Ten books

In the course of a career in psychiatry, finding only ten books that seem worth mentioning is rather difficult. As a serious clinician, you are supposed to have read Jaspers, Kraepelin, Freud and so forth, but reading more than a few chapters of complex translated German tends to have a ‘dusty’ feel. My theme, therefore, is English prose, written with care and love.

Three Hundred Years of Psychiatry, 1535 to 1860 by Richard Alfred Hunter and Ida Macalpine

As an amateur historian of psychiatry who has served his time in the endless repetitions and copper plate handwriting of Victorian asylum casebooks, I cannot possibly exclude Three Hundred Years of Psychiatry, 1535 to 1860 by Richard Alfred Hunter and Ida Macalpine. ¹ Written by practising psychiatrists (mother and son), its subtitle is A History Presented in Selected English Texts. These texts were largely collected by Hunter and Macalpine as a labour of love. From Bartholomaeus Anglicus (who describes melancholy as ‘a humour boystrous and thicke … bred of troubled congealyngs of bloud’), via treatises on everything from hallucinations to witchcraft and ‘hysteric disorders’, there are beautifully annotated sections of often just three or four pages, covering the gamut of writings up to Thomas Laycock's ‘Unconscious cerebration or mentation?’ of 1860. This is more than a gold mine; it sets out the whole planetary system of the development of psychiatry, with all its difficulties and inanities. Whether it be diagnoses, knowing what to do with people, ethics, or the psychology of Shakespeare, it is all here, in a little over a thousand pages. Critics of history tend to mock archaic versions and dated language, but Timothy Rogers' (1658–1728) advice ‘to the Relations and Friends of Melancholly People’ would help every crisis resolution team member feel that they have something useful to do, however badly trained or supported.

Illustrations of Madness by John Haslam

In the same historical vein, and as an inner-city psychiatrist, I cannot leave out the most enjoyable of the writings of John Haslam (1764–1844), apothecary to London's Bethlem Hospital. Haslam wrote the first-ever book-length account of a single psychiatric case, namely Illustrations of Madness, which was first published in 1810. A nicely edited version with an introduction by the late Roy Porter was brought out by Tavistock Classics, ² and it really is a delightful outline of a seriously psychotic individual, the notorious James Tilly Matthews (1770–1815). Matthews claimed (among other things) that he was tortured by a gang of assailants working with an Air Loom machine, which could cause ‘bomb-bursting’, ‘lobster-cracking’, and ‘lengthening of the brain’. Even more wonderful is that Haslam, who was defending his diagnosis in the light of a number of mocking criticisms from other members of the medical profession, produced an illustration of the Air Loom machine, which has now in fact been constructed and lies (I think) in a museum in Newcastle. The whole complex outline of the case is both fantastical and illustrative of Haslam's clear and rather vitriolic prose style. Haslam published it because he thought it could effect some good ‘by turning the attention of medical men to the subject of professional etiquette’, and in the hope that it would curb ‘the fond propensity to form hasty conclusions or tend to moderate the mischief of privileged opinion’. Like psychiatry and psychiatrists today, he struggled with stigma, doubt, ready mockery and sheer ignorance. llustrations of Madness is a mere 81 pages of a detailed description of a complex delusional system, and every other page will chime with clinicians who treat psychotic patients today.

The Discovery of the Unconscious: The History and Evolution of Dynamic Psychiatry by Henri F. Ellenberger

While research in the history of psychiatry has been prolific over the past 30 years and articles are easily available – for example, in the journal History of Psychiatry – the other unique work that cannot be ignored by anyone who wants to understand how we got where we are is Henri F. Ellenberger's The Discovery of the Unconscious: The History and Evolution of Dynamic Psychiatry. ³ Magnificently referenced, and stretching from what the author called the ‘ancestry’ of dynamic psychotherapy, Ellenberger outlines the arguments and theories about the unconscious in ruthless detail, ending with a plea for doing justice to ‘the rigorous demands of experimental psychology and to the psychic realities experienced by the explorers of the unconscious’. Although he insisted on seeing dynamic psychiatry as a science, Ellenberger's clear prose and sheer love of his subject are quite thrilling. Anyone wanting to understand what Freud was on about, why he argued with Janet, where Jung and Adler went to, and all the extraordinary events around psychoanalytic congresses, rejected theories, narcissistic bickering and the rise of psychotherapy will have a wonderful read. It is such a good book you can pick it up, read any chapter and enjoy it because of the level of clarity and information provided, as well as the author's detached understanding of why people thought what they thought and argued so intensely. For example, the comparison between Freud and Adler starts with a list of characteristics in which Freud is described as ‘handsome, imposing, with a well-groomed beard’, while Adler is ‘not particularly handsome, unassuming, with a small moustache and pince-nez’. Ellenberger reckoned there was a fundamental law of the history of culture, namely ‘the swinging back and forth between two basic attitudes of the human mind’. Like all the best historians therefore, not only is he easy to read but what he has to say helps illustrate what we are doing in the here and now.

Organic Psychiatry: The Psychological Consequences of Cerebral Disorder by William Alwyn Lishman

When it comes to reading about psychiatry as practised in the clinical setting, I do not think I would have got through my career had it not been for William Alwyn Lishman and his Organic Psychiatry: The Psychological Consequences of Cerebral Disorder. ⁴ As his registrar at the Maudsley Hospital in the late 1970s, it was enough just to listen to him talk, lecture and adumbrate on why we did things. His definitions of terms were lucidity personified. Likewise, the elegance of his writing in Organic Psychiatry is such that you can open it at any chapter and enjoy the read. The basis of ‘symptoms and syndromes with regional affiliations’, the complexities of epilepsy and head injury, and all the potential obscurities of the relationship between psychiatry and metabolic disorders or neurology are outlined with clarity and verve. One of the tragedies of British psychiatry has been the separation of psychiatric from neurological practice (something not accepted in Germany, for example) and a reading of Lishman can only make one wiser in the broadest context of clinical practice and personal experience. As mentioned earlier, the problem with most textbooks is their appalling prose and sheer dullness (brief papers, such as editorials, are so much nicer), so studying the prose in Organic Psychiatry should be mandatory for any up and coming researcher. If evidence-based practice is the watchword of our times, then clear writing and evidential discourse are essential to ensuring that articles and books are read, that ideas are taken on board, and that they are striking enough to enthuse young and old alike.

Psychiatry in Dissent by Anthony Clare

A more idiosyncratic discourse about the world of psychiatry, especially relevant to the generation that had to work through the anti-psychiatry theories of the 1960s and 1970s, is Psychiatry in Dissent by Anthony Clare. ⁵ Clare is a vivid and engaging communicator; he presented In the Psychiatrist's Chair on radio and television, and was a funny and engaging conversationalist and teacher. The book was nicknamed ‘Psychiatry Indecent’ by colleagues and friends, but it did something vital for the restoration of morale in a profession battered by its negative history, the assaults of sociology, and the disbelief in mental illness generated thereby (which was not helped by the antics of R.D. Laing and colleagues). Here was someone arguing clearly and honourably for psychiatry as the extraordinary unifier of medicine, psychology, sociology, law, history and geography. In a world where schizophrenia was intellectually accepted as a capitalist construction, Clare put up his hand and stated that there really was such a thing as mental illness, and that clinical diagnosis and even hospitalisation were perfectly acceptable procedures to help those who could not look after themselves. This is a lesson perhaps forgotten today, with the over-arching emphasis on home treatment and assumed recovery. Clare also insisted on the professional need for a broad biopsychosocial approach that embraced the profound truths of clinical medicine. He did not refrain from detailing the mistaken enthusiasms of the past, but acknowledged with sympathy the ‘desperate methods’ required to offer any hope whatsoever when managing chronic psychosis in crowded and underfunded asylums. He also recognised the traps by which certain treatments or therapies get promulgated and maintained (gurus and shamans often to the fore), and how brave one has to be to stand up against accepted norms in practice. In the 1940s and 1950s, these were psychosurgery, electroconvulsive therapy and even insulin coma therapy, and after these came the rise of mass psychopharmacology, which is still with us today. Clare was also aware that the British psychiatric service, whatever its faults, was a good deal ‘more efficient and humane than most comparable services in Western Europe or North America’. Many people would suggest that this assertion is still true today, despite the constant assaults and cuts on our community-based services, which in themselves remain unmatched in terms of commitment and resources compared with anywhere else in the world, bar perhaps New Zealand.

King Lear by William Shakespeare

With regard to non-clinical reading – which accounts for most people's reading – any psychiatrist who does not try to engage with some of the world's acknowledged masterpieces is missing out on the best resource we have for understanding character, motivation, the roots of action (and inaction) and the seedbeds of mental illness. The briefest summary of the characters of Jane Austen, George Eliot, Charles Dickens, Henry James et al would show that every variation of psychiatric disorder runs through the canon of English literature. Whether they be ‘nervous troubles’, such as afflict the mother of Elizabeth Bennett in Pride and Prejudice, or psychotic illness, such as provides the basis for Trollope's He Knew He Was Right, bits and pieces of psychiatric symptoms are everywhere to be seen. One of the most unique descriptions of going mad, in a variety of ways, is in Shakespeare's King Lear, ⁶ which even includes someone pretending to be mad (the character of ‘Poor Tom’). This gives us a good understanding, some 400 years later, as to what the common crowd recognised as the overt behaviour expected of real madness. While King Lear is not strictly a ‘book’, it is a prose poem of heart-breaking power, which rewards re-reading and/or re-seeing (both, ideally) on a regular basis. In one of Lear's opening statements – ‘Nothing will come of nothing, speak again’ – there is an intrinsic and fearful sense of the possible bleakness of our existence. Our predecessors felt it so painful that they preferred the happy ending version – the Nahum Tate version, which dominated the English stage from 1681 to 1834. Perhaps King Lear should be prescribed reading for the MRCPsych, although voluntary exposure would be a better way to understand its truth.

Nostromo by Joseph Conrad

Oddly enough, my favourite ‘big read’ of a classic novel starts off with a quote from Shakespeare: ‘So foul a sky clears not without a storm’. This is Nostromo by Joseph Conrad (1857–1924), ⁷ subtitled, rather quirkily, A Tale of the Seaboard. Deemed by classical critics as possibly the greatest novel in English of the 20th century, it is set in South America, possibly Colombia, and deals with the workings of an English-run silver mine and the outcome of a revolution. Its portrayal of characters, their relative isolation, a near-psychotic interlude of utter loneliness and the way people live as ‘social animals’ is unremitting and palpable. In fact, on my second reading, I had to read many of the chapters twice because of the amount of detail, and the sheer joy of just taking it on board made me think ‘why not read it again?’ It is this combination of the clarity of the language – even though English was Conrad's third, after Polish and French – the complexity of action and the way people think and act that makes Nostromo unlike anything else. If you read it through (and it would take a proper holiday away from the hurly-burly of everyday activity and IT) it is likely to change the way you think about things.

Father and Son: A Study of Two Temperaments by Edmund Gosse

An equally haunting description, this time of an intense individual, is provided by Edmund Gosse (1949–1928) in his autobiographical work Father and Son: A Study of Two Temperaments. ⁸ As a leading literary figure of his time, Gosse wrote many critical works and was very much at the heart of the English literature and publishing world. He was, for example, Librarian to the House of Lords before the First World War. His memoir, however, derives from his idiosyncratic upbringing by a parent who, although a reputed Victorian zoologist, was also one of the most radical defenders of religious belief in Britain. Gosse senior fervently attempted to reconcile the findings of geology and scientific theories of the length of the Earth's existence with the description of the beginning of the world in the Book of Genesis, arguing that fossils had been deliberately placed there by God to test our faith. Edmund's young life was characterised by endless readings of the Bible and constant attempts to undermine understandings of the Darwinian world, as well as considerable isolation. Unsurprisingly, he developed a growing distaste for the Holy Scriptures and, while loving his father, had to move away from the world of evangelical religion. Edmund described having no clear recollection of his first outburst against this, which was when his father asked his daily question of whether Edmund was ‘walking closely with God?’ and Edmund responded by fleeing the house. The book is a detailed and loving description of growing up in a world in which he simply did not believe, and having to reconcile his own understanding with a reluctance to break from (and of necessity hurt) a loving parent. The fact that Gosse junior emerged so bright, sociable and integrated with the world, despite this fervent upbringing, is made understandable by the gentleness of his language and the generosity of spirit evident in his memoir.

Sword of Honour trilogy by Evelyn Waugh

As someone brought up by more liberal parents, whose young lives had been dominated by the Second World War, I cannot exclude that particular influence from my piles of reading. Evelyn Waugh (1903–1966) was recommended to me by my father and I first read his work in Kuala Lumpur Railway Station. Waugh produced the Sword of Honour trilogy, ^9–11 which describes his own wartime experiences in novel form. It follows the ‘magnificently chequered’ career of Waugh's alter ego, Guy Crouchback, an idealistic Catholic dealing with a range of mad, funny, desperate and vicious characters as he makes his way through the chaos and betrayal (as he saw it) of his ideals during the war. Waugh writes like a dream; there are episodes of truncated conversations and off-beat discussions in the midst of, for example, landing on a moonlit beach in Crete and being shot at by Germans while drunk. He also dealt with the corruptions of the society that allowed all these events to happen. Although Waugh himself was an apoplectic, socially inept semi-alcoholic with a barbiturate habit (his short story The Ordeal of Gilbert Pinfold describes an episode of hallucinations when withdrawing from barbiturates and should also be required psychiatric reading), his understanding of the way people think about things, and the disconnections between people, is always astute and often very funny.

Mrs Dalloway by Virginia Woolf

Finally, who can leave out Virginia Woolf (1882–1941) and Mrs Dalloway? ¹² I only read this several years ago, having previously felt too fearful of the whole Bloomsbury world, and not realising the extent to which Woolf could write with extraordinary detail and intensity, even about just one day in London (which is the nature of the plot of Mrs Dalloway). Woolf herself suffered from what was probably relapsing bipolar disorder, and ended up drowning herself in a Sussex river in 1941. Her description of Mrs Dalloway's sense of consciousness and the events surrounding her, of a visit to a leading psychiatrist in London, and the intriguing clarity of the way she gets inside her characters are, in that rather tired phrase, ‘part of modern sensibility’. It is not the kind of book you can read and put down quickly. However, although it is deemed some kind of ‘stream of consciousness’, it is wholly practical and clear, and the sort of work that we all think we should be able to write, using a day in our own lives. In that sense it is democratic, wise and sympathetic.

There are of course many other ‘Ten Book’ selections that could fit the bill, with endless permutations, but the task would be sweetly endless. Just trying to describe why a book is worth reading makes me envy the writing skills of my chosen authors.