Neil Scheurich, M.D.

Contact Information:
Department of Psychiatry
University of Kentucky College of Medicine
3470 Blazer Parkway
Lexington, KY 40509
nesche2@uky.edu

Introduction

Most people involved in the teaching of narrative medicine know the experience of working with medical students, residents, or even colleagues who simply cannot summon much interest in the subject. They may be polite about it, and if there is an assignment, they may well read the material and engage in perfunctory discussion. But no sense of passionate or vital interest develops. Generally, of course, such individuals are not serious readers on their own time, and clearly they are not impressed by the values that the instructor locates in reading. Often such persons are quite competent students or physicians as well as apparently successful in their personal lives. Is it presumptuous, then, to think that they are missing out on something crucial?

For a while I felt a certain déj? vu when working with what I would call the unreflective student. At length I realized that the experience was parallel to a common clinical situation: the patient who seems likely to benefit from psychotherapy but who has no inclination for it. Not infrequently patients reject psychotherapy not for financial or other logistical reasons, but rather because they simply prefer the idea of medication or see no value in considering their lives in a systematic way. It often seems that such patients are not merely being difficult; they genuinely fail to appreciate any outstanding virtues of psychotherapy. If medication seems to treat the symptoms they came for, is it an unwarranted imposition of opinion to feel that anything is amiss?

To be sure, students, residents, and colleagues are not patients, nor is reading literature congruent to undergoing or providing psychotherapy, even if it is widely recognized that there is a narrative aspect to both. But the question of why either process should be valued supersedes both literary criticism and purely clinical prudence. Advocates of both literature and psychotherapy often find themselves struggling to articulate the worth of those experiences to unconvinced audiences. In this paper I propose that literature and psychotherapy, while obviously distinct in a number of ways, share a group of core values that are widely seen as endangered within psychiatry as well as within contemporary culture.

A Changed Psychiatry

Why read? Or why discuss intimate details of one’s life to a stranger designated as a therapist? Within English departments and psychoanalytic institutes, respectively, an avid interest in such questions is taken for granted. But within general psychiatry, as in the wider society, literature and psychotherapy are very much situated in a marketplace of ideas (the figure of speech is apt) and require justification. This was not always the case, of course. When psychoanalysis and other psychotherapies were central to psychiatry, both authors and fictional characters served as ideal clinical material; for this and other reasons, psychiatry and narrative modes long enjoyed a natural kinship. In psychoanalytic circles, fiction and film may be as often utilized as ever.

Proponents of narrative medicine have not often emphasized psychiatry, perhaps in the belief that the importance of narrative should be self-evident in that discipline. However, as evidence-based practice, managed care, and standardized diagnosis have brought psychiatry closer to general medicine, the relevance of literature and even psychotherapy have become far from obvious. Residents and medical students face crowded curricula and must master prodigious amounts of information. While I know of no data on the subject, many veteran psychiatrists remark that current psychiatry residents have less interest or background in the humanities than those of past decades. It is perhaps not a coincidence that one frequently encounters residents or even practitioners who wish to confine themselves to “medication management” and leave psychotherapy to social workers. Even in psychiatry, is either literature or psychotherapy worth the time and effort? After a review of attempts to give an affirmative answer for both disciplines, their shared themes will become apparent.

Why Read?

Naturally enough in an increasingly evidence-based medical milieu, literary advocates have tried to demonstrate literature’s instrumental value. One has to market literature, so to speak, by positing its value as information or as ethical admonition. Literature is held to provide clinical case material that trainees may not have the time or opportunity to encounter in actual practice, or it is said to specifically enhance a caring attitude by fostering empathy. However, those who care about literature, myself included, often have misgivings about using it as a crude means to the end of the better completion of a task, even one as subtle and multifaceted as psychiatry. Literature surely is much more than a series of footnotes to Aesop.

Those who prize reading in general, and as more than simple entertainment, often are not reading explicitly to acquire information or to augment their virtue. What kind of approach to a work of literature is simultaneously relevant to the practice of psychiatry and linked to more general notions of aesthetic experience? I would suggest that beyond any usefulness as clinical material, literature is crucial to psychiatry for the same reason that it is important for life. In both cases, literature is not about improved task completion, but rather offers alternative modes of being in the world.

In a recent summary of arguments for and against the importance of reading fiction for psychiatrists, Allan Beveridge (2003) noted literature as a means to other ends as well as an end in itself. Narrative medicine very much recapitulates the venerable aesthetic project of justifying literature and other art. As Arthur Danto (1986) has described, ever since Plato advocated the political control of poetry, philosophers and critics have tended to explicate art and to reduce it to more fundamental terms. Richard Rorty (1989) argued that a primary function of literature is the admonitory depiction of cruelty. Martha Nussbaum (1990) viewed fiction almost as a branch of moral philosophy, one whose narrative form and emotional content appeal specifically to human understanding.
Art’s alleged usefulness has forever provoked spirited defenses of aesthetic autonomy. Kant’s aesthetic theory was based the notion of detached disinterest. In her essay “Against Interpretation,” Susan Sontag (1990) protested criticism that seems to distrust and even attack art’s pretensions. Stanley Fish (1998) has maintained that the reading of poetry is a self-contained professional discipline, of no relevance whatever to one’s political or moral beliefs. To such thinking, art is a hermetic enterprise and quite literally amoral.

Claims of art’s autonomy lead to charges of irrelevance and escapism. If art has no implications at all beyond itself, then arguably the arts may be on a par with hobbies, or any other pleasurable pastimes. If this is the case, then opera and epic poetry, much like bowling or professional wrestling, are merely activities that some people choose to pursue for fun. Of course, devotees of the arts tend to hold that their pursuits do possess a wider significance.
There have been various attempts to balance the autonomy and the relevance of art. Clifford Geertz (1997) pointed out that artists and critics, who tend to argue from a point of view in which the general merit of the arts goes without saying (perhaps not least because it is the source of their livelihood), often lose sight of the fact that any art form only exists within a cultural network of meaning. This echoes the view of John Dewey (1934) that art cannot justifiably be abstracted from individual experience. Such thinkers point out that throughout most of world history art was assumed to be bound to cultural practices; the notion of “fine art” detached from all other interests has arisen only in the last two centuries, and primarily in the West. Barbara Herrnstein Smith (1991) has maintained that aesthetic experience always entails an aspect of evaluation. While we don’t usually read for information or any other concrete end, we do expect some kind of benefit inasmuch as there are various other endeavors that offer competing claims on our time and energy. Since potential readers could choose not to read, they are most certainly “interested” rather than detached.

Many philosophers have arrived at a belief that art is somehow enriching, but not in a way that translates into specific moral precepts. Dewey claimed that the arts function to enlarge the sphere of human possibility, and he concluded his Art and Experience by claiming that “Imagination is the chief instrument of the good…The moral prophets of humanity have always been poets even though they spoke in free verse or by parable” (1934, p. 348). George Santayana (1955) held that aesthetics establishes the realm of positive values, those things that are the ends of life, whereas morality has a necessary but secondary and negative function, that of removing obstructions of those positive values. Heidegger’s (1964) aesthetic theory was similarly visionary – he wrote that art “deconceals” the truth of “Being” and that “Towering up within itself, the work opens up a world and keeps it abidingly in force” (p. 672). Jean-Paul Sartre (1988) saw reading as a challenging, imaginative act that broadens the scope of human freedom. Such accounts second those of poets such as Sydney, Shelley, and Emerson who have championed the transformative aspects of literature.

Recent commentators have touted reading at a time when the visual seems to monopolize our lives. According to Sven Birkerts (1999, p. 108), “The finished work, the whole of it, then enables the reader to project a sensible and meaningful order or reality, one that might be initially at odds with the habitual relation to things.” Harold Bloom (2000, p. 22) has said that we read “in order to strengthen the self, and to learn its authentic interests” but he insisted that the point of reading is not to improve others or our society. Mario Vargas Llosa (2002), dumbfounded and alarmed by the decline of serious reading, mourned the increasingly prevalent notion that reading is a “luxury” for which even educated people cannot seem to find the time. These critics see literature as neither a solipsistic pursuit nor a shortcut to compassion or other attributes. Rather, reading is a mode of being in which time seems to slow down and one’s attentiveness and flexibility of perspective are expanded. As Kafka (quoted in Manguel, 1996, p. 93) famously but violently put it, “A book must be an axe for the frozen sea within us.” Like friendship or love, reading has a spiritual function, the ends of which are inseparable from the means. Such experiences may have favorable consequences, but when merely focuses on results, the point of the activity is lost.

What is one to say, then, of those who read purely for “relaxation” or not at all? Surely there is no simple correlation between reading and morality. It would be ludicrous to claim, for instance, that English professors are necessarily more virtuous than, say, physics professors, and countless literary types in the history of the world have been scoundrels. Conceivably, reading could be said to consume time and energy that could be devoted to actively improving the world. Other things being equal, it is not clear that the non-reader is any less successful than the devoted reader. Indeed, one could suspect that the avid reader is naturally more wicked and less imaginative than others if he feels the need for such extensive moral instruction. Of any given reader who is a wise, virtuous person, it is impossible to say which came first, practice or personality. The reader can probably only say that the non-reader suffers from a kind of spiritual blind spot, that something worthwhile has been missed. The components of the peculiar spirituality in question will be made clear after a review of the battles over psychotherapy in contemporary psychiatry.

Justifying Psychotherapy

Just as many people sail through life without books, many psychiatrists would argue that any psychotherapy that fails to show clearly measurable clinical benefit is dispensable. Remarkably parallel to the situation of literature and medicine, recent attempts to justify the role of psychotherapy within psychiatry have begun with utilitarian arguments but have not ended there. By “psychotherapy” I intend neither psychoanalysis nor any other specific technique, but rather the very broad category of clinical interventions attending primarily to a patient’s subjectivity, motivation, and capacity for internal change.
As alleged support for psychotherapy’s legitimacy, brain imaging studies have demonstrated that the talking cure produces specific and discoverable changes in the brain. For instance, positron emission tomography has revealed that cognitive and behavioral therapies affect the metabolic rate in a specific area of the brain in patients with obsessive-compulsive disorder. The point of this has been to show that talking does not influence a disembodied “mind” or “spirit,” but rather the same organ affected by somatic therapies.

Psychotherapy’s supporters have also acceded to the demands of evidence-based medicine. Glen Gabbard (2002) defended the clinical effectiveness of psychoanalytic therapies but acknowledged that a major evidence-based initiative is needed to clearly show their effectiveness. Gabbard (2001) has also spear-headed the claim that psychiatrists, supposedly trained to contend with all three components of the “biopsychosocial model,” are uniquely positioned to provide psychotherapy. He appealed solely to considerations of effectiveness and cost, however, and omitted further philosophical concerns.

Other voices, many of them outside of medical psychiatry, have protested the very terms of the debate and have advocated a quite different rationale for psychotherapy. Increasingly, psychotherapy has been understood less as a narrowly clinical intervention than as one of many human endeavors of meaning construction—its borders with narrative, philosophy, and religion are fuzzier than ever. As such, psychotherapy is an alternative expression of the human need for significance and therefore valuable far beyond its effects upon clinical symptoms. Eric Johnson and Steven Sandage (1999) argued that any psychotherapy worth its name cannot avoid engagement with general questions regarding the vital concerns of life. Jeremy Holmes (1996) held, in opposition to claims that psychotherapy merely increases attention to the self, that properly executed psychotherapy heightens awareness of all moral considerations, including those of other persons.

Interest in existential aspects of psychotherapy, somewhat neglected since the work of Viktor Frankl (1959) and Irvin Yalom (1980), has regained prominence. Advocating an empowering function of psychotherapy, John Mack (1994, p. 178) stated that being "creator of one’s life…is essential to the sense of self.” Others have noted the salience of existential themes in cognitive therapy. Chris Brewin and Mick Power (1999, p. 143) asserted, “There is little question that issues of meaning form the heart of most forms of psychopathology.” As they noted, however, the mentally ill do not suffer from meaninglessness per se, but rather from a plethora of pernicious meanings such as self-hatred and radical mistrust of others. What psychotherapy calls for, perhaps even more than the interpretation of hidden realities, is the imagination of alternative possibilities.

Advocacy of psychotherapy has been linked to resistance to what are widely perceived as hegemonic tendencies within medical psychiatry: concentration upon efficiency and cost, increasingly standardized clinical understanding, and a related preoccupation with pharmacology. In a typical protest, Osborne Wiggins and Michael Schwartz (1999) decried the “loss of the personal” in psychiatry. Proposing that managed care and evidence-based medicine could distort basic values of human self-understanding, Philip Cushman and Peter Gilford (2000, p. 993) advanced a “hermeneutic vision” as opposed to “the attempt to reduce human being to hyperconcrete, quantifiable behaviors.” A. Donald (2001) described as “the Wal-Marting of American psychiatry” the tendency of mindless cost-control measures to produce a vision of human beings as generic and interchangeable. In her apologia for psychoanalysis, Elisabeth Roudinesco (1999) argued that the claims of psychotherapy’s critics rest upon very questionable assumptions about human nature, such as the desirability of smoothing over conflict and difference.

Outside of the profession, the ascendancy of psychopharmacology has generated the most unease. Critics such as Carl Elliott (2000) and James Edwards (2000) have maintained that medication is often misused for spiritual crises and that we should more carefully deliberate about how it is that we should live. Their critiques implicate not only psychiatrists, but also patients, many of whom are lured by culturally ambient promises of painless fixes for human problems.

The gist of these accounts is that the value of psychotherapy cannot be captured economically, by simple-minded standards of cost, efficiency, and generic symptomatology. Like literature, the endeavor often leads to clearly positive outcomes, but even when it does not, it may produce subtle changes in development and outlook, progressions in self-examination and agency, that have a spiritual aspect. Obviously psychotherapy is no panacea, just as literature is no help for many of life’s challenges. But two individuals who have reached the same quantitative improvement on a depression rating scale, one with Prozac and one with psychotherapy, are not indistinguishable: only one has had an experience as well as a result.

Values Common to Reading and Psychotherapy

I must reiterate what should be obvious, that literature and psychotherapy are not interchangeable endeavors, and there are many human problems for which neither is necessary or even helpful. However, the arguments reviewed above suggest that they share a group of essential values, which I would identify as autonomy, complexity, and for lack of a better term, patience. Such qualities are perpetually endangered, it seems, in both medical and psychiatric training and practice.

Many readers would argue that literature nourishes the autonomous self. It provides self-understanding as well as awakening to novel possibilities. Most important, great literature is endlessly eye-opening, resisting encapsulation by wider systems of explanation. Like “the postmodern” according to Jean-Francoise Lyotard (1985), literature is revolutionary and liberating inasmuch as it challenges totalizing social influences. Analogously but from a quite different perspective, Harold Bloom (2000) exemplifies those who decry the “multicultural” trend in literary studies precisely because they view this as a stunting of the possibilities of reading.

Psychotherapy at its best is likewise fundamentally empowering. Certainly biological treatment also may remove impediments to human freedom, just as psychotherapy that is rigid or inept may do the opposite. However, psychotherapy not only overcomes internal barriers, but also is the preferred setting for exploration and challenge of the ideals of sameness, productivity and unthinking “level of function,” values that are latent but widespread in contemporary psychiatry and Western culture (in alternative cultures or subcultures, a psychotherapy may dispute quite different values). Like the best literature, the best psychotherapy takes nothing for granted: it fundamentally unsettles.

Books and therapists also share the presumption of human depth and complexity, the notion that experience is not reducible to a finite number of meanings. Both resist the idea that understanding is a matter of “sound bites” or that mental life is entirely captured by diagnoses. Both acknowledge a deep ambiguity that is in principle impervious to elimination by scientific advances, an ambiguity that makes people uncomfortable. To appreciate the complexity of human well being is to recognize that there is no adequate way to quantify it, by rating scales or otherwise: depth is inevitably lost in the process.

Finally, I use “patience” for the notion, increasingly foreign in a frenetic culture, that it takes time to engage with issues of autonomy and complexity. In medicine as in society in general, it grows difficult to question the demands of efficiency and productivity. Reading and psychotherapy both undermine the seductive distinction between ends and means; both propose that to be is as important as to do. Immersed in a maelstrom of sorts, both medical students and patients seem to struggle when asked to slow down, to take time to attend to subtle details within and around them. Indeed, a common theme of this discussion is difficulty: it is often superficially easier for people to feel that they have no choice, to reduce the world to tidy bits of information, and to engage in hectic but unthinking activity. The premise of both literature and psychotherapy is that the periodic discomfort of the “examined life” culminates in a more satisfactory way of being. Both endeavors often entail attention to unpleasant, even horrible aspects of experience in the hope that suffering, when properly contained and considered, may widen one’s vision.

Critics of these views might argue that we have plenty of autonomy, complexity, and patience as it is and that these things too easily mutate into rootless individualism, gratuitous complication, and idle self-absorption (if this happens, it seems unlikely that responsible reading would be to blame). And naturally, both literature and psychotherapy have other, less ambitious functions at times, such as entertainment and support, respectively. These are not necessarily trivial, but I would suggest that the unique significance of the two practices, the reason why they rouse such strong feelings pro and con, is the distinctive vision of human possibility they share.

Of course, I have not spoken at all about practical issues. Psychotherapy should not, after all, be a way of life; therapists, more so than authors perhaps, should have the goal of rendering themselves unnecessary. And for those lacking independent means, there is the question of how much the government or third-party payers ought to subsidize the autonomy, complexity, and patience of psychotherapy. The matter is well beyond this discussion, but it is worth pointing out that there is an approximate parallel in the persistent debate over the relative importance of the humanities and the sciences in education. My argument is that tax dollars are supporting similar values whether applied to a high school English class or to a Medicare patient’s psychotherapy. Just as the former does more than train the future “work force,” the latter aims at more than symptom relief.

Literature for Psychotherapists?

Being alive, or being in therapy, is of course not the same as writing or reading a story. The former experiences have infinitely more at stake and less room for error. Commentators such as Robert Coles (1989) and Samuel Shem (1991) have sought a tie between psychotherapy and literature by alluding to patients of theirs who shared literary interests. But this is a rare happenstance, as the great majority of patients, like most people in general, have no active interest in serious literature. If bibliotherapy were enough, then actual therapy would not be in such perennial demand, and there is much more to therapeutic technique than narrative competence. And great literature is obviously not ipso facto redemptive – Ernest Hemingway and Sylvia Plath, like countless others, authored great works yet ultimately succumbed to despair.

Lest there be concern that a paradigm of aesthetic meaning leads to detachment from the “story” of the patient, I would argue that the relation of the therapist to the therapy is preeminently an ethical and not an aesthetic one. Rather, it is the patient who bears an aesthetic relation to the therapy, who seeks a transformation of the life story. After all, it is the patient and not the therapist who is free, within reason, to drift in and out of therapy much as one might browse in a treasured book over time.

Certainly one can use literature to teach psychiatry residents and medical students some of the cognitive nuts and bolts of psychotherapy, such as interpretation of meaning and motivation. That is, authors and fictional characters can be made into clinical subjects of a kind. But I want those I teach not merely to gain a “clinical pearl” or two, but rather to come to care about literature and the values it embodies, values that, I have argued, also underlie psychiatry’s mixed status as both liberal art and science. In other words, I think that literature does more to strengthen the spirit of the enterprise than to convey specific techniques. Just as literature can be a safe and convenient way to vicariously “try out” various ways of life, it can also put us into the right frame of mind, so to speak, for exploring the possibilities of persons.

I suggest that literature can animate, enliven, and restore, although it does these things in a supremely subtle manner, and it is unlikely that reading Pride and Prejudice will provide specific ideas for clinical interventions. Indeed, I would consider a wide-ranging engagement with literature to perform a function analogous to that of ongoing supervision: both defend against fatigue and narrow-mindedness. In his essay “The Noble Rider and the Sound of Words,” Wallace Stevens (1997, p.665) wrote that the imagination “seems, in the last analysis, to have something to do with our self-preservation; that, no doubt, is why the expression of it, the sound of its words, helps us to live our lives.” I would argue that such imagination makes better psychotherapists as well.

The parallel debates of narrative medicine and psychotherapy are therefore not primarily—and certainly not merely—empirical ones. The colloquial notion of “culture war,” if rather too belligerent in this context, nonetheless conveys the often irreconcilable differences between those who see or fail to see the worth of serious reading and listening. Particularly at the level of medical school or residency, the values that drive the two endeavors cannot be imposed, but rather insinuated. Similarly, we obviously cannot compel patients to engage in psychotherapy. Those who care about such things should continue to insinuate, free of the suspicion that there is some as yet undiscovered, ultimate justification that will relentlessly open the eyes of the indifferent.

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