“Psychiatry and the Humanities”: An Innovative Course at the University of Montreal

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SECOND THOUGHTS

Has there ever been a more exciting time for a social view of medicine and psychiatry?

Just in the first dozen columns of “Second Thoughts,” I have declared that social psychiatry has come of age, welcomed a new paradigm with the social determinants of health, and kicked off a series of essays on “terms of the social,” that will range from defining what is social to sociopathy and their relevance from social psychology to social psychiatry.

And all that is social is only one color in the palette of the social sciences, the humanities, and the arts. Medicine and psychiatry would be remiss not to take stock of what they mean for our work and to partner with them for a broader and more meaningful engagement with what being human and healthy means today.

This awareness motivated a group of us senior psychiatrists at the University of Montreal to create a seminar on “Psychiatry and the Social Sciences” for both residents and staff in psychiatry. I had just completed my doctorate in philosophy¹ and invited Odette Bernazzani, MD, PhD, a psychiatrist-clinical researcher, and Marcel Hudon, MD, a psychiatrist-psychoanalyst, to join me. We had a successful run for 2 academic years (2013-2015) and transformed the seminar into a more formal postgraduate course in psychiatry called “Psychiatry and the Humanities.”

With a junior colleague, Ouanessa Younsi, MD, an early-career psychiatrist and accomplished poet who was completing a master’s in philosophy, we created a course to address the complexity of contemporary medicine, illustrated with the biomedical problems of psychiatry contextualized by the humanities. The course debuted in 2016. Alexis Thibault, MD, another early-career psychiatrist with a master’s degree in Medical Humanities from King’s College of the University of London joined the course in the second cycle.

Medical Humanities

The medical humanities, which are mainly preoccupied with training medical practitioners, highlight the interdisciplinary perspectives of the social sciences, the humanities, and the arts to understand and to deal with biomedical problems. In our course, we apply the medical humanities specifically to psychiatry although the students may apply this perspective to any problem in the field of biomedicine that is part of their research or practice.^2-6

The field of health humanities has a broader mandate, linking health and social care disciplines to the arts and the humanities.

Medical Humanities’ Core Values

The values that our course privileges are²:

1. Interdisciplinarity– collaborations and syntheses between medicine and the humanities, allowing these mutually enriching disciplines to address the complexity of human predicaments
2. Dignity– each contribution to the course should reflect the whole and the dignity of human beings
3. Beneficence – a key concept in bioethics translated into French through 2 related terms: bienveillance, reflecting a “positive regard,” meaning an affective disposition towards health and well-being, as well as bienfaisance, connoting “positive action”

Our course at the University of Montreal lasts the entire fall semester of 16 weeks from September to December, with 1 mid-semester study break, an introductory seminar and 2 seminars at the end for students’ oral presentations. The course content is divided into 3 thematic blocks of 12 seminars with contributions by invited faculty members in each block²:

• Psychiatry and the humanities (arts and letters)– cinema and theater, poetry and literature, and music
• Psychiatry and philosophy – bio-ethics, naturalistic philosophy, the concept of negation, philosophy of science and philosophy of mind, and anti-psychiatry
• Psychiatry and social science – anthropology, psychology, and theology/spirituality

I would like to offer just 2 illustrations of the value of medical humanities—one from literature, the other from philosophy.

“I Am Myself What I Have Lost”—Can Poetry Heal?

A good poem is a contribution to reality. The world is never the same once a good poem has been added to it. A good poem helps to change the shape of the universe, helps to extend everyone’s knowledge of himself and the world around him.

– Dylan Thomas⁷

In my book about working with families across cultures, A Stranger in the Family, I told 2 dozen family stories, including this one about a Portuguese family I treated in Canada.⁸ Isabel, the “identified patient” of 15, had a mood disorder and chronic suicidal thoughts. Her father Eddy drank and her mother Cristina cried, despondent over her lost youth in Portugal.⁸

In a family session, Eddy was dismissive of Cristina’s nostalgia for Portugal. “I don’t understand this obsession with the old country,” he said bluntly. “There are two flights a week to Portugal. Jump on one and go.” Yet he had refused to visit Portugal in the past and had no desire to do so now. This makes for a marital stalemate. Cristina lives in the past, killing the present; Eddy lives in the present, denying the past. Two bridges, side by side of the same river, each with its own purpose, never meeting.

In the next session with just Cristina and her daughter, I selected something for her to read in her mother tongue. In a striking sonnet, the Portuguese modernist Fernando Pessoa compares himself not to Boabdil, the last Moorish king as he fled Granada, but to his backward glance, the famous image of the “Moor’s last sigh.”⁹ Pessoa takes the reader through a series of identifications through displacements: not the king himself, not even his last sigh, but the regret for what he is losing—and then a final twist (my translation)⁸:

Now I am that imperial longing

For what I saw of myself in the distance

I am myself what I have lost …

This is the magic of poetry: Pessoa identifies with and then undermines the usual reading of history to reach for a deeper experience of loss—his own self. This is emblematic of all of Pessoa’s work which is a profound negation of the particularities of being, even of being himself, to reach for something outside of himself.

Cristina read it with tears streaming down her face. The poem grasped her feelings better than anything she could say. She repeated the last line to me in Portuguese: Eu proprio sou aquilo que perdi—“I am myself what I have lost.” Cristina made a subtle but emotionally daring connection. She realized that in all those years of sorrow and regret, losing family members and childhood friends she never saw again, she lost something much closer, more intimate: a part of herself and her capacity to live in the present and to hope for the future. “I am myself what I have lost” is a redescription of Cristina’s self, a metaphoric transformation that creates intimacy by bringing experience closer to her known self.

Cristina’s daughter—the “identified patient” as family therapy calls the symptom bearer of the family’s predicament—served as an audience for Cristina’s story. Cristina cannot leave her pain behind—she is her pain. By making sense of her pain, Cristina moved from an impossible predicament to a merely painful one. This was a radically different version of her mother’s story than the one Isabel grew up with.⁸ And it had 2 effects on her—she experienced empathy for her mother’s anguish for the first time and was able to leave the role of the sick one of the family behind.

So, can we rush to the conclusion that poetry is healing? Not so fast! Can we use poetry as a tool in therapy? Perhaps, but we must be careful. Using poetry or fiction—any art really, from literature to painting or sculpture and film—requires more, not less of the therapist. All the requirements of the therapeutic encounter hold and the therapist must know how to read the poem, grasp its possibilities, and be open to novel interpretations. As a therapist, I do use poetry and metaphors in therapy, but thoughtfully, as carefully prepared as any interpretation that we offer.

As Welsh poet Dylan Thomas said of Freud’s work¹⁰:

Freud cast light on a little of the darkness he had exposed. Benefitting by the sight of the light and the knowledge of the hidden nakedness, poetry must drag further into the clean nakedness of light even more of the hidden causes than Freud could realize.

Yet, recall the radical possibilities of a symptom or a dream. Just as we do not find the interpretation of a dream in some kind of dictionary of symbols (a common belief), there is no sure interpretation of a poem. The great English poet John Keats identified negative capability as the artist’s capacity to deal with uncertainty and doubt without resorting to facts and reason.¹¹ In psychology, we call it tolerance for ambiguity. British psychoanalyst Wilfrid Bion, MD, took up Keats’ notion and applied it to psychoanalysis.¹¹

This also implies important things about the nature of therapy. Against those that want to make therapy more “objective” through manuals for therapy, reducing it to protocols and techniques, the nature of therapy is drenched in judgment and subjectivity. More precisely, human judgment and intersubjectivity—the co-constructed world of meaning between a therapist and a patient.

Or, as American philosopher Martha Nussbaum put it, writing of the work of British pediatrician-child psychoanalyst Donald W. Winnicott, MD, “the highly particular transactions that constitute love between two imperfect people.”¹²

Philosophy and Psychiatry: “The Return of the Repressed”

If anyone thinks he can exclude philosophy and leave it aside as useless he will be eventually defeated by it in some obscure form or other. ― Karl Jaspers¹³

While poetry and the arts represent the need for negative capability, a kind of radical tolerance for fragmentary and incomplete knowledge, philosophy addresses the need to get to the bottom of things, to understand them more clearly, or at least know the limits of our knowledge. In a sense, negative capability and philosophy come together when we acknowledge the limits of what we know or can know. With the arts, it is a starting point; in philosophy, it may be a conclusion.

What brought me back to philosophy later in my career as a psychiatrist was my disquiet about the crisis of psychiatry. At the heart of our crisis is the lack of a consensual or unified theory of the person, of psychiatry, and of the nature of change. Lots of stimulating and promising avenues and byways but neither a starting point nor a “final common pathway” upon which we can all agree. (See our volume on Psychiatry in Crisis for a fuller account.¹⁴)

Having done research in neuroscience and psychopharmacology, I worried that psychiatry’s gaps—or aporias as well call them in philosophy—cannot be resolved through empirical research. It does not help that we lurch from one enthusiasm to another in what Swiss psychiatrist and medical historian Paul Hoff, MD, calls a series of “single-message mythologies.”¹⁴

Through my philosophical investigations, I perceived 3 theoretical possibilities to address psychiatry’s crisis¹⁵:

I – Dismiss psychiatry’s crisis as a “pseudo-problem.”15 We can give up on creating a foundation for psychiatry, dismissing it as a “pseudo-problem” or “category error” as Austrian-British philosopher Ludwig Wittgenstein did. In this view, there is no real crisis, just a question of talking about things differently. When I trained in behavioral psychology, for example, we did not try to understand the brain or what was going on in the mind, we just redefined everything in behavioral terms. Much of psychiatric work is neo-Kraepelinian, focused on descriptive projects like diagnostics (DSM or ICD).

II – Opt for “weak thought.”15We can conclude that after 200 years of trying, foundational theories of mind are “weak” since they are either pluralistic (multifactorial) or incomplete, lacking specificity and coherence. Italian philosopher Gianni Vattimo’s “weak thought”¹⁵ resembles logician Kurt Gödel’s incompleteness theorems and makes academic psychiatry centrifugal, meaning dispersed and incoherent. Ironically, this describes the state of psychiatry today: strong on pluralism and diversity, weak on conceptual coherence and completeness.

III – Found psychiatry on “ontology.”¹⁵ Ontology is the philosophy or science of being. Most of our theoretical work in psychiatry or philosophy of mind focuses on epistemology—how we know what we know. Those are different sorts of questions than sorting out the nature of mind. We see this philosophical bent towards ontology in various approaches, such as American sociologist Duncan Watts who applied the “small-world problem” to articulate a theory of connectedness in social, biological, and technological networks.¹⁶ Or American biologist Edward O. Wilson who sought “Ariadne’s thread” to discover consilience, connecting patterns across all the sciences, natural, social, and humanistic.¹⁷

Our approach, with my Bulgarian colleague Drozdstoj Stoyanov, MD, PhD, who is a psychiatrist, neuroscientist, and philosopher, seeks just such a foundation for psychiatry. We agree with German psychiatrist-philosopher Karl Jaspers, MD,¹³ who brought phenomenology into psychiatry, that dismissing philosophical questions or accepting weak answers will get us nowhere. Like Freud’s “return of the repressed,” these questions will come back to defeat us in some form or other.

Resources

Overview:

• Wailoo K. Patients are humans too: the emergence of medical humanities. Daedalus. 2022;151(3):194-205. https://doi.org/10.1162/daed_a_01938
• Reiff-Pasarew F. The medical humanities: embracing the interdisciplinary art of medicine and healthcare. In: Tay L, Pawelski JO, eds. The Oxford Handbook of the Positive Humanities. Oxford University Press; 2022:456-468. https://doi.org/10.1093/oxfordhb/9780190064570.013.32

Journals:

• Medical Humanities (BMJ) https://mh.bmj.com/
• Journal of Medical Humanities (Springer) https://link.springer.com/journal/10912

This link from the Canadian Association for Health Humanities (CAHH) offers a survey of educational programs in health humanities throughout the English-speaking world:

• https://www.cahh.ca/educational-programs/

Dr Di Nicola is a child psychiatrist, family psychotherapist, and philosopher in Montreal, Quebec, Canada, where he is professor of psychiatry & addiction medicine at the University of Montreal and President of the World Association of Social Psychiatry (WASP). He has been recognized with numerous national and international awards, honorary professorships, and fellowships, and was recently elected a Fellow of the Canadian Academy of Health Sciences and given the Distinguished Service Award of the American Psychiatric Association. Dr Di Nicola’s work straddles psychiatry and psychotherapy on one side and philosophy and poetry on the other. Dr Di Nicola’s writing includes: A Stranger in the Family: Culture, Families and Therapy (WW Norton, 1997), Letters to a Young Therapist (Atropos Press, 2011, winner of a prize from the Quebec Psychiatric Association), and Psychiatry in Crisis: At the Crossroads of Social Sciences, the Humanities, and Neuroscience (with D. Stoyanov; Springer Nature, 2021); and, in the arts, his “Slow Thought Manifesto” (Aeon Magazine, 2018) and Two Kinds of People: Poems from Mile End (Delere Press, 2023, nominated for The Pushcart Prize).

Acknowledgements

I wish to thank my fellow directors of the “Psychiatry and the Humanities” course in the Faculty of Medicine of the University of Montreal, Ouanessa Younsi, MD and Alexis Thibault, MD, as well as all the contributors and participants of the course since 2016. In 2022, our course inspired the establishment of the APA Caucus on Medical Humanities in Psychiatry, cofounded by myself and Andrei Novac, MD, a psychiatrist, psychoanalyst, and poet at UC-Irvine. Our inaugural speaker at the APA Annual Meeting in New Orleans in 2022 was Dennis Palumbo, MA, MFT, a former Hollywood script writer, now a detective fiction novelist and psychotherapist in Los Angeles.

References

1. Di Nicola V. Two trauma communities: a philosophical archaeology of cultural and clinical trauma theories. In: Capretto PT, Boynton E, eds., Trauma and Transcendence: Limits in Theory and Prospects in Thinking. Fordham University Press; 2018;17-52.
2. Di Nicola V. “Psychiatry and the Humanities”: Postgraduate Course in the Faculty of Medicine, University of Montreal. Blog of the American Philosophical Association. March 23, 2017. Accessed June 11, 2024. https://blog.apaonline.org/2017/03/23/psychiatry-and-the-humanities-postgraduate-course-in-the-faculty-of-medicine-university-of-montreal/
3. Medical humanities. Wikipedia. Accessed June 11, 2024. https://en.wikipedia.org/wiki/Medical_humanities
4. Axelrod C, Brenna CT, Gershon A, et al. The Companion Curriculum: medical students’ perceptions of the integration of humanities within medical education. Can Med Educ J. 2022;14(2):119-124.
5. Peterkin A, Beausoleil N, Kidd M, et al. Medical humanities in Canadian medical schools. In: Routledge Handbook of the Medical Humanities. Routledge; 2019:364-379.
6. Bleakley A, ed. Routledge Handbook of the Medical Humanities. Routledge; 2019.
7. Thomas D. Quite Early One Morning. New Directions; 1954.
8. Di Nicola V. The Figueroa Family: “I Am Myself What I Have Lost.” In: A Stranger in the Family: Culture, Families, and Therapy. W.W. Norton & Co; 1997:296-299.
9. Pessoa F. Passos da Cruz. VI. In: Obras Completas de Fernando Pessoa. Vol 1.Simoes JG, de Montalvor L, eds. Edições Atica; 1942.
10. Ackerman J. The Welsh Background. In: Dylan Thomas. Palgrave Macmillan; 1996.
11. Negative capability. Wikipedia. Accessed June 11, 20204. https://en.wikipedia.org/w/index.php?title=Negative_capability&oldid=1227018396
12. Nussbaum MC. Philosophical Interventions: 1986-2011. Oxford University Press; 2011.
13. Jaspers K. General Psychopathology. Volumes 1 & 2. Hoenig J, Hamilton MW, trans. The Johns Hopkins University Press; 1997.
14. Di Nicola V, Stoyanov DS. Psychiatry in Crisis: At the Crossroads of Social Science, the Humanities, and Neuroscience. Springer Nature; 2021.
15. Stohlman-Vanderveen M, Di Nicola V. “The Crisis of Psychiatry Is a Crisis of Being:An Interview with Vincenzo Di Nicola.” Recently Published Book Spotlight. Blog of the American Philosophical Association. October 8, 2021. Accessed June 11, 2024. https://blog.apaonline.org/2021/10/08/the-crisis-of-psychiatry-is-a-crisis-of-being-an-interview-with-vincenzo-di-nicola/
16. Watts DJ. Six Degrees: The Science of a Connected Age. W.W. Norton & Co; 2002.
17. Wilson EO. Consilience: The Unity of Knowledge. Alfred A. Knopf; 1998.