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.
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
To be, or not to be, that is the question:
Whether 'tis nobler in the mind to suffer
The slings and arrows of outrageous fortune
Or to take arms against a sea of troubles,
And by opposing end them. To die-to sleep-
No more; and by a sleep to say we end
The heartache, and the thousand natural shocks
That flesh is heir to. 'Tis a consummation
Devoutly to be wished.10
This question is a trick, a false dichotomy that is the product of an intellectual compartment syndrome that plagues all our discourse. The answer is that each illuminates the anomaly in its own way. The clinician who can instantiate the neurobiology of serotonin in the context of the existential dilemma of the patient before him has a far better chance of preventing suicide than one who is entrapped in a solitary paradigm.
The third limitation of purely scientific psychiatry is a positivism that like the child's toy of pegs and holes, has found a category to order every random event of existence and a definition to circumscribe all the loose ends of life. Nowhere is the inadequacy of this approach more apparent than in the established psychiatric formulation of grief, which is mute and impotent before the wisdom of Buddha and Jesus.11 How can something as universal and yet individual as the human reaction to death and loss be declared "normal" if it lasts 2 months and then, should it persist, be pathologized into the common denominator of all human misery-major depressive disorder? I dare anyone to read deeply in the religions of the world and find this understanding of bereavement a cognitively satisfying, much less therapeutically viable, means of caring for a wounded person. What is even more terrifying is that as both university and professional education become ever more instrumental and careerist, this may be the only understanding of bereavement and dying that our trainees ever receive.
This last point emphasizes the most compelling justification for psychiatrists reading the humanities: it has the potential to make us superior clinicians, better generalists, and more effective therapists. Let me illustrate with a case example to show concretely how the abstractions of humanistic scholarship can enrich and enhance the physician-patient relationship.
Mr G is a 75-year-old retired missionary with bipolar I disorder who has been my patient for 5 years. When I meet him for our monthly visit, the complexity of his personality and rich life history demand that I simultaneously engage him on several levels. Despite my distrust of classification systems, they have helped me to situate his illness in the category of manic depression, and from this position, to orient his signs and symptoms. The charted contours of that disorder, his age, and the evidence base tell me he is likely at this juncture to suffer more depressions than manias.12 This diagnostic geography has guided me to choose a mood stabilizer as his primary psychopharmacological intervention, although I am cognizant that in elderly patients some studies suggest an antidepressant may carry a more favorable risk/benefit profile than in persons of a younger age.13
I could easily attribute much of his discomfiture in his group home to the lack of a full response to his lamotrigine (Lamictal), which surely is a factor. But it also is the result of a clash of cultures in which a man who was born and raised as Southern gentry has carried the attitudes and biases of that background into a far and foreign socioeconomic world of less privileged people of color with whom he now resides. I only recognize this conflict because during those long hours in the sun I read Walker Percy, William Faulkner, and other chroniclers of the South. In my psychotherapeutic approach to this man's strained relationship with his children, I certainly use cognitive-behavioral and interpersonal tools. However, I do not think I would ever have built any authentic alliance with him if I had not been able to speak to him in the currency of his own scriptural foundations of patriarchy and to honor, although he knows I do not agree with, the theological beliefs of salvation through faith that keep him both captive and intact.
Recently a fellow medical educator told me he thought the "time for books was gone, you can't expect students to read anymore." His solution is the Internet, video games, short films-whatever will enable students to learn and express themselves. Certainly, music, art, theater, and even artistic films have a salient place in the halls of humanistic scholarship and can be powerful avenues in which psychiatrists can explore the human condition. But because words function as the stethoscopes of psychiatry, enabling us to listen to the vulnerabilities and resilience of the human heart, reading literature must continue to be integral to the development of all future psychiatric healers.
To read a letter regarding this article, click here.
References1. 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.