Images of psychiatrists have abounded in television and cinema, albeit largely in the form of various crude stereotypes (1). However, although madness, suicide, and innumerable other gradations of psychological misery have obviously been prominent subjects for literature since its beginning, intelligent explorations of psychiatrists per se, in their modern manifestation as professional therapists and medical doctors, have been harder to come by in serious fiction.
In contrast, other kinds of physicians have been depicted powerfully and often sympathetically in such major works as Sinclair Lewis's Arrowsmith, Albert Camus's The Plague, and Aleksandr Solzhenitsyn's Cancer Ward. It is difficult to think of any works of comparable stature having a psychiatrist as a significant character. Although Dick Diver in F. Scott Fitzgerald's Tender Is the Night is a psychiatrist (who rather obliviously falls in love with and marries his patient), it can be argued that the novel is essentially a tragic love story that happens to contain vague notions about 1920s' psychiatry (2). The psychiatrist in Ken Kesey's One Flew Over the Cuckoo's Nest is a cipher. The view of psychiatrists in Sylvia Plath's The Bell Jar is mostly resentful, but does allow for some ambiguity. One must advance to Pat Barker's recent trilogy Regeneration, The Eye in the Door, and The Ghost Road, based on the work of World War I (de facto) psychiatrist W.H. Rivers, for a sophisticated and generally sympathetic treatment of its subject.
Interest in the medical bildungsroman—a tale of the development and maturation of a physician—has been a significant part of the burgeoning interest in medicine and literature. It has been recognized that medical students, residents, and physicians may identify powerfully with fictional doctors (3). Fiction has ethical implications that are inseparable from its aesthetic impact (4). In this sense, it is regrettable that there are so few complex and credible role models, either positive or negative, of psychiatrists in serious literature. Samuel Shem (5) has lamented the paucity of psychiatrists as both authors of and characters in fiction and has speculated that realistic psychiatric practice offers insufficient dramatic possibilities. He also noted that psychiatrists have themselves very rarely produced significant literature (a point to which I will return).
In contrast to prose works, the poetry most commonly associated with psychiatry has been confessional, written by sufferers of mental illness. Most infamously, American poets John Berryman, Sylvia Plath, and Anne Sexton, among others, wrote vivid and powerful evocations of depression before ultimately succumbing to suicide. However, psychiatry and mental illness have been relatively rare topics for poets lacking firsthand experience with them. A notable exception is Robert Pinsky's long expository poem "Essay on Psychiatrists," which comprises a self-proclaimed outsider's reflections about psychiatrists and their patients. This poem stimulates discussion of psychiatric issues that are of particular interest to medical students and residents. What does it mean to be a psychiatrist, and what are the public perceptions of psychiatry? What is the nature of mental illness, and what is the relationship of psychiatry to other domains of knowledge and wisdom about what it means to be human?
Pinsky, a prominent contemporary poet and recent Poet Laureate of the United States, published "Essay on Psychiatrists" in his 1975 collection Sadness and Happiness, and it was recently reissued in The Figured Wheel: New and Collected Poems 1966—1996 (6). Surprisingly, the work has, to my knowledge, gone largely unnoticed in the psychiatric literature. The poem contains 464 lines of free verse, divided into 21 titled sections of various lengths. We will focus on the poem's content, which comprises a constellation of incidents, reflections, and observations related to psychiatry. Pinsky's themes include, first, a broad consideration of the psychiatric project, and, specifically, the values embodied in psychiatrists, patients, and the work they do together; and, second, a comparison of psychiatry and poetry as means of understanding and approaching life.
I will argue that this poem, although not narrative in the conventional sense, does function as a poetic bildungsroman of sorts. Instead of exploring a slow development of identity (as George Eliot famously did for a young physician in Middlemarch), Pinsky generates a multifarious collection of images and potential identities of psychiatrists drawn from the media, from the culture-at-large, from literature, and from his imagination. These images collide and struggle with one another throughout the poem, to culminate in a final, yet tentative, literary judgment about psychiatry and its practitioners.
What follows will necessarily be a limited examination of the poem, given that I am specifically interested in the poem's implications about the contested values of psychiatry. Although I will touch on the contribution of Pinsky's language to the poem's impact, I will focus less upon poetic devices than upon the theme of the work. There are, doubtless, many other possible ways to approach the poem, which, much like Alexander Pope's more famous "Essays," may be approached on distinct aesthetic or theoretical grounds.
Literature has lent itself to a number of uses in psychiatry, chief of which, in terms of volume and significance, has been psychoanalytic literary criticism; that is, the application of psychoanalytic principles to authors, as well as fictional characters. An example of this is Norman Holland's analysis of a poem by Emily Dickinson (7). In contrast, the literature of general medicine has more often been used to instill empathy for the experience of illness, as well as to facilitate a broad examination of what it means to be a physician (8). The latter is my objective here; that is, to use this poem not to illustrate specific psychiatric theories, nor to demonstrate stark ethical dilemmas, but rather, as an instrument of professionalism, to catalyze an inquiry into what it means to be a psychiatrist. Because the piece represents a kind of literary critique of psychiatry, I wish to respond to it on its own terms, not to beg the question by subjecting it to a psychiatric critique of literature.
Pinsky's ambivalence about psychiatry is plain throughout the poem (for simplicity's sake, I will refer to the narrator as Pinsky, since no other identity is suggested, although this identification obviously may not be valid). Notable at the outset is his alacrity in declaring, of psychiatrists, that he has "never (even this is difficult to say / Plainly, without foolishness or irony) / Consulted one for professional help (p 265)." The statement, which implies that what follows should be considered untainted by diagnosis or medication, reflects the contested authority and interpretation associated with psychiatry.
In discourse about psychiatry, uniquely among medical specialties, one's perspective and judgment are inevitably called into question; it is necessary to declare where one stands in the diagnostic situation. Pinsky does acknowledge that many of his friends have consulted psychiatrists, a fact that appears to prompt his interest; however, he does not mention ever having known a psychiatrist personally or socially. Evidently, psychiatry is quite foreign to him, and he speaks of psychiatrists distantly: "it seems urgent to try to speak / Sensibly about them, about the psychiatrists (p 265)."
The poem teems with psychiatry's stereotypes, some challenged and some seemingly accepted. The first lines seem to recognize and protest the prevalence of clichés:
It's crazy to think one could describe them
Calling on reason, fantasy, memory, eyes and ears
As though they were all alike, any more
Than sweeps, opticians, poets or masseurs (p 265).
Pinsky casts about for metaphors for what it is that psychiatrists do. Do they clear the mind of debris (like sweeps), enable discernment (like opticians), or soothe and stimulate (like masseurs)? As we will see, Pinsky seems to decide that psychiatrists most resemble poets, and it is in that sense that his ambivalence will crest.
Apparently, some stereotypes are more easily dispelled than others. Pinsky rejects notions of the "shrink," the "religious analogy," and the "Viennese accents and beards," which, he says, "hardly apply to the good-looking woman / In boots and a knit dress… (p 265)" But, later, he writes, "As far as one can generalize, only a few / Are not Jewish. Many, I have heard, grew up / As an only child (p 274)." And he relates an incident in which a woman he knew saw a stranger from afar—who was "Pink and a bit soft-bodied (p 266)"—and correctly surmised that he was a psychiatrist. Encountering such ethnic and demographic caricatures, one senses that Pinsky knows better and perhaps is being ironic, but it is significant that he does not bother to repudiate them.
Prominent in the poem (and perhaps redolent more of the decade in which it was written than of the current era) is the alleged conspicuous prosperity of psychiatrists. At various times, psychiatrists are associated with "expensive running shoes (p 265)," a "jazzy / Middle-class bathing suit (p 266)", and "elegant machines and luxuries, with caroling / And kisses, with soft rich cloth and polished / Substances, with cash, tennis and fine electronics, / Liberty of lush and reverend places (p 280)." Pinsky seems repulsed by the thought of individuals making money from others' misery, and he implicitly objects to a "commodification" of experience that may be a lurking peril in psychiatry, a tendency to view happiness and relationships as things to be bought and sold. He likens some of psychiatry's "cash matters" to those things that "ought not to be sold: Seder / Services at hotels; skill at games from paid lessons; / Fast divorce; the winning side in a war seen / On TV (p 274)."
In addition to the problematic relationship of profit and suffering, there is a wider concern about the values embodied in psychiatric transactions. In the important third section, titled "Proposition," Pinsky writes
These are the first citizens of contingency.
Far from the doctrinaire past of the old ones,
They think in their prudent meditations
Not about ecstasy (the soul leaving the body)
Nor enthusiasm (the god entering one's person)
Nor even about sanity (which means
Health, an impossible perfection)
But ponder instead relative truth and the warm
Dusk of amelioration. The cautious
Young augurs with their family-life, good books
And records and foreign cars believe
In amelioration—in that, and in suffering (p 266).
This passage powerfully captures the view of psychiatrists as soulless and relativistic technicians, committed to no goal or belief system beyond their patients' satisfaction and their own well-being. In recent years, the role of values in psychiatry has become widely considered (9—11). The pretense of value-neutrality in an endeavor such as psychiatry, so closely tied to notions such as empathy, hope, guilt, and responsibility, may carry the risk of moral vacuity. Salient in psychiatry is the inquiry into how it is that one should live, a project that may supersede the purview of clinical parameters as well as formal ethical principles.
Pinsky conjures up a kind of moral wasteland in his likening of some psychiatric patients to those who consult Ann Landers. He writes that beyond a certain threshold of consumer goods, such individuals find that "their capacity / For mere hedonism fills up, one seems to need / To perfect more complex ideas of desire, / To overcome altruism in the technical sense (p 275)." He refers to this as a "standard of cui bono," which, although seemingly opposite to "more Spartan or Christian codes," is, nonetheless, rigorous in its own way:
It suggests a kind of league of men and women dedicated
To their separate, inward duties, holding in common
Only the most general standard, or no standard
Other than valuing a sense of the conflict
Among standards, a league recalling in its mutual
Conflict and comfort the well-known fact that psychiatrists,
Too, are the patients of other psychiatrists,
Working dutifully—cui bono—at the inward standards (p 276).
This is an ugly vision of well-to-do solipsistic patients and their therapists, absorbed in navel-gazing and justification of "the most general standard,"—that is, self-interest.
Interestingly, in his references to psychiatric patients, Pinsky reflects another notorious cliché, the sharp distinction between neurosis and psychosis. In this poem, one encounters the "Ann Landers" clients, suffering from wealth and ennui, but then there are the mad: "Other patients are ill otherwise, and do / Scream and pace and kill or worse." Pinsky concedes that nothing "Helps me to think of the mad otherwise / Than in cliches too broad, the maenads / And wild-eyed killers of the movies... (p 276)." For him, there seem to be no intermediate steps between problems of living and raving psychosis.
Pinsky also flirts with the assertion of a certain philistinism of psychiatrists, who appear not only materialistic, but also bourgeois. He maintains that "‘Greek tragedy’ of course is the sort of thing / They like and like the idea of" (p 270; my italics). He compares a psychiatrist to the "mask-like" comic character Rex Morgan, M.D. and produces a bit of vapid, wooden dialogue between the latter and a young woman whom he takes to a concert (p 271). Elsewhere, psychiatrists are depicted, somewhat condescendingly, as engaged in activities like "recycling their garbage, / Voting, attending town-meetings (p 273)." Psychiatrists have "good sense," and are solid citizens, albeit dull and unimaginative ones. The charge of philistinism is put most bluntly in the following:
But after all—what "cultural life" and what
Furniture, what set of the face, would seem adequate
For those who supply medicine for misery? (p 271).
In this passage, one of only two references to somatic therapy in the poem, psychiatrists are located squarely on the scientific side of the "two cultures," and are made to seem quite oblivious to humanistic and cultural subtleties.
The implicit charges of moral relativism and purblind philistinism dovetail in an arresting comparison of psychiatrists to cowboys. Pinsky writes that psychiatrists "are stock characters like cowboys…Like a cowboy, the only child roams / The lonely ranges and secret mesas of his genre (p 275)." The simile seems based on a common presumption of lawlessness: in the popular conception, psychiatrists and cowboys play by their own rules, far from civilization's standards, and are beholden to no one. Both are cool and utterly in control, yet uncouth and uncultured, roaming their respective barren wildernesses, one, of the landscape and one, of the mind.
Perhaps, for Pinsky, the notion of psychiatrist as moral and cultural "cowboy" follows from the necessary detachment of therapeutic work. In considering the "seriousness" of psychiatrists, he reflects that they are serious only in the way that airline pilots, radiologists, and master mechanics are. Their work, like that of all technicians, suffers from over-involvement. He contrasts psychiatrists with painters, scholars, and (interestingly) surgeons, who presumably may benefit or even attain greatness from giving their lives over to their work, and he fashions an amusing metaphor of the "Terrifying idea — / That a pilot could over-extend, perhaps try to fly / Too well, or suffer from Pilot's Block (p 267)."
Similarly, in order to do their work (and perhaps to model for their patients), psychiatrists must exhibit restraint and balance, must carefully preserve their own lives apart from their work. However, the poem implies that detachment may come only at the price of a certain gray neutrality. That is, psychiatrists must eschew obsession, overcommitment, and conviction, inasmuch as these may impede therapy. As in the psychoanalytic caricature, psychiatrists must become featureless and even vacuous—containers for their patients' transferences. The poem implies that such a need may give rise to psychiatrists' venal and middle-brow lives, combining the worst features of an ethical relativism and a social and cultural conservatism.
In the heart of the poem, Pinsky uses the story of Dionysius and Pentheus from Euripides' The Bacchae to further explore the shadowy figure of the psychiatrist. In the play, Pentheus is hostile to the attempt of his divine cousin Dionysius to bring the latter's self-worshipping religious cult to Thebes. In retaliation, Dionysius inflames with madness the women of Thebes, who ascend Mount Cithaeron to engage in the cult's frenzied rites. When Pentheus goes to investigate, the mad women, including his mother Agave, tear him limb from limb. Pinsky wonders whether Pentheus or Dionysius best exemplifies the psychiatrist.
With his reasonable questions, Pentheus tries
To throw light on the old customs of savagery.
Like a brave doctor, he asks about it all… (p 269).
In this trope of the psychiatrist as somewhat befuddled do-gooder, Pentheus is the sober rationalist who, unfortunately in this case, is wholly ineffectual and overwhelmed by chthonic powers quite beyond his ken. On the other hand:
In a more hostile view, the psychiatrists
Are like Bacchus—the knowing smirk of his mask,
His patients, his confident guidance of passion… (p 270).
This is the view of arrogant psychiatrists who do not treat, but actually foster and fabricate illness and its classifications. This is a primitive dread that is the other half of a striking dichotomy: if psychiatrists are not like Pentheus, that is, if they are not helpless fools and can significantly alter behavior and experience, then perhaps they are to be feared. Patients and their psychiatrists therefore attract complementary stereotypes. Patients are either just like normal people (that is, they just have problems of living and choose to engage in therapy about them) or they are "The Mad," and purely Other. Similarly, psychiatrists are either just like normal people (that is, despite their claims they are just as clueless about human behavior as the rest of us) or they are powerfully manipulative to a sinister degree. According to these stereotypes, mentally ill patients and those who treat them may be either dismissed or demonized: no middle ground of engagement is possible.
So far, it may seem that Pinsky's view is a wholly negative one of coldly mercenary psychiatrists. But this is not the case, for, notwithstanding their alleged cool rationality, they are viewed in the poem as artists of a kind, with whom Pinsky appears to feel, therefore, some kinship:
They are not gods or heroes, nor even priests chosen
Apart from their own powers, but like artists are mere
Experts dependent on their own wisdom, their own arts… (p 272).
And Pinsky sees psychiatrists specifically as poets of a kind. Near the beginning, he asserts, "‘Shrink’ is a misnomer," and, a few lines later, writes that "no small part of the psychiatrist's / Role is just that: to point out misnomers (p 265)." So psychiatrists—like Pinsky—are fundamentally engaged in using language to define experience. Both psychiatry and poetry are interpretive and hermeneutic endeavors, "arts / Of knowing and naming… (p 273)." The terms of psychiatry are likened to "Water thinner than blood or under bridges; bridges / Crossed in the future or burnt in the past (p 273)." Naturally this view—of psychiatric concepts that come and go, like all words and languages—may impugn psychiatry's scientific aspirations.
Of course, this comparison is meant only in the broadest sense, and the poem seems to imply that psychiatry and poetry may, in fact, offer rival, and not complementary, conceptions of experience. They stem from different premises and utilize very different dialects. Considering psychiatric terms such as neurotic, anal, and paranoid, Pinsky seems to have his doubts about the capacity of psychiatry's clumsy terminology to capture experience in the way that poetry does. He writes that it is "Easier to cut thin air into planks with a saw / And then drive nails into those planks of air (p 273)." (one wonders if this is a swipe at psychiatric diagnosis) than to evade what he calls "the terms of myth," such as "Justice, Fortune, and Love (p 273)." In fact, he writes that characters in a poem by Walter Savage Landor are
In a sense, my own psychiatrists, shrinking
The sense of contingency and confusion
Itself to a few terms I can quote, ponder
Or type: the idea of wisdom, itself, shrinks (p 278).
Pinsky is open about his allegiance to ideals of poetry, wisdom, and acceptance of suffering, and seems puzzled that so many of his friends, many of them artists like himself, have felt the need to resort to psychiatrists. He intuitively feels that art, beauty, and knowledge ought to suffice for us, and that psychiatry is, in fact, an inferior poetry.
At the end of the poem, Pinsky is at his most gracious toward psychiatrists, writing, "I find I have failed / To discover what essential statement could be made / About psychiatrists that would not apply / To all human beings (p 279)." Human beings, as well as psychiatrists "try tentatively / To understand, to find healing speech (p 280)." Finally, he speculates that "we are all psychiatrists, / All fumbling at so many millions of miles / Per minute and so many dollars per hour…saying what we can (p 280)."
With this conclusion, Pinsky decisively repudiates the stereotypes and attempts to accept psychiatrists back into the fold of humanity, as it were. Of course, one could say that this dismissal of invidious distinctions may also amount to a back-handed compliment. After all, to say that "we are all psychiatrists" may be tantamount to saying that psychiatrists do not have any separate area of expertise. Few would say that we are all neurosurgeons or that we are all gastroenterologists. But I think that Pinsky would acknowledge that we are all psychiatrists only in the sense that we are also all poets, or all politicians, or philosophers, for that matter. All of these draw upon rhetorical arts, having as their bailiwick the commonality of human experience; and although technique and expertise are real, any endeavor so closely tied to humanity must acknowledge a certain general wisdom that has gone before and cannot lay claim to a hermetic and superior understanding without risking estrangement and self-isolation. So Pinsky voices his hope that psychiatrists "Will respect the means, however pathetic, / That precede them; that they respect the patient's / Own previous efforts, strategies, civilizations…(p 274)."
"Essay on Psychiatrists" represents a poet's sustained attempt to come to grips with an alien endeavor, and the author seems to posit as a common ground the rhetorical and interpretive faculties of poetry and psychiatry. For him, both practices are attempts to use language to make sense of the bewildering flux of experience. The fact that the point of view of the poem is a limited one—the author evidently had no personal acquaintance with the practitioners or the patients of psychiatry, and he wrote at a time when much of the science of the discipline was less mature than it is now—does not negate the interest of the questions it raises.
Perhaps because words constitute his domain, he has little to say about the science or technology of psychiatry; these seem to be as wholly Other as the profoundly insane. Or perhaps he deeply distrusts such a direct application of technology to the problems of human life, which, for so much of history, have been the province of poems and other stories. Arguably, he comes to see psychiatrists as would-be poets of a kind (or, in his more hostile moments, as failed poets), who forsake wisdom and beauty in their desire for a degree of authority, not to mention lucre, that exceeds what mere writers may expect.
The poem's technique and form also contribute to the theme of the uneasy similarity of psychiatric and literary modes. It seems to me that what makes the work poetically significant (and of interest to the average reader and not just to the psychiatrist) is the exhilarating profusion of vivid images and metaphors. As we have seen, at various points in the poem, psychiatrists are likened to sweeps, opticians, poets, masseurs, pilots, radiologists, master mechanics, Pentheus, Dionysius, Rex Morgan, M.D., "mere experts," pilgrims, journeymen, bourgeois savants, gallant seekers, persistent sons, and cowboys, to mention only a few. The poem's wild profusion of metaphor serves to celebrate the capacity of language to open up new points of view and even new worlds of experience; implicitly this project honors psychotherapy's hope of altering subjective, and eventually objective, reality through the "mere" exchange of words. However, it is significant that the poet seems to wriggle free from each metaphor just as he is on the verge of yielding to it; that is, his technique implies a recognition that language and metaphor can entrap as well as liberate. His ambivalence toward his terms is analogous to that of the good psychotherapist.
The poem's form mimics psychotherapy in other ways, as well. It is literally an "essay," inasmuch as various identifications of psychiatrists are tried on "for size," as it were, then discarded, as needed. This practice parallels the tradition of psychotherapy, in which the self is viewed not as some unchanging essence to be discovered, but rather as a field of possibilities to be created by imagination and contingency (12). By the end, Pinsky seems to have given up on finding a metaphor that will precisely illustrate what a psychiatrist really is. Also, the construction of multifarious identities for the psychiatrist bears some similarity to transference, although in this case it is largely "cultural transference," inasmuch as media-derived images are profoundly influential.
"Essay on Psychiatrists" yields a number of uses for psychiatry and its ethics. Judging from the persistent lack of enthusiasm of medical students for psychiatry (13), the field still suffers from the relative disdain and mistrust of other areas of medicine, and it is incumbent upon its practitioners to examine and to question the cultural stereotypes, as well as the social realities, that underlie views of psychiatrists as dull, ineffectual, or parochial.
"Essay on Psychiatrists" provides a sophisticated and stimulating context in which medical students, residents, and their mentors can discuss ethical issues. What does it mean to profit from the illness of others? What standard of living should be adequate for physicians? How much of psychiatry is science, and how much is rhetoric? Notwithstanding the vaunted "Decade of the Brain," psychiatric diagnosis remains embattled, particularly, but, by no means, only, in the popular press (14—16). What are the differing implications, if any, of medication vs. psychotherapy as treatments for mental illness? How does symbolic understanding of patients' experiences coexist with categorical and manualized diagnosis?
What is the role of values in psychotherapy? What is the effect upon one's personality of becoming a psychiatrist? How does one preserve one's identity amid the swirling storms of patients' lives? It seems to me that, as advancing psychopharmacology and standardized diagnosis aspire to make psychiatry more mainstream, too little attention is being paid to the phenomenological and sociological strangeness of what it is that psychiatrists do. Becoming a psychiatrist is still fundamentally different from becoming a surgeon, a cardiologist, or a pediatrician; it entails the assumption of a highly ambiguous role embroiled in stereotypes and contested value systems.
Finally, this poem illustrates the sometimes tense coexistence of what one might call the narrative and the clinical views of experience. In recent years, numerous arguments have been made for the importance in literature of instilling empathy and understanding of the "illness experience" (17—19). Others have countered that the realms of literature and of ethics are not congruent, based, as they are, on different methods and goals (20).
In this work, Pinsky accentuates the more subtle, but no less real, differing implications of the speech of poetry and psychiatry. What, for instance, are the divergent connotations of "love" and the more clinical notion of "attachment"? What very different semantic universes unfold behind such contrasting notions as "evil" and "antisocial personality disorder"? What, in poetry, corresponds to the notion of "global assessment of functioning"? Conversely, what, in psychiatry, captures the concept of wisdom? "Emotional intelligence"?
Certainly, much is often gained in examining life from a clinical point of view: attention to diagnosis and neurochemistry has alleviated much suffering. But other, much older traditions have viewed both joy and suffering as experiences to be understood and explored, rather than necessarily manipulated. In the rush toward empiricism, can psychiatry honor its debt to, and ultimate dependence on, the great faiths and wisdoms that have preceded it? A poem like this confronts us with this question and urges us to examine our own identities; our beliefs about illness, health, and treatment; and the power of language to shape our experience.
In conclusion, I wish to distinguish my own particular interest in this poem from the wider educational uses to which it may be put. As regards the former, I have found that the piece is a powerful reflection of the sometimes tense coexistence of literature and psychiatry. From the time that Freud used psychoanalytic tools to interpret fairy tales and the works of Shakespeare, artistic endeavor has remained a "dark continent," of sorts, that psychiatry has striven mightily to subjugate.
Psychoanalysis is the only subculture of psychiatry that has engaged in any significant collaboration with literature, and psychoanalytic criticism is to literary criticism as a whole as psychoanalysis is to general psychiatry; that is, a crucial and yet not uncontested component. The often-bewildering diversity of psychiatry makes any discussion of the discipline as a monolithic entity difficult, and psychiatry's relationship to literature is ambiguous and multifaceted.
Inasmuch as the tools of psychiatric thought are applied to texts, they constitute the tools of the critic of literature, but inasmuch as they are applied to life, that is, general concepts, such as wisdom, suffering, and values, they may amount to a rivalry with literature. Because literature and psychiatry often use very different means to the shared end of illuminating human experience (both arguably aim to make people not only more content but also more aware, morally and otherwise), they sometimes step on one another's toes and settle for an ambivalent coexistence. Many artists have harbored a mistrust of psychiatry that they have not had reason to hold toward medicine as a whole. Perhaps it is therefore no accident that (pace Shem ) no psychiatrist has yet produced major literature (of the stature, say, of the works of general physicians Anton Chekhov or William Carlos Williams).
As I have implied, however, the poem is educationally interesting for various other reasons. Of the psychiatry residents with whom I have discussed the poem (so far I have utilized it only for optional journal club gatherings), few have taken particular note of the psychiatry-vs.-literature opposition noted above. Rather, many have been struck by the more general notion of psychiatrists as purveyors of values in general; the religious images in the poem have generated discussions of the similarities and differences between psychiatry and religion. Some residents have felt strongly that psychiatry has become much more necessary in modern times as previously assumed value systems have given way to skepticism. Related to this, some have wished to discuss the degree to which their own beliefs or faiths should be disclosed in therapeutic relationships; that is, the extent to which a psychiatrist ought to be "genuine."
Other residents I have supervised have been more interested in the many psychiatric stereotypes and, in particular, the various media images (of the raving mad, of the bland psychiatrist) conveyed in the poem. This has led to discussions of "cultural transference" in general, not only of patients toward psychiatrists, but also of the latter toward their profession. To a degree that is probably unmatched by other medical specialties, individuals come to psychiatry with a tremendous number of culturally induced assumptions. For instance, notwithstanding marked changes in therapeutic techniques in recent decades, many beginning trainees continue to assume that a psychotherapist ought to maintain a relentlessly impassive and taciturn demeanor, presumably because this remains the prevailing stereotype. Also, for a few residents, the poet has evoked the notion of the dreaded patient (often nudged into treatment by a spouse or other family member) who doesn't "believe in" psychiatry. The poet's general appraisal of the discipline as depending much more upon rhetoric than upon science or proven efficacy can give rise to discussions of what it is like—in an experience all too familiar to psychiatrists—to work with patients or even colleagues who may not respect them.
Finally, I have found residents to be intensely interested in contested areas of psychiatric diagnosis. Early clinical contacts often generate questions as to the extent to which complex human experiences—grief, religious enthusiasm, and vicious behavior, for instance—can or ought to be captured by diagnosis. "Essay on Psychiatrists" helps to stimulate such discussions. Apart from what I consider to be its most original theme—the agon between psychiatry and literature—the work also serves as an excellent teaching tool insofar as it is not only poetically interesting, but also because it fosters varied discussions of what it can mean to become that strange personage, a psychiatrist.