The experiencing self

In psychiatry, the major disorders (schizophrenia and mood disorders) do not merely impair the function of the brain but exhibit themselves in behavioural disturbances that are experienced by patients and others as emanating directly from the totality of their person. These conditions are not like neurological disorders that affect motor systems or sensory systems and leave the experiencing self intact to judge and describe. The stance of the experiencing self is involved directly and intimately in psychiatric disorders. Therefore interpretative skills, an understanding of the complexity of language, and a capacity to discern the dynamics of narration and to respond meaningfully and cogently are prerequisites, at least for mastery, in psychiatry. This is to distinguish between competence, which is merely the barest minimum of clinical standards, and mastery, which is the effortless demonstration of skill at a sufficiently high level that it attracts admiration. There is thus a more compelling need in psychiatry than in other medical specialties for an appreciation of the areas of human knowledge that deal and trade in the personal, for example literature, history, linguistics and philosophy.

The role of literature

In this article I will explore what a curriculum of medical humanities in postgraduate psychiatry training exemplified by literature might look like, what texts may be relevant and whether a canon is necessary or desirable. This debate about the role and place of the medical humanities in undergraduate medicine already has recognisable parameters. It is clear in what ways literature may be useful (Box 1). It is also clear how the humanities may be deployed: either as instrumental agents where, for example, literature is a source of case histories depicting varying aspects of psychiatric disorders, or as a subject of importance in its own right which is therefore able to further the general education of medical students (Reference MacnaughtonMacnaughton 2000). Reference EvansEvans (2003) cogently draws this distinction between training and education. Experience has also shown that voluntary courses in the humanities are more successful than compulsory courses (Reference MacnaughtonMacnaughton 2000). This means that literature is more suited in undergraduate curricula to special study modules that students select because of their own interest in the subject.

Medical humanities in perspective

The Association for Medical Humanities argues that the medical humanities concern ‘the nature, importance and role of human experience on the part of patients and practitioners alike, including their experience of the patient–practitioner relationship’ (Reference Arnott, Bolton and EvansArnott 2001). Furthermore, it argues for the medical humanities to be integral to and constitutive of our understanding of medicine. However, I doubt whether this can be the case. Anatomy and pathology are without doubt constitutive of medicine – one could not be a doctor without knowledge of these subjects. No matter how important medical humanities may be deemed to be, knowledge of the literary classics can hardly be regarded as central to the concern of doctors. It seems therefore clear that the medical humanities, or literature in particular, are at present optional extras that may add to the quality and calibre of doctoring but are not prerequisites for competent practice.

The aims of the medical humanities as set out by the Association for Medical Humanities include among other things:

1. • to emphasise education as distinct from training

2. • to contribute to the development of students' and practitioners' abilities to listen, interpret and communicate, and to encourage their sensitive appreciation of the ethical dimensions of practice

3. • to stimulate and encourage a fitting and enduring sense of wonder at embodied human nature

4. • to develop students' and practitioners' skills in thinking critically and reflectively about their experience and knowledge (Reference Arnott, Bolton and EvansArnott 2001).

These are all worthy aims, but need they be encouraged only through a humanities education? It seems to me that it is possible to achieve some of these aims without recourse to the humanities. Certainly a proper understanding of physiology or pathology without regard to its expression in a novel can stimulate a sense of wonder and awe at the machinery of the body and its capacities. Clinical work properly taught and conducted can be the sole basis of an appreciation of the complexity of language such that the student comes fully to grasp the intricacies of listening to, interpreting and communicating with fellow human beings. I am not arguing against the importance or indeed the value of the humanities, I am merely attempting to establish what it is that is distinctive about the humanities. What is that extra something that would be truly missing were the humanities not to be incorporated into medicine? It seems to me that the humanities introduce into medicine the importance of the subjective, the relevance of differing perspectives and the contribution of values to decision-making. I also accept that the humanities may facilitate or act as vehicles for teaching the areas identified by the Association for Medical Humanities, while not being the sole purveyors of those areas of study.

RCPsych curriculum

The Royal College of Psychiatrists' curriculum for psychiatric specialty training does not explicitly include reference to the medical humanities (www.rcpsych.ac.uk/training/curriculum.aspx). There are competencies that have implications for the medical humanities, for example the need to demonstrate an empathic approach, to be sensitive to the effects of chronic illness on patients and their carers, and to demonstrate an understanding of how changes in society influence ethics and good practice. The curriculum does not indicate how these competencies ought to be acquired but methods derived from the humanities may be appropriate. Thus, it may be that local MRCPsych courses will choose to use autobiographical narratives, fiction, diaries, letters or film to teach these subjective and humane aspects of psychiatric practice. In undergraduate medicine, the medical humanities appear to be more readily accepted by students when the students select them because of special and personal interest. However, there is no system of trainee-selected modules of learning within the current MRCPsych courses. Trainees, of course, are involved in choosing their clinical placements but the courses are not structured in such a way as to encourage choice in determining the nature of the material that trainees learn. It seems, therefore, that in postgraduate training, as opposed to undergraduate education, the humanities may need to become an integral part of teaching. It is possible to envisage a 3-hour slot within a module on major psychiatric disorders, for instance, that deals with the experience of mental illness for patients and their relatives using illustrative accounts from literature or film. The learning objectives would be:

1. • to demonstrate an understanding of the scope, focus, concepts, theories and controversies in the medical humanities

2. • to demonstrate an understanding of patients' and carers' subjective and lived experience of major psychiatric disorders.

Thus, this slot would attempt to do two things: to briefly introduce the humanities as a method of inquiry and to refine the empathic skills of the trainees.

This approach raises questions about texts that may be suitable, which indirectly leads to questions about the nature of canonical works, how these might be chosen and what the dangers are in affirming any list of books.

Canonical works

The word ‘canon’ derives from the Greek kanon (akin to the English ‘cane’), referring to a reed. Reeds were used for measuring and in Latin and later Greek the word ‘canon’ meant a rule or a standard. The establishment of a canon of scriptures within Christianity, for example, was meant to define a standard or a rule for the religion. In literature, it has come to mean the texts that establish the standard by which literature in any given language is judged. In English, canonical texts would include the writings of Chaucer, Milton, Shakespeare, Dickens and Wordsworth. Traditionally, religious authority would have been vested in the Church hierarchy and the choice of texts would, by definition, reflect how the hierarchy wanted the Church to be seen. In institutions of learning, the canon would reflect also the interest of the institutional hierarchy. Thus, it is easy to see that a canon reflects and projects the interests of institutional authority and has much to do with orthodoxy. However, there are advantages too: a canon specifies the collection of works that best represent a genre and even though these works are not unified by much other than language, culture and historical epoch, the canon establishes the parameters that define the form.

In a world that has become less respectful of authority, the very idea of a canon has come under attack. Simply put, canons that exclude the voices of marginal communities or of women or indeed of minorities are said not to speak to the richness of society. Thus, any attempt to identify a list of literary texts is problematic not merely for fear that it would be attacked but also because there is no objective, unprejudiced selection method. Despite the anxiety that any proposed list of works may be subjected to criticism and challenge, there is a case for suggesting a tentative list of texts that allows for courses to have a framework to introduce the study of literature into medicine.

Texts can be chosen for each of the different roles listed in Box 1. Clearly, this list is tentative and open to revision.

Repeated themes

Narrative theory assumes that there is a finite number of underlying basic themes despite the apparent multiplicity and heterogeneity of myths in the world. In other words, it assumes that there are constant, underlying structures in myths that are universal in nature and that are recombined much in the way that language itself is built up from underlying basic units. It is therefore possible to see archetypal figures in myths, including the hero, the villain, the damsel in distress and the numerous obstacles that have to be surmounted before her rescue can occur. A full description of these ideas is outside the scope of this article but interested readers will find that Reference EagletonEagleton (1983) provides a good introduction.

The relevance of this for psychiatry is that patients structure their accounts using the same basic elements: the hero who is fighting the medical services for justice; the villain who has been so identified by family or spouse but is really a hero; and the damsel in distress waiting for her rescuer. It seems obvious that to fully grasp the narrative structure of an account, there is a need to distance oneself from the immediacy of the actual detailed content. Novels that are explicitly based on narrative theory are perhaps ideal for illustrating the nature and power of narrative structure. A good example of this is Bernhard Schlink's novel Homecoming (2006), in which he utilises the narrative structure of homecoming after a war and sets his story in post-war Germany. The story explores homecomings in general and as a specific German phenomenon, and of course alludes to Homer's Odyssey. Although it has no direct bearing on psychiatry, the novel provides an opportunity to understand and discuss the force of narrative structure on day-to-day storytelling.

Ethics from literature

Narrative ethics is the use of a literary text to study the underlying ethics of a story. It is a sophisticated method for discussing ethics that builds on the use of clinical cases in which the ethical dilemmas are often limited to clinical ethics. The use of literary texts in this context allows a richer and nuanced discussion and awakens the trainee's sensitivity to ethical questions in daily life. For example, Albert Camus' novel The Plague (1947) can be read on several levels. Certainly, it deals with the question of the doctor's responsibility in the face of an infectious disease, in this case the plague, to which he too is vulnerable, and it has been interpreted as an allegory for the French resistance movement during the occupation of France by Germany in the Second World War. It can also be used as a basis for discussing the nature and limits of the duty of beneficence as opposed to the principle of non-maleficence.

Applying literary theory

Developments in literary theory during the past century have encompassed psychoanalysis, structuralism, deconstruction, Marxist theory and many other theories. These influence wider society well beyond their narrow interest to literary scholars. To take but one example, deconstruction refers to the way that systems of meaning are based on unexpressed binary structures. Our notion of ‘man’ is constrained by our notion of ‘woman’ and the reverse is also true. This is more than simply saying that a man is the opposite of a woman, for it is saying that a woman is ‘non-man’. These binary systems of thinking usually involve opposites, constructed along the dimension of what is acceptable and what is not: self and non-self; sense and nonsense; reason and madness; central and marginal; surface and depth. What is the value of this to psychiatry? It is instructive in that it alerts a trainee to the unspoken, underlying assumptions in textbooks. All texts have a standpoint – the hinge that makes it possible for the reader to open and shut the door, that is, to let light into the text. Some awareness of this will at least allow the trainee to be wary. The writings of Edward Said, particularly in Orientalism (1978), and Chinua Achebe in Hopes and Impediments (1988) are good introductory sources.

Methods of teaching

How should the humanities be taught? The purpose of adding the humanities to the psychiatric curriculum is not to teach facts; rather, it is to teach trainees different ways of seeing the world. Thus, the most important task is to encourage curiosity, discussion and a critical attitude. This should mean working in small groups, with trainees expected to do prior reading and to be prepared to actively contribute to discussions within the group. It is a sad reflection on current teaching in psychiatry that trainees expect to be lectured to, predominantly about facts that appear relevant to examinations. Any deviation from subjects and themes that have ready answers and that are not amenable to assessment by multiple choice questions is usually deemed irrelevant. The humanities cannot be taught in this way.

Conclusions

The value of the medical humanities to undergraduate medical education is now well established, even if the implementation of courses is patchy across medical schools in the UK. However, there has been little discussion about medical humanities in postgraduate training, and many of the ideas considered in this article are relevant to CPD courses.

MCQs

1. 1 Medical humanities include:

   1. a literature

   2. b physiology

   3. c pathology

   4. d nephrology

   5. e statistics.

2. 2 Medical humanities can:

   1. a give an understanding of physiology

   2. b illustrate the lives of sick people

   3. c demonstrate the power and influence of genes

   4. d teach narrative ecology

   5. e exemplify theory of mind.

3. 3 The aims of the Association for Medical Humanities include:

   1. a teaching in small groups

   2. b acquiring historical artefacts for undergraduate teaching

   3. c recognising the importance of community medicine

   4. d emphasising the distinction between education and training

   5. e facilitating evidence-based medicine.

4. 4 Canonical works:

   1. a are written by canons

   2. b contain the wisdom of a culture

   3. c establish the standard of reading

   4. d in English would include the works of Shakespeare

   5. e have been criticised for excluding male poets.

5. 5 Narrative ethics:

   1. a include applying the concept of deconstruction

   2. b can form the basis for teaching clinical ethics

   3. c apply narrative theory to help understand epistemology

   4. d have no place in medicine

   5. e are a version of virtue theory.

MCQ answers

1		2		3		4		5
a	t	a	f	a	f	a	f	a	f
b	f	b	t	b	f	b	f	b	t
c	f	c	f	c	f	c	f	c	f
d	f	d	f	d	t	d	t	d	f
e	f	e	f	e	f	e	f	e	f