When I began my training at the Maudsley I asked which textbooks I should read, and was told not to read any, but to read original papers. This has turned out to be good advice, and it is difficult to nominate ten psychiatric books that I have read from cover to cover. However, books written by non-psychiatrists have indeed influenced me a great deal. Karl Jaspers wrote that:
“in the case of every investigator it is a matter of his human stature as to what he understands, and how far his understanding reaches…only through…the study of poets such as Shakespeare and Goethe, and writers such as Dostoevsky and Balzac, do we arrive at the required intuition, and gain a sufficient store of images and symbols and the ability to exercise the understanding imagination that is necessary. These all decide whether I remain tied to banal simplifications and rational schemata, or whether I endeavour to comprehend men in their most complex manifestations” (Reference Jaspers, Hoenig and HamiltonJaspers, 1962, p. 314).
In my introductory lectures I used to bring Jaspers's list up-to-date, and recommend that my students read novels, poetry and pronography: Stendhal and Saul Bellow, Donne and Dylan Thomas, Appollinaire and Henry Miller. The invitation to choose my top ten books caused me to realise that the authors that I recommended did not all make it to the top ten. To my own surprise, now that I have to put into words the significance of each book to my work as psychiatrist, I found that only Stendhal managed to pass muster. The others that I have chosen have helped my better understanding of three main themes in psychopathology: human development — including relations between the old and the young; the relationship between what David Taylor (Reference Taylor1979) has called “ diseases, illnesses and predicaments”; and the nature of human sexuality.
FATHERS AND SONS
Turgenev's Fathers and Sons (Reference Turgenev and Freeborn1991) most perfectly captures inter-generational conflict, without being partial to either side. In addition, the political ferment of the second half of the 19th century is described here better than elsewhere, and the political developments of the 20th century are easier to understand against this background. The book made a major stir when it appeared, as Turgenev had given a sympathetic account of a nihilist, so letting down his own, older generation. The conflict was between the humane, kindly older generation, who accepted things on trust, and the doubting, materialistic younger generation, who required evidence for their beliefs and who rejected romanticism. The book has an incredibly fresh feeling to its account of the relationship between the generations, almost as if it had been written in this century. It made me understand that it is not merely because fashions change and parents get stuck in the values of their youth that there is this tension: youth itself is a time of optimism and questioning the established order:
“Clouds of affection, from our younger eyes Conceal that emptiness that age descries” (Waller, 1939, p. 319).
But the book is also about passion — both that of a father for his son, and the sons for their lovers. Yet also within the younger generation there was a tension between those who were able to love another person and have a satisfying relationship leading (in the mid-19th century, at least) to marriage, and those whose emotional lives were closed off and must eventually die. It was this that gave the book especial value for me, as it appeared a more profound theme.
Turgenev gives a better account of passionate love than any other authors that I have read — a theme that he returns to in First Love and Torrents of Spring. In the former, a young adolescent boy and his father are both in love with the same beautiful young woman: the son with an uncritical adolescent devotion, the saturnine father with a complex, destructive passion that is only subtly described. There is a parallel tension between the two generations, and between two kinds of love. But if I can award Turgenev only one of my ten choices it must be for Fathers and Sons.
SCARLET AND BLACK
When I read Scarlet and Black (Reference Stendhal and ShawStendhal, 1972) as a young man I was barely aware of its fascinating account of conflicts between Jesuits and Jansenists, as well as between monarchists and republicans, in mid-19th century France. The book excited me because of its descriptions of passionate sexual feelings. At first reading I had supposed that the book equally helped me to understand the passions of women in the same way that it described those of men, but later I came to see that this book, as well as the famous accounts of women that were to follow — Madame Bovary, Anna Karenina, Hedda Gabler and Tess of the d'Urbervilles for example — are all male fantasies about women's feelings. This by no means invalidates them — indeed, all psychiatrists have the task of empathic understanding of the motivations and feelings of the other gender — but it does impose limitations. However, even Elizabeth Hardwick, in her book Seduction and Betrayal (Reference Hardwick1974), largely had to rely on male accounts for her description of the position of women. The arrival of the Virago Press half-way through my professional life provided me with insights that had previously been unavailable to me, and I began to improve my understanding of the female viewpoint. In this respect female psychiatrists have a head start: they understand the problems of their own gender, and they are spoiled for choice in understanding the male position.
Stendhal gives a subtle account of male passion: calculating and unemotional before sexual contact; irrational and risk-taking afterwards. His account of the corrosive nature of sexual feelings is memorable, and he reveals their power to make people behave in impulsive ways. His women are perceived by descriptions of their external behaviour, and the predicaments they are in.
The themes of humiliation and entrapment, recently brilliantly described by George Brown and Tirril Harris (Reference Brown, Harris, Brown and HarrisBrown & Harris, 1989), are of course pre-figured in the great novels of the 19th century. The achievement of Brown and Harris has been to take case histories from real life, and then to use nomothetic methods to investigate relationships between depression and social variables. No amount of novel-reading does that!
A FORTUNATE LIFE
J. B. Facey's A Fortunate Life (Reference Facey1981), written in simple unadorned English, describes the life of a man who became a tram driver in Perth, Australia. His father was working in a distant town and died without seeing him, and his mother left her children with grandparents when he was a child of two. His grandparents were poor, and his grandfather died when he was four. It seems likely that his grandmother was unable to mother him very much, as she had to find work as best she could if her grandchildren were not to starve. The rest of his childhood was marked by unparalleled deprivation and cruelty, and his adolescence by great hardship. Yet he considers his life to have been fortunate, because he met and married a woman who nurtured him and shared his adult life with him.
The book is a starting point for those who have an equal curiosity about the processes that result in resilience, as well as vulnerability. It is a graphic description of how a traumatic early life does not always lead to later disturbances. As a bonus, it conveys a feeling of life in rural Australia at the turn of the century. But the value of this book for the psychiatrist is as a reminder that there is no simple relationship between life stress and the later development of affective disorder. It really seems unlikely that this man had secure attachment in his first two years, so we are left with only two possibilities. Either he completely lacked the necessary genes to facilitate the later development of affective disorder, or a rewarding adult experience can redeem a highly abnormal childhood and adolescence. As usual, the former is post hoc speculation, while the latter fits with some clinical observations. Damage is not always irreversible.
This book, by A. E. Ellis (Reference Ellis1958), describes the ordeal of a young English student who developed tuberculosis before the advent of effective medication, and was sent to a Swiss sanatorium shortly after the Second World War. It was important to me because it was the first good description that I had read of the psychological consequences of physical disease, and the frantic activities of those who realise that conventional medicine has failed them and that they are dying. It seemed to me a greater book than The Magic Mountain (Reference Mann and Lowe-PorterMann, 1996); perhaps because it was expressed in an English idiom with which I could identify. The description of the death of the doctors in the sanatorium punctured my fantasies of medical invulnerability, and the image of the student whose body is found high in the mountain clutching a handful of gentians remained with me indelibly. In my first job as a house physician, I was pleased to work for a physician who allowed his severely ill patients to bring faith healers into the hospital.
This book also heightened my awareness of the problems of the dying, and of the complications of medical treatment. It was the first account that I read of hallucinations produced by therapy with morphine. After I qualified as a doctor I learned far more about psychological reactions to physical illness from my patients, and from the experience of being admitted to my own ward with a physical illness during my houseman year. I found, to my own amazement, that my identifications were with my fellow patients rather than with the medical staff, all of whom I knew very well. After four deaths in a single night, I could take it no more, and discharged myself so that I could recover some vestige of composure at home.
TO BE A PILGRIM
This is the second book of Joyce Carey's (Reference Carey1942) trilogy that ends with the better known The Horse's Mouth. It describes the last illness and death of a difficult old man, who suffers from a mild dementing illness accompanied by occasional hallucinations. However, one needs to read between the lines to perceive this, as the old man is the narrator and he appears to be sane, with the abnormalities always in his attendants. He is cared for by his niece, who happens to be a doctor, and has been given the task of looking after him. His account of the behaviour of the younger generation during his illness, intermingled with his memories of his earlier life, make up the bulk of the book. One uneasily understands that he appears abnormal to his niece and her lover, although to him they are behaving in a most peculiar way. Even when he starts making inappropriate sexual advances to strange women in Hyde Park, somehow it is his behaviour that appears fairly reasonable.
The narrator has outlived his more brilliant brother, who was a failed politician and a poet. After the brother's death, a poem is discovered which contains the lines:
“Not time destroys the old, but creeping spite For all they fought for, in a bungled fight… For triumphs lost, which won would still be mean — They die of laughing at their might have been”
These lines have remained with me, reminding me that reputations are evanescent, and that if one cannot be a Humboldt or a Darwin, one's main contribution will be to the gene pool. In contrast, the narrator is a humble pilgrim:
“The quiet little men are the victims of ideals, of passions. They are the lovers, the pilgrims of the world, who carry their burdens from one disappointment to another”.
It was a book that made a deep impression on me, and taught me more about the experience of growing old and gradually behaving in a way that younger people find eccentric than has any textbook or scientific paper.
I learned more about transsexuality from this book (Reference VidalVidal, 1968) than from many sober papers on the subject. This was fortunate, since by chance a transsexual clinic was assigned to me shortly after my arrival in Manchester, giving me the opportunity of taking several hundred histories over the next 24 years. Hitherto my best book on sexuality had been Ford & Beach's Patterns of Sexual Behaviour (Reference Ford and Beach1952), but this had little to say about gender roles.
The book has a cold, sour humour and one reads it with detachment — but it contains a more illuminating view of the peculiar pleasures of the transsexual role. It is clear to the reader, but not to those in her entourage, that Myra — a superfemale — is not what she appears. She besieges her relative, a memorable character called Buck Loner, whose illiterate streams of consciousness to his tape recorder punctuate the book, and who provides comic relief to what would otherwise be an uncomfortable narrative. At the time I read it my supervisor was a Kleinian analyst who attributed especial importance to the teeth, and the act of biting, in psychological development. I therefore particularly liked Dr Montag, “my analyst and dentist”.
The value of the book lies in its understanding of human sexuality and the arbitrary nature of the sex roles. The driven nature of male sexuality is described, as are the sadistic fantasies of the male transsexual towards his penis. The slang term ‘head’ is an example of this — the penis might be thought of having an independent mind of its own, which may lead its owner into taking disastrous actions. Where earnest papers from Baltimore had described transsexuality from the outside, this book does it from within, and one benefits both from Vidal's style and wit.
MISS LONELY HEARTS
Nathaniel West's (Reference West1949) Miss Lonelyhearts is a young male journalist on the New York Post Dispatch who has to write replies in the agony column. His well-meaning efforts are criticised by Shrike, his editor, who gives him such jaded and worldly advice as: “eat what's on the counter; use the girls upstairs, and never give a sucker an even break”. Gradually he finds that his professional detachment from the pain and distress that his readers ask him about cannot be sustained, and he arranges to meet one of his more tormented correspondents. He finds that he is no longer expected to listen and offer advice, but must have physical contact with her. He becomes depressed, and eventually is shot by her husband, whom he has also tried to help.
This was the book that prepared me for the almost limitless suffering and distress that exists in the community, and for the impossibility of offering people access to my personal life as a way of helping them. Shortly after I began my training as a psychiatrist, I fantasised about taking the patients I was caring for home for the weekend; but I remembered Miss Lonelyhearts, and medicated my kindness.
Softened by Shepherd et al's important book Psychiatric Illness in General Practice (Reference Shepherd, Cooper and Brown1966), it was Miss Lonelyhearts that provoked me into drawing together morbidity in the community, in general practice and in specialised mental health care into a single model.
W. H. R. RIVERS
As one ages and it becomes time to ask what one's own life has been about, other lives become more interesting. The young nihilist in Fathers and Sons, in his terminal delirium, says “obviously I'm not needed. And who is needed? The shoemaker's needed, the tailor's needed…”. Rather than face up to such thoughts, one considers the lives of others. The first really absorbing biography I came across was Douglas Botting's Humboldt and the Cosmos (Reference Botting1973), an account of a brilliant polymath who made an abiding contribution to science. But top place must go to W. H. R. Rivers (Reference SlobodinSlobodin, 1978) an account of a hero who was largely unsung until Pat Barker wrote Regeneration (Reference Barker1992); an imaginative reconstruction of the treatment by Rivers of Siegfried Sassoon during the First World War. Rivers was a psychiatrist trained at the Bethlem Royal, who went on to open the first experimental psychology laboratory at Cambridge, and who became progressively more interested in anthropology. While I would rate Arthur Kleinman's Rethinking Psychiatry (Reference Kleinman1991) as a more influential book from the standpoint of what anthropology offers psychiatry, it was Rivers who made pioneering contributions to three important fields. Like me, he was basically an unbelieving psychotherapist. But for the efforts of a brilliantly creative novelist, Rivers's achievements would now largely be forgotten. Neither Botting nor Slobodin offers any speculation about whether the probable homosexuality of both Humboldt and Rivers, during a period of great intolerance, had any relation to their amazing productivity. Perhaps it has none, and in any case their undoubted ability and boundless energy were far more important.
People like to classify their psychotherapists, but Rivers defied easy classification and never descended into jargon to understand his patients' experiences. Most of his anthropological ideas are now thought to be contentious, and some of his better discoveries in experimental psychology are now attributed to Head. Turgenev would have classified him as someone who would die prematurely, which, in the event, was exactly what he did.
Only two choices left: it turns out not to be true that there are no books worth reading for a psychiatrist. Hirsch & Shepherd's Themes and Variations in European Psychiatry (Reference Hirsch and Shepherd1974) gave me much greater insight into the enormous contributions of German and French psychiatrists to psychiatric thought than the defective knowledge of European languages that my schoolmasters had thought adequate. But with so few choices left, the next must be included.
INSTITUTIONALISM AND SCHIZOPHRENIA
Institutionalism and Schizophrenia (Reference Wing and BrownWing & Brown, 1970) was one of the turning points of my professional life, and I recommended it to generations of postgraduates in Manchester. The reason is that it demonstrates beyond peradventure that social conditions shape even severe mental disorders, and shows which aspects of asylum life are particularly noxious for patients.
At first, my reaction had been that all mental hospitals should be like Netherne Hospital (Coulsdon, Surrey), which I visited many times and where I was shown the amazing set of rehabilitation workshops in which so much of the seminal research had been carried out in the 1950s. However, as time passed I began to see that while the Netherne was probably the least harmful possible version of the mental hospital, life in an institution can only be tolerated in very small doses. It denies personal autonomy and deprives people of personal choice. Thus, when the community bandwagon began to roll, I was happy to investigate it, to find whether there was a price to be paid for having rather fewer facilities than those I had seen in the Netherne.
Without any doubt at all, this was the book that first broadcast the message and carried the best empirical investigations. If the psychotherapist and the biological psychiatrist each have their separate Bibles, then this is mine.
But if I had to choose just one book, and that by a psychiatrist, then it surely must be Jaspers's General Psychopathology (Reference Jaspers, Hoenig and Hamilton1962) the book with which I began. Karl Jaspers was a philosopher who served some years in the psychiatric department in Heidelberg, and produced his magnum opus while there. Afterwards he returned to philosophy, and one suspects that psychotherapy was not really his métier.
My first year at the Maudsley was devoted to his great book, and we discussed 50 pages or so at a time with our tutors as the year gradually wore on. And even that did not put me off — an amazing tribute to a book that is somewhat prolix and not that easy to read. Jaspers is contemptuous of nit-picking systems of classification, and makes the vital distinction between understanding things and explaining things. If this distinction is not grasped, psychiatry must be a truly baffling subject — or alternatively, one just learned by rote, spouting the banalities of the DSM system as a substitute for knowledge.
The book has long been out of print, and in the past 15 years or so I have made it my business to discuss some of its more basic ideas with young psychiatrists. Scharfetter's (Reference Scharfetter and Marshall1980) book of the same title attempts to bring the picture up to date, by putting some psychoanalytic and psychological flesh on some of the basic arguments.
Interesting as Scharfetter's book is, I find myself going back to Jaspers for the most satisfactory phenomenological descriptions, as well as for the best discussion of understanding and explaining. The sick individual needs a clinician who is capable of both: understanding the patient as an individual, in order to relate to that particular life and to apprehend the meaning of his or her puzzling symptoms; but also seeing the individual as a member of a larger group — which may be necessary to explain a person's actions and to select the most appropriate treatment. It is the former where wide reading helps. Throughout my life, I have derived more of my understanding from works of fiction than from either tedious compilations of facts, or bogus theoretical speculations.