Richard Selzer and Ten Terrific Tales

July 20, 2016 at 9:23 am


Richard Selzer and Ten Terrific Tales
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by Tony Miksanek, MD
Family Physician and Author, Raining Stethoscopes

If there were a Medical Humanities Hall of Fame, physician-writer Richard Selzer (1928-2016) would be a first-ballot selection. And likely by a unanimous vote. The diminutive doctor had a very large presence in the field. He energized the medical humanities movement in the 1970's and 1980's with his lectures, readings, writing workshops, commencement addresses, correspondence, personality, and kindness. But it was his writing - earthy and elegant, whimsical and wise - that masterfully mingled the world of medicine with the world of the arts and highlighted the necessity of humanity in health care.
His literary output includes more than 125 published short stories and essays, a work of nonfiction (Raising the Dead), an autobiography (Down from Troy), a novella (Knife Song Korea), and a diary (Diary). Many of his stories reflect an interest (even an infatuation) in decay and death, the beauty of the body, how illness beatifies the sick individual, the power and fallibility of doctors, and the great panacea/contagion - love.
"Writing came to me late, like a wisdom tooth," Selzer proclaimed. Indeed, he was 40 years old when he began writing seriously. His early efforts at crafting stories dutifully occurred between the hours of 1:00 and 3:00 AM. His initial focus was creating horror stories because it was an "easy" genre to handle. That fondness for the macabre and otherworldly never dissipated as he continued to utilize horror (and humor) in many tales. The majority of Selzer's stories involve doctor-patient relationships, surgery, and suffering. Some of his literary work is weird ("Pipistrel"), experimental ("A Worm from My Notebook"), and an exercise in reimagining ("The Black Swan Revisited").
Surprisingly for an MD, he seemed a bit unconcerned about facts in his writing. Rather, he was deeply interested in creating impressions. For Selzer, facts weren't necessarily equivalent to truth. After all, facts change but impressions endure. Still, Selzer stubbornly searched for truth (and love) in his stories. He was enticed by language and the sound of words. From time to time, he manufactured his own words. He disliked gerunds but appreciated onomatopoeia. His favorite doctor-writers were John Keats and Anton Chekhov both of whom died from tuberculosis - Keats at age 25 and Chekhov at age 44.
I don't know which story Richard Selzer considered his best or most beloved, but I suspect that "Diary of an Infidel: Notes from a Monastery" was at or near the top of his list. The rest of us, however, definitely have our favorite Selzer stories. And while there are so many wonderful tales to choose from, I recommend the following 10 not-to-be-missed selections. My list is divided into two sections. Part 1 includes personal favorites and stories that don't get nearly the attention they deserve. Part 2 is comprised of stories and an essay that I find very useful in teaching.
Part 1: Five Fabulous Favorites:
1. "Tom and Lily"
2. "Luis"
3. "The Consultation"
4. "Toenails"
5. "Fetishes"
Part 2: Five Fixtures for Teaching:
1. "Brute"
2. "Imelda"
3. "Sarcophagus"
4. "Wither Thou Goest"
5. "The Surgeon as Priest"
So there you have it. The two greatest stories by Richard Selzer are "Brute" and "Tom and Lily." Of course, that's just my opinion. How do you see it? You are invited to post to the blog with your favorites. (I have a hunch that "Imelda" is going to vie with "Brute" for the top spot.) In the meantime, The Doctor Stories by Richard Selzer is a perfect place for readers to roost - either as an introduction to his work or an opportunity to reacquaint with some notable tales.

The Patient Experience Book Club at NYU Langone Medical Center

March 2, 2016 at 1:41 pm

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When an AP reporter called to tell Erika Goldman, publisher of the Bellevue Literary Press, that its novel, Tinkers, by Paul Harding, won the 2010 Pulitzer Prize for fiction, "it was akin to receiving a blow to the head," she said. "It was concussive." For the first time since 1981, a book published by a small press won the award.

Ms. Goldman told this story to the members of the Patient Experience Book Club at NYU Langone Medical Center, a group that includes physicians, nurses, administrators, analysts and social workers among others. On a recent Friday afternoon, the group met to discuss Tinkers.

Tinkers recounts the last days of George Crosby. Lying in a hospital bed in the middle of his living room, surrounded by the members of his extended family, George's thoughts drift between the scene around him and memories of his boyhood. His father, Howard, a peddler of home goods in rural Maine, had epilepsy. Faced with the possibility that he would be committed to a psychiatric hospital Howard Crosby abandons the family leaving George, his mother and siblings to fend for themselves.

Time is a thematic thread running through the novel (George repairs clocks) as the narrative flows between memories of his childhood and his adult life. Harding describes his book as unlineated poetry. Its rich, descriptive language requires readers to settle into the prose, avoid distractions, and allow themselves the space to fully experience the story.

After a brief introduction by Ms. Goldman about how the Pulitzer Prize process works, the group turned to a discussion of the text. Their interpretations were filtered through their individual experiences working with patients and families. A social worker compared some "not so great" deaths she has witnessed to George's death at home with his family. A neurology administrator pointed out that the stigma attached to epilepsy remains a problem for some of the patients she encounters. Tinkers draws attention to the silence surrounding illness, another commented.

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The Patient Experience Book Club was started by Dr. Katherine Hochman in 2012. She came up with the idea after attending a conference on patient experience that was organized by the Institute for Healthcare Improvement in Boston: "What I took away from that was in order to have an engaged patient, we need to have an engaged staff." She decided to hold meetings every two months to discuss books that related, even tangentially, to patient care. A small grant funds box lunches and copies of the selections. The books are made available in advance of the meeting. Sessions typically draw from 10-30 people from all areas of the medical center. For many, it's a chance to meet co-workers who they do not interact with in their normal daily routines.

Locksley Dyce, a hospital administrator, loves to read and is a regular attendee: "It affords me the opportunity to meet in a multi-disciplinary group and exchange thoughts with healthcare professionals whom I probably would not meet otherwise."

The Club invites a faculty or staff member with expertise in a particular area to lead the sessions. Dr. Joseph Lowy from the palliative care service led the discussion of Being Mortal by Atul Gawande. David Oshinsky discussed his book Polio. And during the Ebola scare, the novel Blindness prompted a discussion of what it would be like for a whole society to be affected by an illness. During that session, Hochman and the group wore blindfolds to experience blindness for themselves.

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Mr. Dyce finds the sessions particularly thought-provoking. "We try to apply the material from the book to healthcare - especially patient care - and the individual roles that we play in it," he said.

As the session on Tinkers drew to a close, and the members prepared to go back to work, ordering tests, analyzing metrics and attending to their patients, they reflect on the issues brought up in the meeting and acknowledge the importance of taking time to connect with their patients.

The group meets next in April to discuss When Breath Becomes Air by Paul Kalanithi.

Rediscovering a history of trauma: An interview with Dr. Annita Sawyer

August 17, 2015 at 2:20 pm

Dr. Annita Sawyer is a psychologist and the author of several essays, stories, and a memoir titled Smoking Cigarettes, Eating Glass, which was published in May 2015.

In 1960, however, Dr. Sawyer was battling mental illness and thoughts of suicide. She was institutionalized and underwent 89 electroshock treatments. Although traumatized by her experience as a patient, Dr. Sawyer survived the broken mental health system of the 1950s and 1960s and went on to graduate summa cum laude from Yale, earn her doctorate and join the faculty of the Yale University School of Medicine. In 2001, Sawyer sent for the records from the years she was a patient at the two psychiatric hospitals. She decided to reveal her past and began to write only after she had begun to recover from revisiting the early trauma and began to remember what had happened to her.

In this interview with Simone Leung, Dr. Sawyer discusses the process of creating her memoir, how doctoring and writing play into her life, and shifting perceptions of mental illness today.

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What originally led you to dig into your history, and why have you chosen to share your story in Smoking Cigarettes, Eating Glass at this point in time?

I'd been working full time for twenty years. As a psychotherapist I had reached a comfortable place professionally. My children were grown and on their own, so I had privacy. My husband and I were meeting with a marriage counselor who was struck by my sometimes vague, otherworldly demeanor, and the fact that in the middle of an argument I would often forget what I was talking about. She recognized this as dissociation, a symptom of trauma. I still had little memory of my first twenty years, and I had questions about my history, which I thought might have answers in the medical records. I wanted to find out the specific number of shock treatments I'd been given - my estimate of 54 seemed way too high. For all of these reasons, we agreed that I should send for the hospital records.

Conventional wisdom holds that the best way to make a point vivid and memorable is to connect it to a story about a real person. Reading the records triggered a dramatic revisiting of my early life - as a child and also as an adolescent in the hospital. All my old symptoms returned, overwhelming me. Memories I thought had been erased by shock treatment returned in many forms. Most striking were intense physical reactions that often lacked thoughts - memories were stored in my body even though they might have been erased in my mind. This experience of the enduring effects of trauma was so amazing to me that I was determined to share what I'd learned. I felt an urgent need to inform clinicians of the harm they could cause by being careless, by not paying attention, beginning with diagnosis.

A mental illness diagnosis has a powerful influence on one's sense of self. Also diagnosis often determines treatment and some treatments have severe life-changing side effects. Misdiagnosis can seriously compromise people's lives.

Beyond medical side effects, shame and stigma adds to the suffering already caused by mental illness. It can lead people to deny that they are having problems, or to avoid getting help, because treatment also carries stigma. This stigma also affects families and friends, who worry about shame by association. I kept my past hidden for most of my life, long after I was working as a psychologist. This secrecy was a given: no one ever suggested that I should stop hiding my past. However, the gratitude people show - friends and strangers alike - along with their references to my bravery now that I am speaking about my experience, makes clear how powerful the stigma is and how important it is that we work to diminish it.

And finally, I'm here, alive, today because I was fortunate to find the right therapist and to recover through psychotherapy. By showing how it worked for me, I want to inspire people both not to give up and to invest in good quality psychotherapy.

When you were sorting through your journal entries and gathering material for your memoir, did you find yourself having to filter out certain details? If so, could you talk about the process of determining what should be made public and what should be left personal?

Initially I was writing from the midst of urgent chaos, seeking to hold myself together by putting thoughts on a page. I repeated lots of fears; I can see looking back that I was in certain ways repeating my earlier hospital thinking. I had a sympathetic and savvy therapist who encouraged me to write down what was happening and to send it to her by email. The details I filtered out over time included primarily what I considered over the top melodrama. I also toned down what felt like was terrifically immature neediness in my relationship with my therapist. There was just so much embarrassing information I could bear to reveal.

In one of your essays, you explain that you initially held back from sharing your history in part due to fear that it would affect your professional reputation. Did opening up about your past and vulnerability affect your practice?

I am not alone in my concern that the stigma attached to acknowledging a history with mental illness could risk my professional reputation. A number of colleagues have confided their own fears. I kept my past hidden until I'd been in practice for more than twenty years.. The first time I spoke at a psychiatry grand rounds, I was a co-presenter and my name was not on the announcement. Before I did that I met with both a long time supervisor, a senior psychologist in New Haven, and with my former psychiatrist, checking with each one to make sure they didn't think I was compromising myself professionally to do this.

All of these precautions may or may not have made a difference. In fact, everywhere I've gone I've been treated with kindness and respect. I have been invited to make further presentations. People express gratitude and confide their own secrets. Among professionals my reception has been consistently positive. My patients appear unfazed. If anything, they say it makes them feel more secure to know how far I've come. They appreciate that I understand suffering.

Could you talk about the shame and fear of stigma attached to mental illness and psychotherapy today? Do you believe our perception of it is shifting and if so, how?

I hope that increased openness on the internet and the presence of more media series that include mental illness and psychotherapy will help to defuse the stigma. But every time there's a mass murder or similar tragedy and the perpetrator is someone identified with a psychiatric diagnosis much of the media hype that follows only serves to reinforce the fear, and thus stigma, again. I don't think there's a good way to change this except for successful, accomplished, public people to begin to refer to their therapy sessions or their childhood therapist or the year they had to drop out of college for treatment, etc. as if that was a perfectly reasonable response to the situation at the time, so that the public perception shifts to seeing mental illness and treatment, especially psychotherapy, as part of a continuum, as much more common that one would think and something that can be dealt with successfully.

Smoking Cigarettes, Eating Glass, "The Crazy One," "The Other Chair," and many of your other works seem to draw almost exclusively from your personal experiences. What is appealing about writing nonfiction to you?

Nonfiction is what I know. I haven't tried to write fiction because I worry I couldn’t create a good enough story. My own life in psychiatric hospitals, however, delivered hundreds of stories already made. I just had to learn how to capture them on the page. There's the challenge of telling a good story as a way to make a psychological point. By using myself I can show the many sides of a simple action - the shame, fear, excitement, dread and hope that can be part of making a decision or taking a stand. I can illustrate emotions and psychological dilemmas without wondering if I'm accurate or not. The truth has sort of been handed to me and I'm using it.

As a psychologist and an author, you straddle the worlds of medicine and humanities. Could you talk about the interplay between your professions?

At the center of both medicine and humanities is the individual human experience. Yet that experience takes place in a context. We're all products of families and cultures, which vary widely, to say nothing of the larger forces of economics and the natural environment.

For me personally, your question itself couldn't be more affirming. You accept as given that I am an author as well as a psychologist; you refer to my professions, plural. And today this is true: I belong to both worlds. Each enriches the other. I find joy in both. Often the mistakes I make in therapy, the times I'm insensitive or overlook something important, come from rushing, from filling in the blanks with my own assumptions rather than being patient and listening with respect. The more open we are to varieties of experience, the better we can listen and appreciate any particular individual we encounter.

Are you currently working on any new projects?

I have pages of ideas for new projects, but I haven't yet been able to develop one beyond a few tentative stories. I'm learning that to have a book accepted for publication and then actually published and available is only another step in a long, ongoing process. It sounds trite, perhaps, but it's like having a baby. Labor and delivery is just the beginning! I'll be going to a residency in the fall where I'll have three weeks to really focus on beginning something new. I want to write stories about psychotherapy from a variety of points of view - the patient and therapist perhaps, but also the patient's parent or partner or child; people in the therapist's life. I want to see if I can convey the effects of psychotherapy as they ripple beyond the consulting room, to show how it heals (or doesn't) and how one person's change affects a whole system. And I'm beginning to think I want to write a novel that would tell what I imagine to be my mother's story.

Simone Leung is an intern at the Bellevue Literary Review. She is a rising junior majoring in Global Studies at Colby College and is interested in creative writing.

Sawyer's story "The Crazy One" appeared in The Bellevue Literary Review: http://blr.med.nyu.edu/content/archive/2012/spring/crazyone

Reading the Body: Live!

July 16, 2014 at 10:29 am

Stacy Bodziak, Managing Editor, Bellevue Literary Review

Not many literary evenings are divided into sections on "Dissection," "Bone," "Brain," "HEENT," and "Heart," but then again, it's not often that the readings are selected to complement Frank Netter's iconic illustrations. This past spring, the Bellevue Literary Review (BLR), a journal published by NYU School of Medicine, hosted "Reading the Body: Live!" an evening of poetry and prose that celebrated the closing night of the MSB Gallery's exhibit honoring Netter, "The Michelangelo of Medicine."

The featured readings - which span the BLR's thirteen-year archive - were brought to life by Kelly AuCoin and Carolyn Baeumler, talented actors that captivated the audience. Introductory remarks were made by Danielle Ofri, MD, PhD, editor-in-chief of the BLR, and Matthew Vorsanger, MD, Chief Resident, Internal Medicine. The evening was sponsored by Division of Medical Humanities and the Master Scholars Program in Humanistic Medicine.

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Writing And Medicine: Making It Up As You Go Along

February 26, 2008 at 10:21 am

A pair of round glasses on a sheet of writing, Wellcome Library, London, Photograph 2004
Commentary by Perri Klass, M.D., Professor of Pediatrics and Professor of Journalism at New York University, and Medical Director of the national literacy program, Reach Out and Read

Many many years ago, I think back when I was doing my residency, someone asked me to talk about the connectionsaor the differencesaor maybe the balance between writing and medicine. I was neckdeep in medicine, of course (or maybe it would be a truer metaphor to say that I was often out of my depth), and I was trying to write both fiction and nonfiction, as I could, along the way. I was therefore a de facto expert in what writing and medicine did or did not have in common, but as is so often the case with de facto expertise, it was a long way from anything I had actually thought through, let alone tried to articulate.

But though it may not be quite as effective as the knowledge that one is about to be hanged, the need to prepare a lecture does concentrate the mind, and so I eventually sat down to make some notes to myself about writing and medicine. Since much of my non-fiction writing at the time (and still) was drawn pretty directly from my clinical experiences, I put that to one side, and instead found myself thinking specifically about the ways in which writing fiction brought experiences and intellectual sensations and challenges into my life. And I came up with three ways in which I decided to argue that writing fiction balanced out residency. And now, a couple of decades later, I still find myself reaching for those ideas, whenever it comes time to discuss writing and medicine, two subjects still much on my mind, and much in my life. And I have to admit, I find myself wondering whether I reach for them because they happened to be the three points I invented for myself under pressure, when I had a lecture to give, or whether they were the three points I invented in the first place because they so resonated with the different parts of my lifeaand my brain.

Putting It Into Words

First of all, I said, in medicine, words mattered for the information they conveyed. If you could get the information across, if you could identify the correct term, you were using words appropriately (and "appropriate" is still one of those words that I never use without feeling I am taking refuge in a mildly unpleasant piece of pseudo-medical jargon). You don't have the luxury of using words for the sake of beauty or harmony or impact as part of daily clinical medicine; you wouldn't choose to spend twice as much time (or space) discussing a clinical situation, just because you had thought of an interesting and novel way to use language, or a less-than-straightforward structure in which to tell your story. On the other hand, there is no limit in fiction save the boundaries of your own genius (or lack thereof); the way you use your words is all. Go ahead and tell the story backwards, or inside out, go ahead and let the real story unfold by implication, make it as simple or as complex as you like, make your sentences deliberately brusque or stunningly lyrical; make your story structure as direct or as oblique as you like. The only limitation is your talent, the only measure is your success. Using the language in a bold new way may turn out to be a wonderful ideaaor a disasterabut the choice is yours.

Second, I said, medicine was a culture of availability, of turning yourself outwards and listening for various kinds of calls and cries. Clinical practiceaand most especially residencyawas about being on-call, being on the spot, being findable and reachable and moving fast when someone needed you. I invoked the beeper, of course. I described the "fishbowl" on the pediatric ward where I trained, the many-windowed room where residents sat to write up charts, easily and deliberately visible to every passer-by. Writing fiction, on the other hand, means shutting yourself alone in a room, looking deeply into what is there in your own mind, your own imagination, your own experience. Instead of listening for beepers going off and questions to be answered and cries of distress, you turn your attention to characters and stories that no one else can see or hear, until you have made them real.

And finally (and this was my socko finish), when you write fiction, you get to choose the ending. You get to decide who lives and who dies, who has what we would call (in the language where "inappropriate" means anything from wrong to crazy to rude) a good outcome, and who has a bad outcome. And the single harshest lesson of medical training, after all, is that while of course you do your very best, you don't actually get to determine the outcome and choose the ending.

Telling Stories About Telling Stories

Well, a couple of decades later, I still write fiction. And I still value it for what it adds to my life, for the ways it pushes my brain out of intellectual routines and into unfamiliar pathways. But even as I occasionally go on citing my three distinctions, I've come to believe that they are oversimplifications which shortchange both the complexities of practicing medicine and the challenges of writing fiction.

Take language. It's true enough that language carries a different value in fiction, where there is always the possibility of finding language which transports or shatters, shocks or overwhelms. And after all, if you were a writer of genius, you would find that languageawriters of genius somehow manage to do just that. But language in clinical practice is much more than the efficient coding of patient histories into the formula of case presentation and progress note. Language in clinical medicine is also the currency of communication and explanation, and it encompasses tragedy and confusion, resilience and generosity. I think about the many ways over the years that I have tried to find words to convey unwelcome information, and the many ways that parents have found to evoke their lives and their emotions and their questions. Sometimes there have been questions and comments that stayed with me for their poignancy or their beauty or their unexpectedness, like the teenager who asked me, "What do you do when your body really wants to do something and your brain isn't sure?" I have come to realize that the language of the exam room is the language of people narrating their lives, making up their own stories, or finding ways to articulate and examine the stories in which they find themselvesaand that the language there, as much as in anything a writer sits down to write, cannot be separated from the story.

Or consider availability, collaboration, inward-ness and outward-ness, whatever you want to call it. I think I always knew this was a somewhat false distinction; I would never write fiction if I did not spend time out in the world, mixed up with other people and their lives. It's true that sometimes writing can serve as a retreat, an interval of consideration and examination, even meditationabut I've never been a writer able to write out of the rich and glorious furnishings of my creative imagination. The inside of my head is hung with the scavenged scraps and the mismatched patches of my daily life, and what I do when I "turn inwards" in that rather affected phrase of mine is take the time to look more carefully at what I've carried home.

And finally, there's that issue about choosing the ending. Every writer who has struggled with fiction knows that isn't necessarily true. Characters don't do what you tell them to, or you find yourself disliking someone you had created and expected to find wholly admirable, or you watch in shock as two of your characters inexorably move into a doomed and destructive relationship. I mean, probably if you write certain kinds of formula stories, your characters do as they're told; if it's a romance novel, and the talented, spirited, but cynical and defensive heroine (oh, and beautiful, did I mention beautiful?) takes a job as sous-chef to a demanding, brilliant, but severe and critical chef (oh, and he's amazingly handsome, did I mention amazingly handsome?), and they dislike one another on sight…..well, probably they will behave themselves and fall passionately in love among the saucepans by page 120. And that's fair enough. But characters have a disconcerting way of speaking up for themselves ("The hell with the chef; I think I'm falling for that punked-out waitress with all the piercings!"). I have several times had the experience of coming to like and understand my villains much better than I had ever meant to do, or even worse, watching my heroes and heroines evolve at least a little in the direction of villainy, as it turned out their motives were less pure than I had planned, their standards of behavior a little less lofty.

So yes, when you write fiction you get to choose the ending. But it isn't always the ending you thought you were choosing, or the ending you wanted. In the writing of fiction, as in the practice of clinical medicine, you can learn a lot by listening carefully and watching closely. And I'm not sure there's really a good or useful distinction between the language of daily life and the more writerly language of literature; stories cannot be dissected out from the words used to tell them. And every story, as it is formulated into words, carries the potential to shake you up or shock you or move you in a variety of directions. It's about listening carefully to the characters, and valuing words in many different ways, it's about figuring out the ending, whether or not it's the one that you were hoping for (or that the characters were hoping for), and perhaps it's also about understanding, as a doctor or as a novelist, how your own limitationsalike your own abilitiesaare part of the language and the story and the outcome.

A Psychiatrist and a Poet

December 8, 2007 at 5:42 pm

Brain and Perception

Commentary by Ron Charach, M.D., Toronto psychiatrist, poet, and essayist.

To be both a psychiatrist and a poet is either a dual calling or a double whammy, depending on what you choose to emphasize. Such a medical/literary hybrid has surely won the sweepstakes in the personal sensitivity department. I am often asked whether being a psychiatrist helps me to be a better poet, though the reverse question is asked less frequently, especially since I don't do 'poetry therapy' in my psychotherapy practice. Before answering the question, a little more wordplay on the dual title may be in order.

One raises fewer eyebrows if one says "I'm a psychiatrist who also writes poetry" than if one says, "I'm a poet who does psychiatry on the side." The obvious difference in job security and monetary status of the two activities might lead to offbeat explanations like, "I couldn't make a living as a psychiatrist, so I went into poetry for the money" or, "Poetry is my day job, but I do psychiatry out of love."

There haven't been many psychiatrists/poets writing in English, at least not to the point of publishing (as opposed to self-publishing) several books. In the United States, people like Richard Berlin and Ronald Pies spring to my mind. A few others are represented in the anthologies of world physician poetry, Blood and Bone and Primary Care, published by the University of Iowa Press.

The late/great American poet Robert Lowell had a psychiatrist - er, actually, he had cause to visit his mother's psychiatrist, Merill Moore- a man who penned verse in what he nicknamed his 'sonnetarium'(oooh) at the back of his New England home. In other languages, Sweden's Tomas Transtomer, who had a psychology background, saw patients, and specialized in writing about people on the brink of doing something truly desperate, or at least, transformative.

I started writing in deadly earnest in pre-adolescence, and entered many essay and poetry-writing competitions, usually getting an honourable mention or placing second or third, which only whet my appetite to try harder. After being a psychiatrist for the past 27 years and psychotherapist for the past 30, I would say that practicing the craft has given me a good ear for dialogue and monologue, for how people actually talk and think. Dream analysis has also sensitized me to the value of using dreams as bridges to more fully understanding people’s fears, preoccupations and goals.

Psychiatrists from the past whose work informs my own include Freud, whose main prize, the Goethe Prize, was in literature, not medicine, and the late Heinz Kohut, whose nearly unreadable books nevertheless are rich in their appreciation of the powers of the literary imagination and very rich indeed in their conception of the needs of a viable self. I also get a lot of tips from more prosaic theorists like Aaron Beck, who invented cognitive therapy.

Being a poet informs my work as a psychiatrist insofar as both callings focus intensely on language and its many layers of meaning.The mind is hard-wired to make and to understand metaphor, something the neuroanatomists have only begun to study. Many of my poems are about medicine in general and psychotherapy in particular, and I would refer the reader to rather amusing if vaguely unsettling pieces on such procedures as "MRI" and "Colonoscopy", both poems written from the perspective of the wary physician/patient who 'knows too much'.

Anyone who would like to see the many subjects which a psychiatrist/poet might take on is invited to look at my latest book, Selected Portraits, published this autumn by Wolsak and Wynn, which contains poems about relationships from my first six collections.

I would offer a caveat for those who want to join me in the dual calling. Being a psychotherapist is especially hard on the back, given the relatively fixed postures one must sit in for large portions of the working day. Being a writer can also be hard on the back; ask Philip Roth who often works at a stand-up desk. Poets, of course, have it easier than novelists, but the physical issues add another form of double jeopardy to the work.

Psychiatrists and psychoanalysts are often talent manques, men and women who are reluctant to come out from behind their therapeutic neutrality. They get few opportunities to assert themselves as people with strong opinions and viewpoints, at least not in the consulting room, where to do so might be inappropriate. I work a lot with adolescents, who have ‘automatic shit detectors’ and tend to appreciate frankness. Knowing I am a poet, other physicians often send me referrals who are actors, screenplay writers, even the occasional poet.

The patients I write about are composite creations, actual patients sometimes serving as springboards for fictional portraits that may include auto-biographical takes on the poet and his own family. It might sound overly cautious, if not downright paranoid to state, at the end of a book of poetry which everyone knows to be a work of fiction, "No character in this book is identical to any living person", but I've often been tempted to do exactly that. In the end, though, I find the first-person-singular voice to be very effective and collar-grabbing and am usually willing to run the risk of the reader's deciding that the views presented in the poem are identical to that of its creator. Consider it the third hazard of this unique double calling.