of the "bipolar spectrum": did Aristotle anticipate Kraepelin's broad concept of manic-depression? J Affect Disord. 2007;100: 7-11.
4. Coles R. The Mind's Fate: A Psychiatrist Looks at His Profession. Boston: Little, Brown & Company; 1975.
5. Caldwell RC. Selected bibliography on psychoanalysis and classical studies. Arethusa. 1974;7:115-134.
6. Luhrmann TM. Of 2 Minds: The Growing Disorder in American Psychiatry. New York: Knopf; 2000.
7. Homer. The Iliad of Homer. In: Richards IA, ed. New York: Norton; 1950:102.
8. Shay J. Achilles in Vietnam: Combat Trauma and the Undoing of Character. New York: Scribner; 1994.
9. Nordstrom P, Asberg M. Suicide risk and serotonin. Int Clin Psychopharmacol. 1992;6:12-21.
10. Shakespeare W. The Tragedy of Hamlet, Prince of Denmark. In: Wright LB, LaMar VA, eds. Folger Library General Reader's Shakespeare. New York: Washington Square Press; 1958: Act 3, scene 1, lines 65-71.
11. Hanh TN. Living Buddha, Living Christ. New York: Riverhead Books; 1995.
12. Kupka RW, Nolen WA, Altshuler LL, et al. The Stanley Foundation Bipolar Network. 2. Preliminary summary of demographics, course of illness and response to novel treatments. Br J Psychiatry Suppl. 2001;41: S177-S183.
13. Altshuler L, Suppes T, Black D, et al. Impact of antidepressant discontinuation after acute bipolar depression remission on rates of depressive relapse at 1-year follow-up. Am J Psychiatry. 2003;160:1252-1262.