Ten books

It was the last 6 months of my general practice training, but it changed the course of my life. My move into psychiatry coincided with the birth of my first son, a sleepless infant. Reading about psychiatry at that time consisted of the bare essentials to pass the Royal College of Psychiatrists’ membership examinations and jump through other career hoops. Reading books for pleasure was hardly an option, especially after the birth of two more sons, even though they slept better. So, much of the reading that opened additional doors of insight into the world of mental well-being and illness, and the lives of my patients and colleagues, came later.

As an old age psychiatrist, I became fascinated by history across older people's lifetimes, including history of psychiatry. I draw here on some books, sequenced chronologically by the era to which they relate, which have educated and inspired me and which I hope have shaped my understanding to be a better psychiatrist and have given depth to my historical analysis of our specialty's past.

Children of the Ghetto by Israel Zangwill

It is rare to find, in the opening pages of a novel, reference to Prescot Street (then spelled Prescott), today the location of the Royal College of Psychiatrists. Israel Zangwill's 1892 novel about Jewish immigrants in the East End of London described ‘congeries of “apartments”’ in Prescot Street's large houses, formerly homes of the ‘aristocrats of the Ghetto’ (‘Few relations had they with Belgravia, but many with Petticoat Lane’).¹ Zangwill described streets that retain their names and along which we might walk near the College, passing some Victorian edifices. Some of the community organisations Zangwill mentioned still exist, such as the Jewish Board of Guardians (now Jewish Care) and the weekly newspaper, The Jewish Chronicle. The East End is now home to more recent immigrant communities. Bringing with them their language, culture, religion, customs, dress, food, humour and hope for the future, they encounter challenges of adaptation similar to their Jewish predecessors.

Some of Zangwill's Yiddish and Hebrew idioms may be unfamiliar to readers today, as they were to non-Jewish readers a century ago. However, many of these words perpetuate colloquially and culturally, familiar to many Jewish people today who speak neither Yiddish nor Hebrew. For faith-based minority groups, depth of religious practice and belief may vary, but aspects of personal identity may still be drawn from deeply embedded cultural roots which their ancestors brought to these shores.

Christina Alberta's Father by H.G. Wells and Cathy Rossiter by Mrs Victor (Jessie Louisa) Rickard

A recent excursion into interwar psychiatry led me to two fascinating but little-known novels, Christina Alberta's Father ² and Cathy Rossiter.³ Both were carefully researched, beautifully written and popular in their day. They shed light on urban and rural life of different social classes, people's expectations for a better world, and how the public perceived the medical profession, asylums and mental disorder.

Christina Alberta's Father is said to have been stimulated by an after-dinner conversation between Wells and Carl Jung.⁴ It tells the story of Mr Preemby, a ‘midget personality’, who believes that he is ‘Sargon, the servant of God’ who must bring harmony to the world. After acquiring numerous followers around London, he was admitted to an asylum, and escaped. Jung praised the book by his ‘friend the great English writer’.⁵

Rickard created a fiendish female general practitioner, distrusted by other women, at a time when women doctors were rare. In that oft-asked question today ‘Where were all the women doctors?’, perhaps women's attitudes contributed to the answer. The book also tells how Cathy Rossiter is ‘certified’ into an asylum, where the medical staff could best be described as well-meaning but impotent.

Both books sadly portray many unsatisfactory aspects of asylum care, compatible with factual accounts at the time. Deliberately revealing the worst scenarios may have contributed to stigma, but may also have helped garner public support for initiatives to improve care and liberalise mental health law.

When the Siren Wailed by Noel Streatfield

The Second World War took place within living memory of some of the oldest people in our communities today. For some, long-past experiences may foster resilience or despair. Similar experiences for people with Alzheimer's may intrude into consciousness, vivid as if they had just happened.

In some ways, understanding the lives of previous generations resembles that of cross-cultural psychiatry, requiring us to empathise with life experiences well beyond our own. Sometimes, children's literature, such as When the Siren Wailed,⁶ can help. It is based on Noel Streatfield's experiences in London during the Blitz. Her home was bombed, and she worked in civil defence. The story is about Laura, age 9, and her younger brothers Andy and Tim, evacuated to Dorset from a happy but materially impoverished south London home. The children run away from their foster family, return to London and find their former home destroyed. Complete strangers show them much kindness, but being trapped by rubble blocking the stairs to their air raid shelter must have been terrifying. Eventually, they were reunited with their mother, who was in hospital recovering from a head injury, before being driven back to Dorset by car. This powerful story, about children's resilience and resourcefulness when faced with restrictions on their lives in a time of national emergency, may also help us think creatively about children in today's time of COVID-19.

Maus by Art Spiegelman

Years ago, a distinguished psychiatrist who had fled Nazi Europe and arrived in England in 1939 told me to read Maus.⁷ ‘Amazing cartoon book’ he said ‘about the Holocaust, and all the characters are animals. Won a Pulitzer, rightly’. Initially, the idea of an anthropomorphic graphic novel about the Holocaust – Jews as mice, Nazis as cats, Americans as dogs, and so on – put me off. But I was wrong.

The main character is Vladek, who was married to Anja. Both survived Auschwitz and later settled in New York. Anja and Vladek's first son, Richieu, did not survive the Holocaust, and a photograph of him always hung in his parents’ bedroom.

Maus features Vladek, then elderly and widowed. His estranged adult second son, Art, prompts him to relate his Holocaust experiences. The subject was previously taboo, but Art thought their dialogue might help reconcile their relationship and help him understand some of his father's apparently inexplicable attitudes and behaviours. Throughout, images heighten the powerful emotions, and the final pages reveal a clue to Vladek's and Art's estrangement: Vladek calls him ‘Richieu’. Vladek had never ceased to mourn for Richieu, and Art could never be the idealised murdered son.

The book is about the Holocaust, but it may help us understand survivors of more recent inhumanities, wars and genocides, and the emotional consequences for the next generation.

Institutional Neurosis by Russell Barton and Adventure in Psychiatry by Denis Martin

The roots of ‘anti-psychiatry’ were credited to a multidisciplinary clutch of authors, Michel Foucault,⁸ Thomas Szasz,⁹ Ken Kesey,¹⁰ Erving Goffman¹¹ and R.D. Laing,¹² their books published between 1960 and 1962. With the authors’ roots in France, the USA, Hungary and Scotland, one can be forgiven for thinking that other places lagged behind when it came to radical views on psychiatry. These authors’ sociological and philosophical approaches, and the drama of Kesey's One Flew over the Cuckoo's Nest, gave their writings a sense of timelessness, contributing to this perception.

However, equally radical books by psychiatrists in England were published at the same time: Institutional Neurosis by Barton¹³ and Adventure in Psychiatry by Martin.¹⁴ Both aimed to tackle rigid, authoritarian, hierarchical, them-and-us, anti-therapeutic modes of care associated with submissiveness, apathy and loss of individuality and interest suffered by patients in institutions. Barton wrote textbook style. Martin narrated a journey with challenges, hazards and successes, replacing a feudal system with democracy, liberalising the culture of a 2000-bed mental hospital, and facilitating patients and staff working together as equals, developing ‘to the full their particular gifts’, and the doctor ‘the servant of the community’. When the institutions closed, both books appeared redundant and faded from memory.

Today, some National Health Service (NHS) psychiatric services resemble the task-driven, rigid, hierarchical systems of former mental hospitals, an organisational style that can undermine staff trust, confidence and creativity integral to a healthy workforce and to patients’ well-being. The enormous mental hospitals have gone, but the staff dynamics less so. Barton's and Martin's books make us grateful about what has changed for the better, and provoke thought about current challenges and future prospects.

Sans Everything: A Case to Answer by Barbara Robb

This book was written by a heroine of mine, Barbara Robb, whose story I learned many years after she died. Shocked by the disrespectful and undignified care she observed when visiting an elderly woman in a psychiatric hospital in the mid-1960s, Robb wrote Sans Everything ¹⁵ to inform public and policy makers and lay foundations in her campaign to improve psychiatric care. As well as describing the problems, she also proposed solutions. Her sheer persistence, even in the face of unwarranted discrediting by defensive NHS leaders, remains inspiring. Ultimately, Robb and Sans Everything stimulated much NHS policy, including modernising psychiatric care, establishing an ombudsman, inspectorate and complaints procedures, and formulating guidance for managing violence in hospitals.

Sans Everything inspired others to speak up. The extent of inadequacies exposed, and persisting press coverage and public concern, led one cabinet minister, fearful of political consequences for the government, to try to ‘placate’ her. Robb was personally acquainted with Jung, who said: ‘She decidedly leaves you guessing’.¹⁶ If Jung could not fathom her out, then UK politicians had no chance.

Although standards of care for vulnerable people have generally improved since Sans Everything, we still hear of dreadful inadequacies and inhumanities. What would we do if we witnessed inhumane practices today? Would we be able to inspire others to speak out, or have the guts to take on the government, like Robb did?

The Lunatic by Anthony Winkler

While working in Kingston, Jamaica, and wanting to read books by local authors, The Lunatic ¹⁷ caught my eye in the Liguanea bookshop. I bought it, without even glancing inside. I laughed out loud when I first read it in 1994, but worried that, in today's cultural climate, it might seem dated and crude. Not so. It had retained its magic, a wonderful spectrum of human interaction, a colourful depiction of rural life, a good smattering of patois and some important take-home messages. Aloysius, the local ‘lunatic’, lived outdoors under the flame-heart tree, which was his ‘best friend’. He conversed with the tree, and with bushes, cows and goats, much to the consternation of the local people. They generally avoided him, unless he was needed for his fast-bowling prowess in the village cricket team. Cricket, the Queen, religion, parliament, wealth and graveyards are integral to Aloysius's story, as is Inga, a buxom ‘White’ German woman, who seduces him.

Winkler created Aloysius rather like Shakespeare used the character of the fool to explore broader themes. By the end of the story, others in the village appeared far madder than Aloysius. The narrative, including matters of gender and skin colour, is candid and humorous (what colour is God?), criticising societies that divide people into ‘Black’ and ‘White’: ‘we don't see a man only in two color in Jamaica because God don't make man only in two color. God make man in at least thirty forty color, and here in Jamaica we see dem all’.

50 Quranic Comforts for Mums by Nazmina Dhanji

Some of the books I've referred to may be difficult to come by, but 50 Quranic Comforts for Mums ¹⁸ is readily available. Its author, Nazmina Dhanji, is a mother of four children and a well-known scholar of Islam living in England. She takes up Donald Winnicott's ‘good enough mother’ concept and presents it to us alongside Quranic quotations and modern and traditional interpretations, which inspired her in the ups and downs of motherhood. Topics include being a single parent, accepting help and supporting other mums, teaching children to pray and to fast, expressing gratitude, looking for the silver lining and not trying to ‘keep up with the Joneses’. It is easy to read, and there are spaces for mums to write down their own thoughts to help them consider how Islamic teachings might relate to them.

The book was written primarily for women in the British Muslim community. Published in 2019, I wish it had been written years ago. It would have helped me, as a non-Muslim, to understand aspects of Islam relating to the well-being of my Muslim neighbours, and some of my patients, in our diverse, multicultural, multi-faith society.