A Rounded Dozen

Welcome to a new series in which we invite distinguished psychiatrists from around the world to select the 12 books they have found valuable in shaping their ideas and influencing their clinical practice. I must be candid. I was totally won over to the intrinsic worth of doing such an exercise when I was invited to contribute to the ‘10 books’ series of the British Journal of Psychiatry. I had to think long and hard but the effort was exhilarating. I discovered in an odd sort of way the figures who have proved central to the development of my career. Peter Tyrer, the Editor of the British Journal, graciously encouraged me to imitate the 10 books column. Hence the ‘rounded dozen’ concept. (I had immense difficulty confining myself to 10 books when I had to make my selections and thought a couple of extra places would not go amiss!)

I am delighted that a dear friend and mentor, the eminent German psychiatrist, psychoanalyst and family therapist, Helm Stierlin, acepted my invitation to launch the new column. His ‘essay’ is not only replete with fascinating psychiatric history but also reveals a colleague who is able to maintain an eager curiosity about the nature of our marvellous profession and a willingness to alter his way of thinking in the light of new conceptual and empirical knowledge. I commend his essay to you and hope you are as inspired by it as I am.

I shall be inviting other eminent psychiatrists to prepare a ‘rounded dozen’ but welcome any suggestions from the readership for potential contributors.

Sidney Bloch Editor

I had a hard time deciding which books I should include in my Rounded dozen. Finally, I have chosen 12 books that I have come to view as landmarks and/or turning points in a psychiatric career spanning over half a century.

My career began in fact when I made the acquaintance of Karl Jaspers, a man who started out as a psychiatrist but turned more and more into a philosopher. From 1946 until 1948 I attended a number of his philosophical seminars. These focused mainly on Immanuel Kant and Max Weber, the latter then known as a sociologist, but in Jaspers' eyes the greatest philosopher of the modern age. In searching for a topic for my doctoral thesis in philosophy I finally settled on John Dewey. Jaspers was not familiar with him and therefore turned to Hannah Arendt for advice. Her message was – Dewey is not a philosopher; he is an educator. Jaspers nonetheless let me stick with Dewey. The title of my thesis was ‘On the concept of responsibility/models for conceiving a scientific ethic with special consideration of John Dewey in comparison with Immanuel Kant and Max Weber’. The concept of responsibility has continued to preoccupy me as a psychiatrist and psychotherapist. I have therefore chosen Human nature and conduct [1] as the first book of my dozen. In it Dewey elaborates the principles of his pragmatic philosophy succinctly and provides many examples of how notions about human nature have consequences for human conduct.

My second book is also outside the field of psychiatry. I view Max Weber as one of the greatest scholars who taught at the University of Heidelberg. By the time I started studying there he had been dead for more than a quarter of a century but he was present in many of our discussions and encounters. Jaspers was not the only one to refer to him constantly. His widow, Marianne Weber, hosted monthly seminars, several of which I attended. and his younger brother, Alfred Weber, conducted seminars for students in his apartment. At one of these I delivered a paper on Dewey in which I referred to Weber. This caused Alfred – an impressive thinker yet always in the shadow of his famous brother – to comment: ‘It's high time that I got to grips with the works of my brother’.

Weber's Sociology of religion [2] impressed me particularly. I know of no other book which so clearly links basic assumptions guiding human conduct to different historical and social settings, thereby showing how they impinge on belief systems and motivational dynamics (that also underlie psychiatric disorders).

Karl Jaspers' General psychopathology [3] first appeared in 1913. I studied the 6th edition (it came out in 1953) during my last year in medical school. It is an amazing work of 748 pages. Jaspers wrote it when he was in his late twenties and working as a trainee in the University Psychiatric Hospital in Heidelberg. In rereading the book I am still astounded at the scope of his erudition and endeavour to provide psychiatry with a philosophical grounding. The index lists Kant almost as frequently as Kraepelin, who was then the most frequently quoted psychiatrist alongside Eugen Bleuler. The book was later translated into English and has found many readers world-wide. Although it ranks as a classic, it presents problems given the many research findings in our field which have accumulated since. It presents Jaspers as more of a theorist than as an experienced clinician. This is understandable in the light of the author's limited experience and access to patients at that time (partly because he suffered from a chronic medical condition which restricted his activities). His disdain for psychoanalysis also comes through in many ways. Freud was, for Jaspers, an evil genius liable to perturb a psychiatrist's orientation and conscience.

Perhaps most pertinent from my present vantage point was Jaspers' insistence that inner dynamics underlying psychosis are not accessible, through empathy, in the way neurotic behaviour is to a participant observer. He spoke repeatedly of an abyss of incomprehensibility that separated psychotic from ‘normal’ and neurotic dynamics. (However, there are passages in his General psychopathology which indicate that he was willing to modify his stance.) Eventually, he also softened his criticism of Freud. As his biographer, Hans Saner, mentions, Jaspers turned once, later in life, to the picture of his great hero, Max Weber, with the words: ‘He looks like Sigmund Freud; maybe there is more to this similarity than I have thought.’ Be this as it may, during my final year as a medical student, Jaspers' stance on the incomprehensibility of psychotic symptoms was repeatedly affirmed by Kurt Schneider, then director of the University Psychiatric Hospital.

I purposely acquainted myself with Freud despite, or because of, Jaspers' disdain for him. Two of my teachers, Alexander Mitscherlich and Viktor von Weizsäcker, guided me. I was inspired by Freud's New introductory lectures on psychoanalysis and other works [4]. I liked the didactic way in which he presented his ideas as well as his clear style. I also was so intrigued by what I read that to learn first hand about psychoanalysis I underwent an analysis in Munich, where I worked after graduating from medical school.

Freud's thoughts had, however, not caught on in German psychiatric circles. In fact, the contrary was the case. This was also evident in the Department of Neurology at Munich University where I took care of patients with psychiatric as well as neurological disorders. In line with the teachings of Jaspers and Kurt Schneider, psychotic patients were viewed as suffering from a brain disease of unknown origin. As antipsychotic drugs were not yet available, these patients were treated with sedatives, ECT and insulin shock therapy. After having been diagnosed and given initial treatment, most were transferred to local state hospitals. There, many became long-term residents. This kind of psychiatry did not satisfy me at all, particularly since only 10 years earlier, some of the psychiatrists in charge had participated in the atrocious Nazi euthanasia program.

It came as a relief and a revelation when I obtained a certain book in the local Amerikahaus (now the German-America Institute). The Amerikahaus had been established by American funds after World War II and was intended to give Germans an opportunity to learn about American democracy, literature and culture, and I did indeed benefit from this opportunity, not least because of the book Conceptions of modern psychiatry [5] I found in that library, written by an author whose name I was not acquainted with – Harry Stack Sullivan.

The book marked a watershed in my thinking. Suddenly, symptoms of psychotic patients which Jaspers, Schneider and other prominent German psychiatrists had described as the incomprehensible expression and consequence of an as yet unidentified brain disease began to make sense or promised to make sense when viewed in the context of the patient's upbringing, life experiences and social links. I was so taken by Sullivan's ideas that I decided to go to the US at the earliest opportunity to acquaint myself with this approach. I made every effort to find a job in one of the places where he had been active. I was lucky enough to be accepted at the Sheppard Enoch Pratt Hospital in Maryland where Sullivan had held a senior position even as a young doctor. After leaving Pratt he worked at the St. Elizabeth Hospital in Washington DC up to his death in 1949. He left behind a group of students who continued to edit his journal Psychiatry, incidentally then published on yellow paper which, Sullivan believed, was good for both eyes and mind.

Another significant book for me was Psychotherapeutic intervention in schizophrenia [6] by Lewis B. Hill, also a disciple and friend of Sullivan. Hill was my supervisor during my two years at Pratt where evidence of Sullivan's work was still detectable. For example, the so-called R-Building which Sullivan himself designed as a centre for young men with schizophrenia was still operating. He had decreed that only male nurses should have contact with these patients, given his view that schizophrenia was primarily due to a disturbed passage to genital adulthood.

Hill incorporated Sullivan's ideas and those of the psychoanalyst Sandor Ferenczi, whom he had visited in Hungary. With Ferenczi and Sullivan as mentors, he viewed schizophrenic symptoms as understandable and treatable with psychotherapy. This stood in stark contrast to what I had learned from my teachers in Germany. I was so taken by Hill's book that I later translated it into German. Hill also directed my attention to other authors who subsequently became important to me. One was Frieda Fromm-Reichmann, the other was Gregory Bateson. I was fortunate to know both personally.

I met Frieda in 1957 when I started work as a staff psychiatrist at Chestnut Lodge. The ‘Lodge’ was then the Mecca of psychoanalytic and Sullivanian psychotherapy for psychoses and Frieda its revered supervisor. By the time I met her she had become famous on account of I never promised you a rose garden [7] by Hanna Green, in which the latter had given a fictionalized account of her three-year treatment by Frieda at Chestnut Lodge. Frieda had been inspired by Freud and Sullivan when writing her own oeuvre, Principles of intensive psychotherapy [8]. The book became my Bible. In it, Frieda described and analyzed psychotic symptoms similar to the way Freud had approached neurotic symptoms. However, in her view conflicts resulting in psychotic symptoms originated earlier and became more deeply entrenched than conflict engendering neurotic symptoms. They therefore required a longer, deeper working through in the activation of transference and counter-transference. Frieda also believed the human environment could possibly contribute to schizophrenia and introduced the term ‘schizophrenogenic mother’. Alas, this subsequently caused much harm because it insinuated that parents were guilty of producing schizophrenia in their offspring. Nonetheless, Frieda was, besides Sullivan, one of the first therapists to pay attention to what I came to call the ‘existentially relevant system of belonging’. She was also instrumental in directing me to the next book on my list Invisible loyalty [9], by Ivan Borszormenyi-Nagy and Geraldine Spark.

Invisible loyalty has been translated into many languages. In Germany it became a bestseller in psychotherapeutic circles. I have been in close touch with Ivan for 40 years and had the opportunity to witness the evolution of his ideas. They fit into a multigenerational perspective in which generations of family members make up the existentially relevant system of belonging. Ivan pays special attention to two processes which a psychotherapist of families as well as of individuals should bear in mind: ‘invisible loyalties’ and ‘invisible accounting’. Invisible loyalties can engender conflicts which reverberate across generations. ‘Invisible accounting’ alerts us to the dynamics of ‘give and take’ which play a pivotal role in intimate relationships. Ivan compares his position with that of classical psychoanalysis but instead of focusing on why intrapsychic conflicts develop, he examines the history of the family and pays attention to intrapsychic and interpersonal conflicts originating in that history. Ivan has extended the context for psychoanalytic observation and thinking. His work inspired me to develop my own concept of ‘delegational dynamics’ [10–12] which I have elaborated in various writings.

Gregory Bateson's Steps to an ecology of mind [13], which appeared in 1972, is subtitled Collected essays in anthropology, psychiatry, evolution and epistemology. More than his other works, Steps reveals Bateson as a restless wanderer between scientific worlds, who in seminars and written word gives evidence of ‘loose’ and ‘strict’ thinking. Loose thinking is highly metaphorical which, Bateson believes, can lead us to discover new phenomena and connections. Strict thinking then critically scrutinizes and orders these constructs. He is best known for his double-bind theory, which intrigued and inspired many clinicians and researchers grappling with the riddle of schizophrenia. Bateson altered this position later and no longer regarded the double-bind as pathogenic. The essay on this topic is only one chapter among many. In its totality the book reveals Bateson as the pioneer of systemic thinking. Not surprisingly, at one point he refers to cybernetics as the most pivotal event of the 20th century, alongside the peace treaty of Versailles! His reflections and observations have caused me to reconsider many basic assumptions which had guided me as a therapist. All in all, his thinking is in accord with what Nietzsche once wrote: ‘It's not the courage of your convictions that counts but the courage to question your convictions’.

My next book is actually a collection of four articles by Lyman Wynne and Margaret Singer, which were published as a special issue of the German journal Psyche (1965; 19:82–160) and appeared originally in the Archives of General Psychiatry [14–17]. They deal with the subject of how certain patterns of parental communication may contribute to the development of schizophrenic symptoms. Their studies centre around the nature, significance and possible predictive power of ‘communication deviance’. In order to identify the disturbed patterns in their probands, the authors used the Rorschach test to study interpersonal communication. Their focus was on how probands made sense of the pictures and how the parental couple communicated with each other about what they saw. Singer then made predictions whether schizophrenic symptoms might show up in their children. Although she was amazingly successful, the studies were heavily criticized and could not be replicated. Nonetheless, I would maintain that these pioneering studies ushered in a hopeful phase in our understanding of schizophrenia and of human communication generally.

Wynne and Singer's work also inspired our own Heidelberg research team in the 1980s. Most of our clinical and research activities were then geared to the family therapy of schizophrenic, bipolar and schizoaffective patients. We were interested in patterns of communication in families with diagnosed offspring and their implications for psychotherapy. We paid special attention to how the family members communicated – clearly or obscurely, sharing a common focus of attention or not, and the occurrence or not of complementary or symmetrical patterns (as described by Bateson).

Our group also came to appreciate the work of the Milan family therapy team: Mara Selvini Palazzoli, Gianfranco Cecchin, Luigi Boscolo and Giuliana Prata. We were fortunate that we were able to welcome them to Heidelberg on several occasions and learn first hand from their experience. We also benefitted from their Paradox and counter-paradox [18], another selection for my list. This book helped us to become experts in devising paradoxical interventions. Although we abandoned their use in the early 1980s, I still reminisce about a time when we were enthusiastic, albeit shortsighted, researchers. In retrospect, it seems our families did gain from this enthusiasm, as shown in follow-up studies. This also accords with observations of the Milan team. As Boscolo told me recently, they also had most enduring results when their inventive use of paradox and counter-paradox flourished.

The last of my rounded dozen was the main text for my last period of teaching at the University of Heidelberg: An uncommon casebook [19]. O'Hanlon and Hexum collected brief summaries of 316 patients treated by the legendary therapist, Milton Erickson. Each summary contains a description of the presenting symptom, therapeutic approach, number of sessions and results of follow-up (whenever feasible). In many cases Erickson applied hypnotherapy but often used other procedures. One patient was a pilot, a hero of the Korean war, but presenting with severe alcohol dependence. When he first saw Erickson he presented a sheet of paper which listed all the honours and medals he had earned. After a brief glance at the list, Erickson flung the sheet into the waste-paper basket. The patient was understandably perturbed. ‘You are no longer this man of achievement; you are just a miserable drunkard’, Erickson told him. Within a few sessions, he managed to provoke and engage the patient in such a way that he ceased drinking, was successfully re-employed as a pilot and reorganized his life. I found it noteworthy that Erickson did not use the same approach even with patients presenting with similar symptoms. I derived the book's main message as: psychiatry and psychotherapy challenge us both as scientist and artist.

Milton throws up a challenge to us. On the one hand, we need to reduce the ever growing complexity in our field so as to facilitate clear communication and cooperation with our colleagues and with our patients and, on the other hand, we need to accept and learn to live with this complexity.