When I received the invitation to contribute to the ‘Ten Books’ series, I resonated more with the phrase ‘sources of inspiration’ than with the guideline to select books that have had ‘a significant impact on my professional life’. It so happens that this rather unusual challenge is the second to have come my way in recent times. We initiated a similar project for medical students at the University of Melbourne in which faculty members select a text that ‘matters’ to them, ostensibly in a professional way, although the request is left intentionally vague. Then, as now, I surmised that the books that have influenced us professionally are not dissimilar to those that occupy a central place in our lives generally.
The importance of childhood
My choice for the medical students was Childhood and Society by Erik Erikson (Reference Erikson1963). It remains at the top of my list, for several reasons. First published in 1950, the book has gone through innumerable printings and can readily be regarded as a classic. As a clinician, I have always needed a framework that facilitates the understanding of how people at different stages of their lives deal with the ‘slings and arrows of outrageous fortune’ and how their internal psychological experiences interdigitate with the human environment in which they function; Childhood and Society is just such a framework.
Erikson was the first to capture the point that, throughout life, we have to negotiate a series of ‘crises’ (I prefer to call them ‘challenges’). Through intriguing anthropological illustrations (commendably based on actual observation), he highlights how our lives are shaped by the social forces that impinge upon us. Thus, the native American Sioux of South Dakota differ from the Yuroks living along the Pacific coast in that the children of each community are reared quite differently because of their respective life circumstances. Erikson's individual life studies, following in the tradition of Freud and psychoanalysis generally, are as masterful in revealing the inextricable link between childhood development and broader social forces. Notwithstanding the inherent limitations of psychobiography, his accounts of Hitler's and Gorky's childhoods are also captivating.
Erikson is best known for his eight ‘ages of man’, a prominent feature of Childhood and Society. Adding an extra age to the seven described by Shakespeare in As You Like It (see below), Erikson's observations about how we necessarily traverse these stages of life are intuitively appealing. Towards the end of his life Erikson, together with his wife Joan, added a ninth age: gerotranscendence (Reference Erikson and EriksonErikson & Erikson, 1982).
A decade and a half after the first publication of Childhood and Society, Erikson brought together six lectures he had delivered on the ethical dimension of psychoanalytic thinking. Insight and Responsibility (Reference EriksonErikson, 1964) may lie in the shadow of Childhood and Society but warrants our attention, since here Erikson grapples with moral questions relevant to developmental psychology and the psychotherapist's pursuit. His treatment of the Golden Rule is especially engaging, as is his notion that the potential strengths inherent in each stage of the life cycle are akin to ‘basic virtues’.
Psychiatry's three-legged stool
Reference to the virtues brings me conveniently to The Ethics of Aristotle (Reference ThomsonAristotle, 1955 reprint). I have had occasion to propose the humble stool as a symbol of our profession (Reference BlochBloch, 1997). I see the psychiatrist perched stably on the stool by dint of its three identically sized legs which represent the science, the art and the ethics of the clinical enterprise. With regard to the last, a key question arises: where are we likely to find anchorage among the many competing moral theories available to us? I suggest we need look no further than the 4th century bc and Aristotle's Nichomachean Ethics (named after his son Nichomachus), a treatise encompassing his mature thinking on what constitutes the virtuous life. At the heart of his argument is the postulate that the happy man will spend most of his time in virtuous conduct and contemplation. Much will depend on the vagaries of fortune but even in the face of tragedy, the virtuous person's ‘nobility’ will prevail (I think of the biblical Job and his travails in this regard). A cardinal aspect of Aristotle's contribution is his dissection of the nature of virtue and the related concept of character. We are offered an impeccably coherent account of the intellectual virtues, among them practical wisdom, understanding and prudence, and the moral virtues, which include generosity, self-control, courage, patience and amiability. Pertinent to us as clinicians is how we may acquire them. Aristotle is explicit about this - we learn through doing; the role of ‘habit’ is paramount. Further themes covering moderation, justice, moral choice, friendship and the role of education in cultivating the virtues are handled with typical Aristotelian rigour.
Since my own interest in the ‘ethical leg’ began in the wake of the misuse of our profession for political purposes in the former Soviet Union (Reference Bloch and ReddawayBloch & Reddaway, 1977), I have explored other moral frameworks in addition to that revolving around virtue and character; they are principally Kantianism, consequentialism, casuistry and the framework of four principles propounded by Beauchamp & Childress (Reference Beauchamp and Childress2001). Although the last is probably the most pragmatic, incorporating as it does the fundamental concepts of autonomy, beneficence, non-maleficence and justice, I always return to the Nichomachean Ethics as my principal guide. I believe psychiatry could well benefit by adhering to its tenets, both to prevent abuse and to enhance the ethical foundations of clinical practice and research.
When I offered a three-legged stool as a symbol for psychiatry, I alluded to the ‘art’ of clinical practice. This leg, the most elusive of the trio, resists ready definition. The authority I have valued most to tease out the relative roles of science and art is Karl Jaspers. I only wish that my teachers had pointed him out during my training. If I were to prescribe an ‘essential’ text for all contemporary trainees, General Psychopathology (Reference Jaspers, Hoenig and HamiltonJaspers, 1997 reprint) would either head the list or be close to the top. Fortunately, the book has been republished by Johns Hopkins University Press in the original translation by Hoenig and Hamilton and is readily available (the 1962 Manchester University Press edition is virtually impossible to come by). That Jaspers completed his magnum opus after only a few years of experience in the field of clinical psychiatry (in 1913, at the age of 30) attests to his sheer brilliance. Thereafter, the several revisions he made throughout his life - as a philosopher - reveal his refreshing open-mindedness and flexibility.
Jaspers is most commonly associated with phenomenology, which he defines as an ‘empirical method of enquiry maintained solely by the fact of patients’ communications’. The form and content of mental phenomena, he posits, need to be clearly distinguished from one another, so allowing their objective and systematic study. Furthermore, we are challenged by the need to examine how these phenomena interrelate. Jaspers introduces us to two possible forms of enquiry - explaining (erklären) and understanding (verstehen). The former, restricted to objective, causal links, is similar to the process we apply in the natural sciences; the latter deals with associations gleaned from empathising with the internal experience of the other. Thus, for example, we strive to understand a person's growing suspiciousness after the experience of being cheated, or the emergence of anger in a person in the wake of unjustified criticism. Here, we enter the realm of interpretation, which by its nature cannot attain the level of scientific proof, but instead only reaches a degree of probability. Moreover, the sum of understandable connections offers us insight into a particular personality and character.
Interpretation: science or art?
How does this all tie up with the art of psychiatry? Jaspers himself answers this by quoting Eugen Bleuler: ‘Interpretation is a science only in principle; in its application it is always an art’, highlighting the type of creative understanding (or intuition) we should try to emulate, namely that exhibited by the great artists and philosophers - Shakespeare, Goethe, Dostoevsky, Aristotle, Pascal and Nietzsche. Jaspers is aware of the impediments in making meaningful connections and, in this context, brings his critical (but not destructive) stance to Freudian thinking. As he puts it: ‘Psychoanalysis has always shut its eye to these limitations and has wanted to understand everything’. If I had read these arguments at an early stage in my career, I could have been spared the continuing anguish I felt in wrestling with the question of whether psychoanalysis is a science or not. With Jaspers’ critique in mind, I can apply the insights of psychoanalysis to patients much in the same way that I can resort to the insights on human nature generated by the genius of Shakespeare, Tolstoy or Plato (see below for further reflections on the role of psychodynamic thinking). I can be further reassured by Jaspers’ contention that explaining and understanding stand alongside each other as complementary and synergistic. Indeed, he summarises his position in this way: ‘Natural science is... the ground work of psychopathology and an essential element in it, but the humanities are equally so and, with this, psychopathology does not become in any way less scientific but scientific in a different way’.
The experience of ageing
All three authors whose books I have referred to thus far cover, in one way or another, the experience of ageing. Erikson's account of ego integrity versus despair, his ‘eighth age’ and the later addition of a final age - gerotranscendence - are especially valuable. But why turn to ageing? In psychiatric practice, as in every sphere of contemporary life, elderly people make up a growing proportion of the population in Western societies. Although I have not worked in psychogeriatrics, I have often encountered elderly people in two other domains: consultation–liaison psychiatry, in which many of the patients we see are in their latter years; and in psychotherapy, where the dramatis personae may include ageing parents (and, on occasion, grandparents) who need to be understood by the patient, and where elderly people themselves have come to be recognised as potential beneficiaries of psychological treatment. I recall participating in Peter Hildebrand's pioneering workshops on psychotherapy of the older patient in the 1980s at the Tavistock Clinic.
Shakespeare's King Lear is arguably the most penetrating account of the perils of ageing. I have observed the remarkable insight that Shakespeare brings to audiences again and again, whether in stage or film versions. My most recent encounter with this play was perhaps the most riveting of all: a ‘one-actor’ in Beijing opera style, with Taiwan's foremost stage performer Wu Hsing-Kuo assuming no fewer than ten roles! In As You Like It, Jaques describes old age in his celebrated speech on the seven ages of man:
‘Last scene of all, That ends this strange, eventful history, Is second childishness and mere oblivion, Sans teeth, sans eyes, sans taste, sans everything.’
(Act II, scene vii)
In the tragedy of Lear we witness such an ending with the disintegration of a once powerful monarch, blinded by vanity and self-pity. His lack of wisdom and inability to see reality when it stares him in the face lead to his downfall. Upon his further humiliation, sparked off by the ingratitude of his two elder daughters, Goneril and Regan, Lear swears his revenge in most harrowing fashion:
‘You see me here, you gods, a poor old man, As full of grief as age; wretched in both!
If it be you that stir these daughters’ hearts Against their father, fool me not so much To bear it tamely; touch me with noble anger, And let not women's weapons, water drops, Stain my man's cheeks! No, you unnatural hags, I will have such revenges on you both That all the world shall - I will do such things - What they are yet I know not - but they shall be The terrors of the earth. You think I'll weep; No, I'll not weep:
I have full cause of weeping, but this heart Shall break into a hundred thousand flaws Or ere I'll weep. O Fool! I shall go mad.’
(Act II, scene iv)
It comes as no surprise that the Lear theme has been pursued by other writers. Two are noteworthy and slip into my Lear ‘sublist’ - Jane Smiley's A Thousand Acres and Philip Roth's Sabbath's Theater (Reference SmileySmiley, 1992; Reference RothRoth, 1995). In Roth's epic novel, Mickey Sabbath, like Lear, is the ultimately tragic, lonely figure who, damning himself as a ghoul, even fails in his suicide bid when assailed by merciless forces.
Lear's inexorable fate is played out in the context of a fractured family. Clinically, the vulnerability of elderly people is not uncommonly bound up with transgenerational forces. These have been impressively explicated by such theorists as Boszormenyi-Nagy (Reference Boszormenyi-Nagy, Gurman and Kniskern1991), a prominent leader in the family therapy movement. Despite such a contribution, our profession is marked by its inadequate attention to family assessment and treatment. Together with three colleagues I was spurred on to improve the situation by conceptualising a framework within which to consider the role of the family in clinical work. The resultant volume, published a decade ago, was favourably reviewed but gained only a small readership (Reference Bloch, Hafner and HarariBloch et al, 1994). I should have been more ‘savvy’. As a branch of medicine, psychiatry has long regarded the person presenting with symptoms as the target of treatment. The international disease classifications ICD–10 and DSM–IV do little to improve the status quo. The Axis V diagnoses in the DSM, for instance, some of which specify relational problems as a primary focus, are little more than a tag, a mere ‘shopping list’ without any elaboration.
Alas, many clinicians take a scanty family history. The family tree, for example, comprises a handful of factual items such as parents’ and siblings’ ages and occupations and a note about the prevalence or otherwise of mental illness among the identified patient's relatives. How can we highlight the relevance of the family for contemporary psychiatry and for a new generation of trainees? I would urge the latter to read such scientific literature as the work on family psychoeducation in schizophrenia, the material on caregivers of a relative with dementia, and ‘responsible’ contributions to family therapy. I do concede that the wildness of some theorists who shape their ideas unrestrainedly with unrepresentative samples and a minimal concern for assessing the outcome of their initiatives makes a sceptic even more suspicious.
The power of the dramatist
Another valuable source of knowledge on the family is the ‘genuine literature’, namely the work of great literary artists. I am especially struck by the contribution of the dramatist. Greek tragedy, for example, is pre-eminent. How could one find a better exploration of revenge in a family than Euripides’ Medea, in which the protagonist goes to the extreme of killing her own sons. Many other illustrations come to mind: the depiction by Shakespeare of Hamlet's paralysing indecision when faced with the conflict of how to avenge his father's murder; Anton Chekhov's portrayal of intricate family dynamics in plays such as The Three Sisters and The Cherry Orchard; and Eugene O’Neill's poignant (virtually autobiographical) dramatisation of a doomed family in Long Day's Journey into Night.
I know I am cheating in my ‘book count’ by naming several plays. But were I to be pinned down to choose one play which provokes me to appreciate how decisive family forces can be in affecting its members, Arthur Miller's Death of a Salesman would win hands down (Reference MillerMiller, 1953). Willy Loman deceives not only his family but, much more significantly, also himself until suicide becomes his only recourse. Amazingly, the play was written in a mere 6 weeks (although it had been gestating in Miller for a decade). The playwright disclosed his goal for Salesman thus: ‘to set forth what happens when a man does not have a grip on the forces of life.’ Loman is indubitably one of the most profound characters of drama ever created.
Suicide is the principal mode of death that we as clinicians in psychiatry are called upon to prevent. However, with the evolution of the new sub-specialty of psychooncology in recent years, we have assumed a leadership role in helping patients undergoing palliative care to face their death. This is a tough assignment. After all, as Freud (Reference Freud and Strachey1915) mentioned nearly a century ago, our own death is unimaginable to us. To empathise with people who are terminally ill is correspondingly an immense challenge. Systematic research over the past couple of decades is accumulating steadily with the findings of both descriptive and interventive studies serving as valuable resources for the clinician. However, there is nothing to rival Leo Tolstoy's celebrated 1886 novella The Death of Ivan Ilyich in shedding light on what the experience of dying is truly like (Reference Tolstoy and EdmondsTolstoy, 1995 reprint). Read in conjunction with his anguished religious essays, this story enables us to appreciate the ghastliness of isolation in death, and the destructive effects of an alienated family on all its members. By way of contrast, Tolstoy highlights the value of unconditional support, as offered by Ilyich's manservant Gerasim, who ‘knows’ instinctively how death fits into the mosaic of life and what is needed from those who accompany the patient on their final journey.
So overwhelmed was I by Tolstoy's imagination that I commissioned leading Australian playwright Jack Hibberd to adapt the story for the stage. The effect of the dramatised version on audiences ranging from young medical students to oncologists and psychiatrists has invariably been profound.
Suffering and civilisation
Oncologists witness exquisite suffering in their day-to-day practice (one in four adults will suffer from cancer). Cancer often brutalises and dehumanises its victims. Mental illness also bears that potential. Notwithstanding the exciting scientific advances in the psychological and biological therapies, especially in the past two decades, we still encounter enormous suffering. Consider the anguish of a patient (and her family) with melancholia who fails to respond to any treatment; a family struggling to come to terms with an adolescent's suicide; the demoralisation of a young person facing yet another bout of schizophrenia; the grief of an elderly woman who has ‘lost’ her husband to Alzheimer's disease; a family's struggle in the face of a child's severe autism; a young woman's reluctance to acknowledge her self-starvation which prevents her from receiving professional help. The list is endless.
My response in the face of personal inadequacy to relieve suffering is to face the inescapable fact of its existence and search for a source of understanding - or at least consolation. I have often turned to the Book of Job (as well as to Ecclesiastes) to deal with my sense of bewilderment. For me Job is the book of the Bible. We have no idea of its authorship or even whether Job actually lived or not. We can none the less best construe him as Every-man, as a figure who suffers without good cause and whose friends try to console him. Job is resolute. He insists that he does not deserve to have lost his ten children and to have borne all the other trials that have befallen him. The friends’ efforts to console are to no avail (indeed, they are later reprimanded by God for their paltry initiatives). Job insists on his day in court (the ecclesiastical one). He demands justice from God. The ultimate encounter is awesome but brings relief. God instructs Job in his ways, reminding him of the difference between them: God is all-powerful, the creator of heaven and earth, whereas Job is a mere mortal. The latter ultimately realises that he has tried to ‘grasp the infinite’ but must accept his status, ‘comforted that I am dust’. I do not advocate that all psychiatrists should turn to Job and accept its underlying philosophy, but I do claim that the issues it throws up can help us to cope with the ostensibly meaningless suffering that is an intrinsic part of the fabric of life. I heartily recommend Stephen Mitchell's translation (Reference MitchellMitchell, 1992); it is, as Oliver Sacks remarks, ‘an extraordinary poetic achievement’.
The prevalence of suffering in our area of work is matched by its omnipresence in the world at large. In times past, many a definition of mental health incorporated the concept of ‘adjustment to society’. This is a manifestly absurd notion when confronted by the sheer inhumanity that typifies so many nations. Passage into the new millennium has brought no relief from the chronicle of woe. When we pause to reflect that over a hundred million innocent lives were lost as a result of warfare in the 20th century, that the horror of terrorism continues unabated, that hosts of children are abused physically, emotionally or sexually, that the prevalence of torture shows no evidence of declining despite its shocking cruelty, that millions of refugees live aimless lives awaiting - probably futilely in most cases - the chance to improve their lot, and that a third of the world's population experience hunger, one wonders how decent, sensitive human beings do not descend into an abyss of despair. Of course, much can be and is being done to deal with these tragedies. I can testify to this personally. I had the privilege recently of participating in an inspiring programme in East Timor, whose citizens had never been offered mental health care throughout the Portuguese and Indonesian colonial eras. An esteemed colleague Derek Silove (an expert in refugee mental health) has demonstrated how, even with limited resources, splendidly useful projects can be implemented.
How does this foray into the miseries of our times relate to books? For years, I conjectured that barbarism, cruelty and humanity could be understood, at least in part, psychologically. Such understanding, I believed, could lead to ameliorative strategies. Indeed, I remain an optimist for this very reason, living in the hope that humans may rise above their often inglorious condition. One work that helps in this regard is Freud's profound essay, Civilisation and its Discontents (Reference Freud and StracheyFreud, 1930), published when Freud was in his eighth decade and had been appalled by the devastation on the battlefields of the First World War. The essay is, I maintain, one of the most incisive contributions to the study of man's inhumanity to his fellows (ironically, Freud was not to know at the time of its writing that several members of his own family would die a wretched death in the Nazi concentration camps within a dozen years). My claim for the essay is bold; I do not make it lightly. I approach the work on the premise advocated by one of Freud's most able biographers, the social historian Peter Gay (Reference Gay1995). He postulates that the ‘study of human institutions must begin with the study of human nature’. In his introduction to Civilisation, Gay proclaims that ‘this little book is a fertile and original meditation on the irreparable conflict between the individual and his institutional surroundings. Hence it may claim a place on the short list of essential writings on political theory’.
This is not the place to provide a précis or commentary of Freud's thesis. Suffice to say, he avers that the demands of basic instinct, particularly that of aggression (derived from a transformation of the death instinct), are inextricably bound up with the constraints applied by a civilised society. Through superego functioning mediated by the experience of guilt, social institutions accomplish a civilised sense. The defence mechanism of sublimation is central in converting destructive drives into higher mental activities. The snag with the process is its fragility and how civilisation hangs by a thread.
It was, as I mentioned earlier, Freud's acute sensitivity to the ravages of the First World War that prompted him to look into the abyss of death. Interestingly, this occurred in a Jewish context, in a presentation to Bnai Brith (a society to which he belonged throughout his life), at which Freud expressed his deep sense of shock and disillusionment about the mass killing that violated his ‘Europe of culture’. Indeed, we can discern from his other writings that he had harboured a hope, perhaps naïvely, that the ‘scientific and artistic standards of civilisations’ would save modern Europeans from the primitive brutalities lurking in the depths of human nature. It is not surprising, therefore, that 6 months into the First World War his hopes were shattered by witnessing the scale of wanton destruction. Although the essay that emanated from the Bnai Brith talk, Thoughts for the Times on War and Death (Reference Freud and StracheyFreud, 1915), and his subsequent explorations into sociology are characterised by inconsistency, particularly in the loose interchange of terms such as ‘conclusion’, ‘assumption’, ‘fact’, ‘belief’ and ‘hypothesis’, he did concede that his speculations were vague. None the less, he still hoped that inherent uncertainties, his ‘artificial structure of hypotheses’, could be substantially reduced by science.
Nearly three-quarters of a century later, Freud's essay on civilisation remains hypothesis-bound. The challenge for those of us who value his insights is to mould his thesis into testable forms. Rather than level the criticism that ‘psychoanalysis explains all’, a more creative option is to apply his myriad concepts as a resource for further reflection and exploration. I would argue trenchantly that our task will always, necessarily, have to be informed by ‘psychodynamic thinking’. The ‘repertoire’ is strikingly rich, perhaps unrivalled in shedding light on so many facets of human nature. I would regard it as a matter of professional competence for every practitioner to be able to think psychodynamically, whether in advising an oncologist in consultation psychiatry about a patient's use of denial and rationalisation; attempting to clarify a depressed person's ambivalence about accepting a psychiatric diagnosis and medication; trying to sort out a split in a ward team's response to a patient's self-mutilation; and identifying and understanding the underlying resentment a parent might feel towards a substance-misusing child.
This point of view paves the way for my last two choices, both in the sphere of the psychotherapies. I was attracted from my first days in training to the challenge of understanding the inner life of patients. Three decades later, after hundreds of clinical encounters, I conclude that we are extraordinarily privileged to be given the opportunity to assist millions of people to gain a fresh, and often liberating, view of themselves. All the psychotherapies, in one measure or another, provide us with the wherewithal to pursue this goal. When I took up a research fellowship in the early 1970s at Stanford University to study the psychotherapies, Irvin Yalom, my guide at the time (who became a most valued and generous mentor), pointed me towards the work of Jerome Frank. We had embarked on a series of studies that required us to grasp fully the potency of factors common to a range of psychological treatments. Frank had researched these ‘non-specific factors’ (I myself have come to refer to them as ‘common basic factors’, so emphasising their centrality). His initial interest in the 1950s was in group therapy. By the end of that decade, he had attracted a team of research-minded colleagues who, in a most impressively cohesive fashion, worked for three decades on a series of what can only be referred to as foundational themes in psychotherapy. Their investigations covered topics such as patients’ expectations and their relationship to outcome, the placebo effect, the drop-out phenomenon, treatment as countering demoralisation, preparing patients for their psychotherapy experience, the place of emotional arousal, the effects of short-term psychotherapy and the comparison of different approaches to depression.
Apart from many research reports, Frank distilled his observations and intuitions in his now classic book Persuasion and Healing, first published in 1961. How satisfying it must have been for him to produce a third edition, 30 years later, with his daughter Julia as co-author (Reference Frank and FrankFrank & Frank, 1991). In conjunction with four of his research colleagues, another effort at distillation emerged in the form of a book entitled Effective Ingredients of Successful Psychotherapy (Reference Frank, Hoehn-Saric and ImberFrank et al, 1978). I had the privilege of meeting Jerry around this time and was immediately won over by his clarity of thinking combined with a genuine commitment to improve the lot of his patients. As a first-time editor, I was chuffed when he agreed to contribute a chapter entitled What is Psychotherapy? to the 1979 first edition of An Introduction to the Psychotherapies. Twenty-five years later, this chapter still fulfils the purpose of orienting the novice to the psychotherapeutic world (Reference BlochBloch, 1996).
My tenth book is always at hand to guide my psychotherapeutic efforts and for teaching. Irvin Yalom's Existential Psychotherapy (Reference YalomYalom, 1980) remains as fresh as it was on the day I first perused it in 1980. When I arrived at Stanford University, Dr Yalom invited me to participate in a course run by a Norwegian philosopher, Dagfin Follesdal, and himself on existentialism and psychotherapy. Although I had read authors such as Camus and Kafka during my medical student days, I had never given much thought to incorporating the tenets of existentialist philosophy into my clinical work. Professor Follesdal gave us insights into the thinking of such key figures as Husserl, Heidegger, Nietzsche, Sartre and Habermas, while Yalom created bridges between the philosophical and therapeutic worlds. What an intellectual feast it was! I still use the notes I took then in my own teaching. Existential Psychotherapy was obviously in its early gestation during that course.
What I value about Yalom's book is the skilful way in which the author weaves together four sources of knowledge: astute clinical observation, the contributions of great literary artists (Tolstoy, Joyce, Camus and Conrad among them), the philosophical tradition and the results of empirical research. I try to emulate this heuristic model in my teaching and writing, and I eagerly recommend it to my colleagues. Even if one does not practise existential psychotherapy per se, the book offers ways of looking into what Yalom calls man's four ultimate concerns: the inevitability of our own death, the freedom we have to choose and to act, our fundamental existential isolation in that we enter and depart this world on our own, and the need for us to create our own sense of meaning and purpose. This existential orientation has proved salient for many of my patients in diverse ways. An obvious illustration is the situation I alluded to earlier of a person with a terminal illness facing imminent death. Another example is the patient with a disabling, recurrent psychosis who has to come to terms with the loss of a past sense of himself and search for fresh ways of self-fulfilment. The most common application of the ‘four concerns’ in my own work and that of many supervisees is in the context of the ‘mid-life crisis’, in which a person struggles to find a deeper purpose in life and a corresponding sense of authenticity.
Reflecting on the process of selecting and commenting on ten books that have mattered to me, I must confess to a fleeting thought at the outset as to whether the task was not a little gimmicky. Having completed it, I can say unswervingly that it has proved a wonderful opportunity to reminisce about my psychiatric odyssey - identifying landmarks and notable events. Not everyone will have the privilege of contributing to this column, but I would none the less recommend the selection exercise to all colleagues. I am sure that you will find it an illuminating way to discuss what you value in your professional life. Perhaps the selection of ten books could be a rite of passage for all graduating psychiatric trainees, who could share their inspirations with their peers. My fantasy is one of unbridled excitement among the graduates as they exchange their lists, and the joint experience of an energising force as they embark on their careers.