The Wisdom of the Ego by George Vaillant

The Wisdom of the Ego ^{Reference Vaillant2} is George Vaillant’s creative take on the data that have been collected as part of the Harvard Study of Adult Development, which started in 1937. Vaillant was recruited as a young researcher to oversee the interviews with over 500 men and women, who agreed to give repeated interviews over decades and answer questions about their mental and physical health, their relationships and work patterns, and their drinking habits. Retention has been remarkable; over 50% of participants are still engaged in the project.

Vaillant has published several books about this study. His main area of interest is how, over time, people adapt to ordinary and extraordinary life stressors through the use of psychological defence mechanisms: by which he means those affective and cognitive processes that we all must use to manage the inevitable rough patches that we will meet in a long, happy mammalian life. Vaillant concludes that happiness in life is associated with the use of mature defences (altruism, suppression, anticipation), making enduring attachments to other people, and not drinking too much alcohol.

These may not seem remarkable conclusions now, especially since subsequent studies of development and resilience have confirmed these conclusions. But what I took away then, and still find impressive now, is Vaillant’s understanding of human life as a story, with possibilities of narrative twists and turns at every stage. He describes many cases that looked pretty hopeless at one time point; but by the next time point, there had been change, often of a most unexpected kind. As psychiatrists, we meet people at a particular point in their life story, and we need to be aware that none of us knows the future. Sometimes, it may be more helpful to understand a set of symptoms as defences against stressors that are particular to this person’s predicament and their appraisal of it, than putting people into a diagnostic category and claiming we know what happens next.

A Secure Base by John Bowlby

It is difficult to overestimate the importance of Bowlby’s work to the psychology of human distress. Attachment systems in humans are neurobiological networks that activate at times of threat, pain and fear, especially in the interpersonal domain; and generate care-giving and care-eliciting behaviour patterns. Unlike many other psychological theories, attachment theory is empirically based on descriptive animal studies that include neurobiological data; and in humans, longitudinal observational research that is able to analyse and parse out the contribution of attachment relationships to the risk of developing abnormal personality organisation and other psychiatric disorders, especially disorders of mood and arousal regulation.

For those who feel daunted by the ‘Attachment and Loss’ trilogy ^{Reference Bowlby3-Reference Bowlby5} (attachment, separation and loss), I recommend this user-friendly collection of Bowlby’s lectures ^{Reference Bowlby6} that describes the essential features of attachment theory, and offers some particular insights that are helpful to psychiatrists. Highlights include the chapter about anger as a response to loss, and the threat of loss (which makes one look at human violence in a different way); and the chapter which describes how the therapeutic alliance becomes a secure base for exploration of new ways of thinking and appraisal of thinking. This notion of ‘security’ of mind has a special resonance for those of us who work with men (and rarely women) who have gained a type of physical security at a great cost to themselves and others.

Regeneration by Pat Barker

I came across Regeneration ^{Reference Barker7} just as I was moving into working in the field of traumatic stress. In the course of that work, I first met military personnel who had been exposed to a variety of traumatic stressors, on and off the battlefield. This book is a fictionalised account of Siegfried Sassoon’s admission to Craiglockhart Hospital, and his meeting there with W. H. Rivers: anthropologist, psychiatrist and politician. Although Sassoon figures largely, Pat Barker also introduces us to the psychiatrists of the day, and the professional clashes of temperament and techniques that still characterise psychiatry as a profession. Rivers is a quietly heroic figure, who is kind, down to earth and uses his knowledge of psychology practically rather than competitively. There is a harrowing scene set at Queen’s Square in which a Dr Yelland treats traumatic mutism in a soldier by applying electrodes to the tongue and turning up the pain until the man is forced to make a sound. With Rivers, we are also mute observers of this instance of psychiatric brutality, and painfully aware perhaps that this will not be the last time psychiatrists exhibit contempt for psychological vulnerability and distress, and do harm to those they have power over in the name of clinical benefit. One of the strengths of Barker’s work is the research that supports it; Yelland’s work was published in the BMJ and he was highly thought of as psychiatrist.

How Not to be a Perfect Mother by Libby Purves

I was given this book when I was pregnant and I have given it to countless other people since. Although a little dated now (pre-dating mobile telephones and the internet), How Not to be a Perfect Mother ^{Reference Purves8} is a guide to being a ‘good enough’ carer for a small baby, about what is important and what is not. Pregnancy and parenthood are experiences that are pretty indescribable to those who have not experienced them: and for people who are used to being in charge of their lives, a change is about to occur that will disorganise the most secure of minds. The charming books that tell you what to expect when you are expecting do not tell you that being the parent of a newborn or a toddler is like having a gorgeous but irascible, vulnerable and unpredictable celebrity to stay: who then decides to stay for the foreseeable future. Your life now revolves around this celebrity who takes all your time and attention, and who may generate a maelstrom of conflicting emotions in everyone who lives in or visits the house, including grandparents, postmen and the cat.

Purves suggests that we can all lighten up about being parents, and we all need to cut ourselves some slack. Does it really matter what the baby wears so long as it is warm and dry and you can do clothing and nappy changes without the aid of a passing octopus? Why shouldn’t the baby play with household objects if they are safe and more interesting than the conventional ‘toys’ on offer? Why not organise a child’s routine to coincide with yours, if possible; especially if this means that you will be less irritable and more up for reading Where The Wild Things Are ^{Reference Sendak9} at least five times before bed? Purves invites us to be kind to ourselves and to each other as parents, and to accept that things will go wrong and be messy from time to time. It is how we deal with the messiness and mistakes that makes us good-enough carers, and this is just as true for medical care as it is for parenting.

This book gave me permission to occasionally dislike being a mother and mothering, and so paradoxically allowed me to move on from my dislike and find new depths of pleasure in caring roles more generally. I hope that Libby Purves, who is a psychologically sophisticated writer and journalist, will do an updated version of her book for 21st-century parents; complete with advice about smart mobile telephones for toddlers, Facebook for parents and the perennial problem of what working mothers who escape from secure settings at the end of the day can use for small talk about their work at parents’ meetings.

A Life Apart by E. J. Miller & V. Gwynne

At the start of the A3 in Putney is a huge brick building that quite literally used to have ‘institution’ written all over it. Specifically, it had ‘Putney Home for Incurables’ etched into the brick work in letters, each one of which must have been a foot high. A Life Apart ^{Reference Miller and Gwynne10} is an observational study of two homes for the physically disabled in the 1960s by social scientists who were influenced by psychodynamic thinking applied to social systems, including healthcare. A psychodynamic approach also assumes that human thinking is complex - that humans engage layers of thought and thinking, and that there is always more going on than meets the psychological eye.

What Miller & Gwynne discovered was that staff tended to use two ways of relating to the residents: one they term ‘warehousing’, the other ‘horticultural’. The warehousing approach tended to see the purpose of residential care as just holding helpless individuals whose outlook was rather hopeless. The horticultural approach took a much more optimistic view and assumed that all the residents could grow if only they had the right medium. Inevitably, staff tended to oscillate between these two stances; one hopeful, one hopeless. Not all staff felt the same way at the same time of course, and disagreements between staff about how to treat the residents were obvious, frequent and affected the management of the homes.

This book should be essential reading for anyone working in or managing a long-term residential care facility; which in practice is likely to be a secure service of some sort. Miller & Gwynne describe the residents as suffering a kind of ‘social death’ because they are unable to act as fully autonomous adults and are excluded from the world of work. This concept of social death is an exquisitely and painfully accurate description of the experience of residents of forensic settings - I recognise the oscillations between hopefulness and hopelessness in forensic settings, not just in the staff but also in the patients. These cognitive and affective oscillations cause emotional disturbances in the milieu and atmosphere of wards and I suspect may be one of the risk factors for disturbed behaviours on wards. We urgently need a revised version of this book that incorporates a forensic view, especially as the medium secure estate continues to expand and the high secure units become ever smaller and more concentrated in their dynamics.

Into That Darkness by Gitta Sereny

If you are a psychiatrist who is interested in what one might term ‘cruel and unusual’ states of mind, then the mind of a person who oversaw the murders of 900 000 people must be of some interest. Into That Darkness ^{Reference Sereny11} is Gitta Sereny’s description of a series of interviews with Franz Stangl, who was commandant at Treblinka: one of the death camps (as opposed to the work camps) that were demolished by the Nazis before the end of the Second World War. Stangl escaped after the war to South America and lived a blameless and ordinary life there for decades until he was captured by Israeli intelligence and brought back for trial. Sereny interviewed him over a number of weeks, and found him ordinarily defensive, pleasant, and apparently unconcerned. Only in their last few meetings did he begin to demonstrate uncertainty and confusion about his ‘work’, and in their last meeting, he expressed some distress and regret. He died 3 days after their last interview.

Stangl appears to have been able to leave his murderous identity behind him and compartmentalise his experience, so that he had an ‘ordinary’ identity or ‘cover story’. As he talked to Sereny, this cover story broke down and a new narrative of identity emerged, in which Stangl was able to acknowledge ownership of the commission of cruelty and violent death. Sereny comments, that at the end Stangl ‘became the man he should have been’ and speculates that he experienced horror and shame that he could not have let himself feel before, which then overwhelmed him. Just as for the trauma survivors, the perpetrators too need time to face the emotions that come with taking responsibility for ending life: the acknowledgement that in doing so, they have changed the ‘world entire’. It is for this reason that we proceed very slowly in the therapy groups we run for men who have killed, remembering Macbeth’s cry of ‘I am afraid to think what I have done’, and trying to imagine what it might be like to be afraid to think.

The Mask of Sanity by Hervey Cleckley

Out of sheer altruism, the Cleckley family has put this book online in the public domain, so it is possible to download and read at leisure. ^{Reference Cleckley12} It is probably best known as the inspiration for Professor Robert Hare’s study of violent prisoners, which led to the development of the Hare Psychopathy Checklist ^{Reference Hare13} and the vast literature on psychopathy which keeps psychologists, psychiatrists, journalists and screen writers both informed and entertained.

I recommend The Mask of Sanity for its case histories; this is a book that repays detailed study and analysis. It is also interesting for what it does not say. Violence is not a significant feature of the lives of Cleckley’s ‘psychopaths’ (although acquisitive crime may be); what Cleckley describes is a massive lack of attachment, social engagement and interpersonal mutuality. Without this affective experience, Cleckley’s psychopaths cannot be reliable or responsible, and they are unconcerned by others’ distress. What comes across is the social bafflement about what can or should be done with people who do not appear to have what Robin Dunbar calls a ‘social mind’.

Cleckley wondered about a lack of or damage to the emotional neural system, and one can only imagine how interested he would have been in the possibilities that functional neuroimaging offers for understanding these types of deficit. The study of affectless and predatory violence by Professor Hare and others has been enormously valuable, but I think it is time for renewed interest in Cleckley’s psychopaths, who seem so normal and yet lack that which makes us human. The Mask of Sanity is also worth reading for Cleckley’s writing style - he has a Maugham-like waspishness of his own, and his description of a psychopathic psychiatrist is a novella of viciousness.

Truth and Beauty by Ann Patchett

Ann Patchett is a distinguished novelist and I can recommend most of her published work. But the book that I have bought most often to give to friends is her non-fiction account of her relationship with Lucy Grealy: a writer and poet who died in 2002. ^{Reference Patchett14} Lucy and Ann were trainee writers together; learning how to write creatively, sharing the travails of surviving on no income while trying to get published, competing for grants and scholarships. They played, drank, sang, danced and cried together; and Patchett’s prose conveys their affection and intimacy in depth with a lightness of touch.

But Lucy was a trauma survivor; or perhaps not so much a survivor but a veteran with scars. Her scars were physical as well as psychological, due to facial surgery for cancer in her jaw when she was a child. Bone was taken from her leg to replace that in her jaw, and she was left with facial disfigurement and the prospect of many and further operations. This physical suffering and experience was at once of great interest to Lucy and of no interest to her as a writer: she wanted to be recognised as a poet and a creative writer, not a plucky heroine. Patchett writes with tenderness and clarity about their relationship, and how it was affected by her success and Lucy’s; then by Lucy’s lack of success in relation to her health and her fears about her future; and then, most sadly, the development of Lucy’s addiction to painkillers and heroin, and her early death at the age of 33. This book is a witness to the creative possibilities of friendship and how our identity is rooted in relationships with real friends. Patchett’s writing is so powerful, that at the end of the book you feel that you know Lucy and you grieve with Patchett for the burning out of this bright, particular star.

The Mindful Way Through Chronic Depression by Mark Williams et al

I have come very late in my career to the vast literature on mindfulness - the practice of non-judgemental attention to the present moment - which was first described 4000 years ago and has been going strong ever since. Mindfulness was first described in those works attributed to a man called Gautama (more commonly known as the Buddha), and it has perhaps suffered through its association with religious beliefs or rituals. But with the development of the ‘third wave’ of cognitive therapies that take a meta-perspective on the mind, there has been renewed interest in those mental practices in which the mind is observed as a series of events. A visit to the Mindfulness Research Monthly website (www.mindfulexperience.org/newslatter.php) will show the vast number of studies and trials that support claims that mindfulness practice can reduce distress and enhance resilience.

In this book, Williams et al ^{Reference Williams, Teasdale, Segal and Kabat-Zinn15} provide a lay account of the cognitive theory of depression and provide a plan for using regular mindfulness practice. I recommend this book because I like the CD that goes with it - I found the practices doable and I liked Jon Kabat Zinn’s voice. Does it work? The National Institute for Health and Care Excellence guidelines recommend mindfulness-based cognitive therapy for anyone who has had three or more episodes of depression; ¹⁶ I was one of those people and I haven’t had to take antidepressants for 3 years now. I don’t suggest that we all become Buddhists (although that might not be the worst thing in the world), but I do think that mindfulness-based approaches to therapy are offering something intriguing and complementary to other interventions. They may be of particular use to healthcare professionals, especially those whose attachment histories mean they are inclined to dismiss their own needs for care and compassion.

Tinker Tailor Solider Spy by John le Carré

Tinker Tailor Solider Spy ^{Reference le Carré17} is much more than a spy story, although that is the genre with which the author is associated. It is a story about the suspicion that the British Secret Service has a double agent working within it, and the appointment of an ex-member of the service to investigate. This ex-member is called George Smiley, and he is not a conventional hero in any sense. He has no gadgets, amphibious cars or watches that fire rockets; there are no chases or explosions. He uses evidence, memories and reflections on relationships to expose the truth; after which nothing obviously changes, although no one is quite the same as they were at the beginning of the story.

I have lost count of how often I have read this book. I like its prose style, which is uncomplicated, and I love its observations of human foibles and personalities. In tiny details or almost throw-away comments about his characters, le Carré creates real people who stay in the mind long after the book is finished. Above all, this is a book about love, the inevitable betrayal and disappointments of love, and how love survives betrayal, battered but persistent.