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Psychiatrists have often turned to literature for theory building, clinical understanding and teaching. Hamlet is a common example, beginning with Freud. Most psychiatrists, like Freud, look at content (character and motivation) when using literature. However, the process (interaction between characters) can also teach us much about the psychiatrist-patient encounter.
Ever since Sigmund Freud persuasively answered the paramount puzzle of 19th-century Shakespearean criticism--Why does Hamlet delay his revenge?--(in short, Hamlet cannot kill his stepfather because his crime comes too close to Hamlet's repressed wish), psychiatrists have often turned to literature for theory building, clinical understanding and teaching.
Curiously, despite other advances, psychoanalysts and psychiatrists have mostly followed Freud's example of focusing on the psychology of individual characters in literature (e.g., what they are like, what makes them what they are, what intentions--often apparently not conscious--seem to motivate their actions and attitudes). Artists/writers are approached as psychologists who teach us something about human nature, as troubled creative human beings who are attempting to work out their conflicts in the writing of their stories, and as artistic seers who offer us a new vision about the meaning of existence. Many excellent works continue to be produced within this paradigm; yet, their impact on our profession and presence in teaching appear limited.
My foray into literature started when I saw a production of Hamlet on the eve of teaching a seminar on psychiatric interviewing and the basics of the doctor-patient relationship to beginning residents. Most of the residents were relative newcomers to U.S. culture and language, and, even more visibly than their native peers, they needed to learn not only the technique and mechanics of interviewing but also how to integrate such technical skills with an awareness of the sociocultural and psychological dimensions of their encounter with their patient. A key difficulty they struggled with was to give priority to developing and sustaining an emotionally responsive communication with the patient, rather than to fall back on the firing away of specific rote questions from their list of things to ask.
Watching Hamlet, I was struck with how this play's action is, like that of no other, propelled by the main characters' systematic efforts to find out--to extract from one another--the hidden truth. They do this because events (see Insert) force them to start doubting themselves and everybody and everything else that matter to them, and they must resolve their doubts. I realized that seeing characters react so strongly to each other's perceived emotions and imputed intentions, rather than the ostensible questions at hand, would vividly impress on my trainees the primacy of attending to their emotional and ethical relationship with the patient.
From Content to Process
Thus the focus of teaching shifted from content (character) onto process. Instead of learning the myriad ways psychiatrists have construed Hamlet, we look at what characters do (e.g., what they say, what they appear to emote and think) in response to each others' speech and imputed feelings and designs. The give-and-take entailed in the collision of their wishes, needs and pasts at specific points in the plot, and their reciprocal (mis)perceptions and (mis)interpretations, is especially relevant to understanding and teaching how to comprehend and manage the emotional valences of the therapist-patient relationship--often thought to be the most complex aspect of being/becoming a psychiatrist (Podrug, 2003). While such interactions are often explicit in, or can be adduced from, novels, short stories or poems, the one form to which they are intrinsic is drama.
That the interactions of dramatic characters may speak more directly to the psychiatrist-patient encounter should not surprise us given their common origins in ritual and religion, and kinship with myth and play. (Recall how Winnicott  conceptualized play and cultural experience as "neither a matter of inner psychic reality nor a matter of external reality," but as "located in the potential space between the individual and the environment.") Furthermore, no postmodern perspective is needed to appreciate that in both, reality is constructed not by one or another character or narrator, but by participants' mutual exchanges.
Since the ghost commanding revenge had questionable credentials, Hamlet must first find out what really happened (Act 2, Scene 2, lines 594-600):
The spirit that I have seen/May be a devil, and the devil hath power/T'assume a pleasing shape, yea, and perhaps/Out of my weakness and my melancholy,/As he is very potent with such spirits,/Abuses me to damn me. I'll have grounds/More relative than this.
He puts on "an antic disposition" partly to make his grief and thoughts harder to read, partly to provoke Claudius--and maybe his mother--into a telling (over)reaction of their own. But primarily he acts so because he has no choice but to give vent to the painful emotions he tries to and yet can no longer contain ("But break, my heart, for I must hold my tongue" [Act 1, Scene 2, line 158]). Claudius has the symmetrical problem of needing to find out what Hamlet's strange behavior purports. In addition to relying on the interrogative cunning of his chief minister Polonius, he commands Hamlet's old friends, Rosencrantz and Guildenstern, to spy on him. Thus, most of Acts 2 and 3 are shaped by the mutually opposed efforts of Hamlet and Claudius to extract information from the opponent while secreting their own.
It is from that part that I show several video segments, demonstrating the corrosive, corrupting effect of these intrusive, deceitful queries on the other characters who find themselves inexorably drawn in and forced to choose sides. The balancing acts with which they apportion their allegiances slip into betrayals even before they realize it. My audience and I easily find our own pertinent experiences. Bennett Simon, M.D., following Aristotle, noted, "The actions portrayed in tragedy are generally deeds (things done) but also include wishes, fears, and, particularly important for dramatic action, the ascribing of meaning to the actions of others." Simon (1984) discovered an analogy between partially correct interpretations offered within the psychodynamic therapy and
how the characters in tragedy inexorably misinterpret what they see and what they hear. They interpret it correctly enough and plausibly enough so that we are faced not with the ridiculous or the absurd, but with the believably incorrect, or partially correct ... These interpretations are actions that move the plot.
The play probably comes closest to mimicking a psychiatric-like interaction (several centuries in advance!) when Polonius, still excited from expounding on Hamlet to the royals, "boards" him to prove his theory. What ensues is a quasi-interview by a proto-psychiatrist of a pretend-patient. In this context it always elicits a knowing recognition by the audience of uncanny parallels between this scene (Act 2, Scene 2, lines 171-219) and when, enamored of some smart idea, we push too hard to elicit confirmatory information from the patient.
Hamlet at once mockingly parries Polonius's pandering, yet officious approach ("Do you know me, my lord?" "Excellent well. You are a fishmonger"), but the latter is too taken with his pet notions to notice. Instead of heeding cryptic warnings of his interviewee, which seem to indicate Hamlet sees him misusing Ophelia, Polonius discounts him ("he is far gone") and veers off into false empathy ("And truly in my youth I suffered much extremity for love, very near this"). To his credit he recognizes Hamlet is saying something ("Though this be madness, yet there is method in't") and even something important: ("How pregnant sometimes his replies are--a happiness that often madness hits on, which reason and sanity could not so prosperously be delivered of").
Then, as Polonius announces he will take his leave, he gets insulted again, this time unmistakably so: "You cannot, sir, take from me anything that I will not more willingly part withal ...." As enacted by Kenneth Branagh in 1996, the next few seconds are exceptional: Recognizing the insult, a glimmer of hurt comes over Polonius's face. Hamlet thereupon adds, "except my life, except my life, except my life." First he utters it spontaneously, as if disarmed by seeing for the first time a wounded old man and not a smug, snooping courtier, and indirectly apologizing to him, by revealing his own distress. He repeats it the second time in earnest, as if surprised himself at what he has just said and taking it in; but the third time he repeats it farcically, to mask his meaning out of concern that he has let on too much to the prying adversary whose facial expression has by this point quickly changed to that of keen calculation. Maybe I am, following Branagh, reading too much into the text; but I feel supported by Harold Bloom's (1998) general remark, "Hamlet keeps overhearing himself speak ... [and] he changes with every self-overhearing." Incidentally, Bloom postulated self-overhearing is the royal road to individuation, out of which our present-day mode of consciousness developed.
I'll mention only one more interaction. What an inoculation against manipulative prying it is to see Hamlet give a recorder to Guildenstern and demand he play a tune; when the latter demurs, "I have no skill with the instrument," witness Hamlet tell him (Act 3, Scene 2, lines 354-361):
Why, look you now, how unworthy a thing you make of me. You would play upon me, you would seem to know my stops, you would pluck out the heart of my mystery ... do you think I am easier to be played on than a pipe?
"This is interesting, but how is a literary exercise more useful than watching an actual tape of a patient?" is a common attitude. The answer has profound implications for psychiatry.
A century ago, psychiatrists saw no need for a theory of the therapeutic relationship. But then, before the profession became sophisticated enough to realize it needed one--and much before general social and scientific advances would be great enough to require it--psychiatry was provided with it by Freud's psychoanalytic theory. However, the presence and influence of the psychodynamic paradigm in psychiatric education has diminished to the point that its power to provide the glue that coheres our clinical skills is questionable. Yet our profession seems mostly unperturbed, except for residency training directors and trainees who find themselves on procrustean beds of psychotherapy competence requirements.
What can fill this gap? After a century of leading medicine in understanding its human side, psychiatry may learn from it. Things have changed from what Arthur Kleinman, M.D., (1988) found almost 20 years ago, when medical schools expected that "what is useful in social science can be acquired intuitively by the 'sensitive' physician," leading to neglect before and during medical school, and commonly rendering the practitioner "functionally illiterate when it comes to [their] basic terms, concepts, and modes of inquiry." At least medical educators now believe that as our understanding of the mechanisms of disease and the associated diagnostic and therapeutic technology become more complex, so, too, do the human interactions and concerns that accompany them (see the October 2003 Academic Medicine: Special Theme: Humanities Education). There will indubitably be some cul-de-sacs in these efforts to enlist humanities, but their presence in medical schools can only stimulate psychiatry. To appreciate the maturity of one such endeavor, hear Charon (2001):
As the physician listens to the patient, he or she follows the narrative thread of the story, imagines the situation of the teller (the biological, familial, cultural, and existential situation), recognizes the multiple and often contradictory meanings of the words used and the events described, and in some way enters into and is moved by the narrative world of the patient. Not unlike acts of reading literature, acts of diagnostic listening enlist the listener's interior resources--memories, associations, curiosities, creativity, interpretive powers, allusions to other stories told by this teller and others--to identify meaning. Only then can physician hear--and then attempt to face, if not to answer fully--the patient's narrative questions: 'What is wrong with me?' 'Why did this happen to me?' 'What will become of me?'
This is narrative medicine, which boldly states, "Effective practice of medicine requires narrative competence, that is, the ability to acknowledge, absorb, interpret and act on the stories and plights of others." It asks physicians to acquire additional tools to "understand the meaning and significance of stories through cognitive, symbolic and affective means" (Charon, 2001), through, for example, close reading of literature and reflective writing. While typical overworked, managed-care-frustrated physicians may not have heard of this, it just might save them if they do. Psychiatrists might argue there's nothing new here for us, but would be mistaken.
Another source of inspiration are some recent advances in sciences of the brain (e.g., neuroscience, linguistics, evolutionary biology, cognitive science). However complex the processing of information is, the human brain/mind still must engage in the construction of meaning. Moreover, often the meaning comes first, and information processing follows. Story and parable precede grammar; language is a complex product of such mental capacities. Metaphor is a foundational, indispensable cognitive tool and only secondarily a figure of speech (Modell, 2003). It will take years, maybe decades, for these insights to gel into mature theories, but it is happening.
The brain possesses multiple memory systems with differing roles in organizing our evolving personal interactions. Its declarative (what we know), procedural (what we do) and emotional learning systems are relatively independent of one another. Transference phenomena, for one, encompass both procedural and declarative memory (Gabbard, 2000) and require the therapist's facility with both. Yet most of our professional learning is in the form of declarative memory. Our procedural memory is, especially early in our careers, a product of our pre- and extra-professional experience. Teaching is more effective the more it activates the building blocks that are already there, the more it makes explicit and available to us for further development something we already "know" but didn't have readily accessible because it was stored elsewhere, habitually activated by different functional neural networks.
This is where literary experiences come in. By partaking in the catharsis of the pity and fear of a great drama, we inevitably put our theatrical experience in relation to our procedural and emotional professional knowledge. To the extent we actively, successfully engage in literary/clinical exercises, we make this potential exchange more powerful and can extend it to declarative knowledge, too. Experiences that connect us with the wonder that is language, and its artful transformation in drama or a novel, will rekindle, recover something we may have already sort of known and will give us building blocks for creating richer, more capable professional selves.
Dr. Podrug, former director of psychiatry at University Hospital of Brooklyn, is leaving the State University of New York-Downstate Medical Center to pursue independent scholarship in New York City, where he is also in private practice.
Bloom H (1998), Shakespeare: The Invention of the Human. New York: Riverhead Books.
Charon R (2001), The patient-physician relationship. Narrative medicine: a model for empathy, reflection, profession, and trust. JAMA 286(15):1897-1902 [see comments].
Gabbard GO (2000), Neurobiologically informed perspective on psychotherapy. Br J Psychiatry 177:117-122.
Kleinman A (1988), Rethinking Psychiatry: From Cultural Category to Personal Experience. New York: Free Press.
Modell AH (2003), Imagination and the Meaningful Brain. Cambridge, Mass.: MIT Press.
Podrug D (2003), Hamlet as process: a novel approach to using literature in teaching psychiatry. Psychiatry 66(3):202-213 [comment].
Simon B (1984), "With cunning delays and ever-mounting excitement": or, what thickens the plot in psychoanalysis and tragedy? In: Psychoanalysis: The Vital Issues, vol. 2, Pollock GH, Gedo JE, eds. New York: International Universities Press, pp387-435.
Winnicott DW (1971), Playing and Reality. London: Tavistock Publications.