Ten books

Ten books that have had a significant impact on my professional life: an invitation to what? To pomposity, self-advertisement and self-deception - or perhaps self-revelation? After all, for my generation you are what you read, not what you stuff in your mouth. The problem is ‘ten’: not one, not one hundred. ‘One’ invites the arch, the Kama Sutra, or more truthfully the Penguin Guide to Jazz on CD. ‘One hundred’ is easy, assuming you can lay claim to having read a hundred books relevant to your professional life, because there is safety in numbers and no one will spot you among the volumes. Ten, however, given even a modicum of honesty, invites an act of exposure - indecent exposure.

Previous contributors have usually considered their book choices under separate headings, each book an object which they evaluate, respond to, praise, and pass on. This is surely the best and proper approach, but one that my enmeshed relationship with the written word makes virtually impossible.

My attitude to books is ambivalent. In childhood and early adolescence they were a bulwark against the outside world. Escaping at least in part from the thrall of books was a necessary step toward living in some semblance of a shared reality. I was driven from the womb of the local public library, and from my book-filled bedroom, by the imperative of a sexual desire no longer controlled by solitary and vicarious satisfactions. Ever since then, the probability of lapsing back into an autistic existence in a public reading room has dogged my heels. Books are the ever-present alternative reality, the temptation which when fully indulged will return me to that solitary time out of time.

Freud's Case Histories

Books might have been displaced from total hegemony over my adolescent world but they continued to direct and limit my options. Medicine was chosen as the only possible future while I was immersed in the pages of the likes of George Sava's All This and Surgery Too, in Garet Rogers' Brother Surgeons (a fictional account of William and John Hunter), in André Soubiron's stories of medical school life in Paris and even, it has to be admitted, in Richard Gordon's fantasies of medical life. Psychiatry became a future possibility when an indulgent librarian gave me access to the locked cupboard for salacious books, where Rabelais, Zola, Casanova and Lawrence rubbed spines with an edition of Freud's Case Histories (Freud, 1906-1920). I was captivated by Freud's stories of the relationship between extraordinary behaviours, particularly extraordinary sexual behaviours, and his patients' internal worlds of fantasy and desire. Here were humans laid bare, stripped of their capacities to intimidate and control, a comforting vision for an anxious, oversensitive adolescent terrified of other people. Freud's case histories are for the most part mystery stories, with convoluted plots and as many surprise twists as Agatha Christie managed at her best. They usually lack an actual murder, although murderous fantasies abound, but then why the Wolf Man has a predilection for coitus a tergo is at least as interesting as the propensities of a Hannibal Lecter. It is entirely appropriate that Sigmund Freud was nominated for the Nobel Prize for Literature, and it will be a loss when mental health professionals cease to read these dramas of the internal world - and an even greater loss if they lose curiosity about the mysteries of human behaviour that generated these narratives.

Man Into Wolf

Forensic psychiatry first entered my world at about the same time as Freud when I read Man Into Wolf by Robert Eisler, purchased for a few pence at the Farringdon Road book market. This book still sits on my shelves; a curiosity with a brief text but numerous and extensive notes in which are contained extraordinary accounts of murder and mayhem. Eisler's thesis was that mankind ‘developed its present predatory, murderous and jealous habits only under extreme environmental pressure [and by the] imitation of the blood-lustful enemies of its own species’ (Eisler, 1950: p. 51). Fortunately this optimistic thesis did not prevent detailed descriptions of such blood-crazed mimesis. Was I captivated by the voyeurism, or by a sense that here were real questions about human destructiveness worthy of rigorous study and thought? Perhaps the superficially acceptable motivation was masking the true, but embarrassing, drive. After all, it is so much easier to admit to voyeurism.

The Divided Self

The 1960s were a fortunate time to be a student in London. Even our medical school was briefly touched by hope and its progeny, revolt. Study groups did not exactly flourish but they briefly flowered, with readings of Marx, Freud, Althusser and Mao, interspersed with cannabis and the still entirely legal hallucinogens. Which books stand out from this time as relevant to my psychiatric development? First and foremost Ronald Laing's The Divided Self, with Sartre's Being and Nothingness and Marcuse's Reason and Revolution close behind. It is easy to dismiss Laing as part of youthful 1960s enthusiasms, as blind to the nature of the world as to the painful realities of serious psychiatric disorder. Laing, particularly in The Divided Self, brought the reader into a sympathetic collision with the distressed and disintegrating worlds of young people with schizophrenia. Moreover, he offered insights into our psychological functioning which went far beyond the worlds of madness. On rereading The Divided Self I noted a number of formulations that I have usurped so often over the years as a therapist, I had come to regard them as my own. For example:

‘The isolation of the self is a corollary of the need to control... he prefers to steal rather than to give, to give rather than have anything taken from him... [but] the individual who is sure of his own being does not require to adopt such measures’ (Laing, 1959: 83).

The Divided Self emerges out of psychoanalytic thought and practice. The influences of Winnicott and the object relations theorists, notably Guntrip, are clear. It is, however, at a vast remove from Freud. Freud, for all the poetic complexity of his models of the mind, remained, like his near-contemporary Kraepelin, a physician observing pathology in the patient. Laing, in contrast, sits with a fellow-sufferer, exploring together, not looking at or subjecting to dispassionate analysis. Laing's sharing was later to slide into identification, and finally into romanticisation, in which the ‘being with’ was to be lost in self-indulgent dramaturgy. In The Divided Self, however, we have a troubled genius at the height of his powers, and it is a mistake to devalue this book on the basis of what was to follow.

Madness and Civilization

Foucault is here because I know he influenced me. I did not just read his books in the late 1960s and early 1970s, I pored over them. I took from them what I needed, irrespective, I suspect, of whether my reading bore any relationship to the text. Rereading him today is frankly rather embarrassing. Unlike rereading Laing, it is not a joyful return to a half-forgotten pleasant land, it is an ‘Oh my God, why did I bother’. Foucault, for all his grandiloquent posturing and lack of interest in those little matters of historical and scientific evidence, seemed to me to expose the mechanisms of power and how it relates to the way we both construct and impose views of the world. Foucault wallowed in obscurantism, but back then I thought he was rescued by a playful latitudinarianism and the creation in the reader of moments of insight which, however chimaeric, brought a semblance of intellectual satisfaction. He writes, for example,

‘What we call psychiatric practice is a certain moral tactic contemporary with the end of the eighteenth century, preserved in the rites of asylum life, and overlaid by the myths of positivism’ (Foucault, 1961: p. 277).

So apparently profound, but what does it mean? Is this anything more than a delightfully frothy conceit? Foucault's quotations, generalisations and above all his denunciations tumble over each other, creating a portentous jumble. Paradox, declamation, denunciation sailing on a sea of dubious scholarship. Why continue to give house room to such silliness? Perhaps for auld lang's syne. Perhaps because he just seemed so so intellectual.

Jaspers' General Psychopathology

Training at the Maudsley in the early 1970s still entailed reading books. A few stand out, above all Karl Jaspers' General Psychopathology, which remains the psychiatric text I visit most often. Perhaps now such visits are more about the reassurance of the familiar than the search for new insights, but even after all these years it is a work that can challenge and (if you will forgive the word) inspire. Recently studying once again what Jaspers wrote about querulousness and the development of delusion, I was confronted with the realisation that I had seriously misread him in the past on a number of critical issues. As a matter of fact I prefer my misreadings to the original, but I remain engaged and willing to be persuaded otherwise. Sadly, recommending General Psychopathology to trainees has rarely produced benefits. Perhaps Jaspers is too much part of the philosophical and ideological environment of middle Europe in the early years of the 20th century to be easily accessible to those of the anglophonic 21st century. Can Jaspers be usefully read by someone for whom Nietzsche, Husserl and Hegel are at best mere names? If General Psychopathology is now part of psychiatry's history, we can only hope some equally open-minded but rigorous and learned text soon emerges that places for new generations the central issues of today's mental health disciplines in the cultural, philosophical and scientific context of their century.

Mental Disorder in Earlier Britain

Reading history has been a lifelong pleasure, although histories of medicine and psychiatry have had no particular priority. Nevertheless, it is partly through the prism of history that I view such matters as madness, emotion, desire, treatments and the development of mental health services. Choosing an example of a book on the history of psychiatry that has had particular influence is no easy matter. Should it be Rosen's Madness in Society, any of a number of Roy Porter's volumes, Henri Ellenberger's The Discovery of the Unconscious (a delight to read, although its short-comings as history may irritate latter-day pedants) or even Hunter & MacAlpine's selected texts from Three Hundred Years of Psychiatry? In the end I nominate Basil Clarke's Mental Disorder in Earlier Britain. Part of Clarke's book examines contemporary accounts of the mental disorder of Henry VI and the cult that grew up around him after his murder in 1471. Clarke's scholarship gives the lie to theories about the invention of psychiatry in the 19th century as an extension of medical hegemony, and here are to be found at least some of the answers to those who would use gaps in the historical record to postulate the emergence of schizophrenia de novo in 18th-century Europe.

Crime and Insanity in England

The book that has had the greatest impact on me in forensic practice is also in part historical. I bought the first volume of Walker & McCabe's Crime and Insanity in England in 1973 and read it from cover to cover over a weekend on call. It is that kind of book, but it is also a book I return to again and again when considering issues of insanity, automatism and even psychopathy. Lawyers tell more good stories than psychiatrists, and Walker & McCabe exploit to great effect the writings of court reporters and verbatim accounts of evidence. For example, in the trial in 1760 of Earl Ferris for shooting dead one of his servants, the then Physician Superintendent of Bethlem, John Monro, gave evidence. Walker & McCabe reproduce part of the cross-examination of this psychiatrist by the accused, who is attempting to establish his own insanity:

‘Q. Whether spitting in the looking-glass, clenching the fist and making mouths is a symptom of lunacy?

A.I have frequently seen such in lunatic persons.

Q. Whether walking in the room, talking to him-self and making odd gestures, are symptoms of lunacy?

A. Very common ones.

Q. Whether drinking coffee hot out of the spout of the pot is a symptom of lunacy?

A.I should think it one in the present case, though it is not a general one’ (Walker & McCabe, 1968: p. 61).

I have experienced less pertinent cross-examinations in today's courts. If only there were more books like this, in which scholarship and relevance go hand in hand.

The Wretched of The Earth

Reading philosophy is an occasional professional influence. Philosophy as a discipline has never interested me particularly, only how such ideas can be appropriated - and misappropriated - in the pursuit of purely psychiatric ends. I read philosophy with unselfconscious superficiality, like a jack-daw picking out the shiny bits which catch my eye. Some sort of background ideology was acquired in youth from reading Marx and Nietzsche, and something must have remained from my regular, if desultory, reading of certain contemporary philosophers such as Solomons, Lyotard, Mac-Intyre and Hacking. In my first draft of this essay, Max Scheler's Ressentiment occupied this spot for a philosophy book. It became clear, however, that none of the ten books I had selected was written by a practising psychiatrist, unless you count a neurologist turned psychotherapist, a psychiatrist who gave up medicine in his youth in favour of philosophy, or a psychoanalyst turned guru. I needed a practising mental health professional as author, not an eccentric phenomenologist and theologian like Scheler. Frantz Fanon qualifies as a psychiatrist. That he was a clinical psychiatrist was important for me when finally making my commitment to psychiatry, because he legitimised the specialty in the eyes of a youthful iconoclastic malcontent. It could be argued that Fanon was less a philosopher and more a political theorist but, as the man said, it is the job of philosophy not just to explain the world but to change it. The Wretched of The Earth raises for me the nature of impact and influence. Why were Fanon's writings an influence? Why were they important to me? Sufficiently important for a dedicated monoglot to drag himself through one volume of Fanon's then untranslated essays in the original French. Reading The Wretched of The Earth today it seems curiously tame, even tendentious - not to say banal - in parts. Was the excitement it once generated created by the image (an image worth repeating, doubtless, but an image nevertheless) of the dedicated revolutionary doctor sacrificing himself in a foreign land in the cause of the oppressed? Fanon's writings have not become less relevant with the passing of the years. Perhaps they have never been more relevant as I write, with certain Western leaders apparently on the brink of reimposing colonial domination over the Muslim world, or at least over the only bit that now matters, the bit with the oil. What Fanon had to say has been subsumed into mainstream thought, even into mainstream psychiatry where his ideas about reactive psychosis (touchingly mistranslated in the Penguin edition as ‘reactionary psychosis’) and the psychological impact of victimisation are now commonplace. Once he was a hero; now, just a reminder not to despair.

Decline and Fall of the Roman Empire

Many years ago I remember coming across in the Lancet or BMJ Michael Shepherd's personal list of essential books for a psychiatrist. Included, if my memory serves, were the works of Freud, naturally in the complete edition, Isaac Deutscher's biography of Stalin, and Gibbon's Decline and Fall of The Roman Empire. I could not believe at the time that my own tastes could in any way overlap with this doyen, not to say mandarin, of psychiatry. Now it is my turn to add Edward Gibbon to a similar list. Over my desk is a quotation from Gibbon's autobiography: ‘the power of instruction is seldom of much efficacy, except in those happy dispositions where it is almost superfluous’. Delightfully irritating, not to students, but to many visiting academics. Gibbon warned against enthusiasms, distrusted the crowd and reduced the beliefs of the commonality to laughable absurdities by yoking irony and scepticism to his cart of scholarship. Nevertheless, he remained the optimistic man of reason, writing:

‘man's progressin the improvement and exercise of his mental and corporeal faculties has been irregular and slow... yet the experience of four thousand years should enlarge our hopes and diminish our apprehensions; we cannot determine to what height the human species may aspire in their advances toward perfection; but it may safely be presumed, that no people, unless the face of nature is changed, will relapse into their original barbarism’ (Gibbon, 1776-1788: p. 1055).

Amen to that.

The Lancet, 1963-1970

Missing so far are influences on the aspects of my professional life involved with research. Our central task as health professionals is to mediate the medical sciences for the benefit of our patients and, for the privileged few, to contribute to that science. When I was a medical student The Lancet offered student subscriptions at a rate within the reach of even the impecunious. The Lancet began to arrive weekly when I was still a preclinical student. Having no precedents to draw on, I read each issue as if it were a book, starting at the editorials and ending at the public health statistics. After all, even at a bargain price each journal cost as much as a second-hand novel, and I wanted reading value to compensate. This ritual continued until after I qualified and obtained a junior research fellowship, when I soon learnt that journals were for storing not for reading. When I began reading The Lancet it was for me little more than hieroglyphs interspersed with constipated little sentences on themes of mind-numbing obscurity. In a relatively brief time it became an entirely familiar and accessible world. Reading a good journal regularly is like watching a soap opera: the same characters keep reappearing, shifting their allegiances, having their moments of drama and then fading into the background. Good papers, like good characters, were clearly articulated and moved the plot forward; the poor ones were confusing, self-contradictory and took us nowhere in particular. The Lancet was a special refuge from so much of medical practice as it revealed itself to a student of my generation. There were good teachers, well informed and open-minded, but there were far too many who were arrogant, opinionated oafs who placed their own prejudices (i.e. clinical experience) before the research findings of their betters. These pompous ignoramuses wanted to teach us to be ‘real doctors’ whose authority would lie, like theirs, in position and power. They called it learning the practice of medicine, learning to communicate, they called it etiquette (now they call it ethics), they claimed it was 90% of good medicine. They still do, and they are still fools trying to exert personal power separated from the science that is their only justification for being. The weekly Lancet made it possible to avoid being entirely intimidated by the vaunting power of such ignorance. It helped to keep alive the hope of a medicine whose authority lay primarily on the status of its science, not on the position and personal qualities, however commendable, of its practitioners. Such are the dreams of youth.

Conclusions

Now, if this list had not been about the impact on my professional life but about ten books to take to a desert island, my selection criteria would have been a combination of length with sufficient quality and complexity to encourage repeated reading. Sadly, on this basis, only Gibbon would still find its way into my sea chest to sit alongside Leo Tolstoy's War and Peace, Charles Dickens' Bleak House, Robert Musil's The Man Without Qualities, James Joyce's Ulysses, Anthony Trollope's Palliser novels, Patrick O'Brian's Aubrey-Maturin novels, Marcel Proust's Remembrance of Things Past, Tolkien's Lord of the Rings and, for those long, lonely nights, Casanova's Memoirs. So it goes.