When art and medicine collide: using literature to teach psychiatry
When we read alone and for pleasure, our defences are down - and we hide nothing from the great characters of fiction. In our consulting rooms, and on the ward, we so often do our best to hide everything, beneath the white coat, or the avuncular bedside manner. So often, a professional detachment is all that is left after all those years inured to the foibles, fallacies and frictions of our patients' tragic lives. It is at the point where art and medicine collide, that doctors can re-attach themselves to the human race and re-feel those emotions which motivate or terrify our patients . . . Every contact with patients has an ethical and artistic dimension, as well as a technical one.1
AIMS OF THE CHAPTER
Duncan Macmillan House is an imposing Victorian building that was formerly an asylum, at the edge of Nottingham city. Nowadays, with the city's enlargement, it occupies a less peripheral position and is the headquarters of an NHS mental health trust. It no longer serves as a hospital. Thoroughly modernised from the inside, it still retains an impressive but somewhat sombre visage. Each time I enter, I wonder what life was like for those who lived or were incarcerated there.
Much of this chapter was written sitting in the library of Duncan Macmillan House, opposite a section devoted to 'fiction and mental illness'. Its shelves hold a wide range of literary styles and works from Bronte's Jane Eyre, through F Scott Fitzgerald's narrative of a troubled psychiatrist, Tender is the Night, to more recent books like Mark Haddon's accurate portrayal of the world as experienced by a young man with autism, The Curious Incident of the Dog in the Night Time.
Six years ago when I started work as a junior doctor, this section of the library's catalogue didn't exist. Today, judging by the steady stream of visitors, it is one of the most used sections. What this large collection of books illustrates is how pervasive mental illness themes are within our culture and how rich a resource these fictional accounts are in the training and further development of mental health professionals.
Over the last few years, I have had the opportunity to teach psychiatry to both postgraduate and medical undergraduate students. Hesitantly at first, I started to use examples of characters from books and films to illustrate psychopathology, diagnoses and the complex psychosocial problems that often accompany mental illness. I thought that this approach might clarify and reinforce concepts that students often described as abstract. What could be more 'real' than the character suffering from morbid jealousy in Enduring Love (1997), who stabs the rival for his love in delusional rage?
Soon after they started, the 'literature' sessions were over-attended. Anyone who has ever tried to maintain the enthusiasm of students on late Friday afternoons will know, this was a considerable achievement.
A couple of years later, the opportunity to teach undergraduate medical students as part of a humanities-based module looking at the links between arts and psychiatry arose. Since then I have led the seminar on 'Literature and Psychiatry' as part of the module.
There is a growing awareness of the usefulness of medical humanities within the medical curriculum. However, the idea that this is an 'add-on' to the mainstream curriculum remains prevalent. Writing in 1999, at the introduction of a new journal on medical humanities, Evans and Greaves noted: 'In many ways, the position of the medical humanities resembles that of medical ethics 20 years ago, when its modern form emerged in Britain as an absorbing academic discourse but not yet the integral part of medical education and practice that it has now become'.2
The situation has improved since then, however the use of humanities is still viewed as a peripheral supporting activity rather than a mainstream method of imparting knowledge, skills and attitudes. When I started using these methods a few years ago, other clinicians would comment on how the students would appreciate doing 'something' a bit different and how they might gain 'something' from it. Although I appreciated their acceptance of my teaching style, implicit in their comments was the notion that at best, the humanities would just add 'something' and were not an integral factor in medical education. Richard Smith has observed: 'The additive view is that medicine can be 'softened' by exposing its practitioners to the humanities; the integrated view is more ambitious aiming to shape the nature, goals and knowledge base itself'.3
I am aware that some people are sceptical about the approach that this chapter, and indeed this book, takes and they believe that the arts are too 'woolly' to impart meaningful knowledge to the student. There are commentators who suggest that the arts do not make people more sensitive. Harold Bloom, a literary critic, has observed that reading literature is a selfish activity and does not necessarily make us better, more caring people; it can expand our intellectual horizons but does not engender a sense of altruism.4 Oscar Wilde famously declared that 'All art is quite useless' and denied any suggestion that it could be educationally or morally uplifting. After considering both the pros and cons of reading literature, Beveridge concludes that it is up to the individual psychiatrist to decide whether literature is worth exploring in his or her professional development.5
This chapter is a practical guide to establish a session using literature to teach psychiatry. I will also consider the arguments in favour of using literature to teach psychiatry as this might be discussed at such a session. The chapter also includes a list of resources that could be used, however these are not explored at any great length. Oyebode has provided an excellent account of many of the resources that could be used.6