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BMJ Case Reports 2013; doi:10.1136/bcr-2013-009990
  • CASE REPORT

Jung's archetype, ‘The Wounded Healer’, mental illness in the medical profession and the role of the health humanities in psychiatry

  1. Rashid Zaman2
  1. 1National Institute of Health Research Academic Clinical Fellow Psychiatry, Manchester University, Manchester, UK
  2. 2Department of Psychiatry, University of Cambridge, Cambridge, UK
  1. Correspondence to Dr Ahmed Hankir, ahmedzakaria{at}doctors.org.uk

Summary

Carl Jung used the term, ‘The Wounded Healer’ as an archetype to describe doctors who have suffered from an illness. Reading and writing autobiographical narratives of the ‘Wounded Healer’ is gaining popularity among doctors with mental illness as an effective form of adjunctive therapy. Moreover, reading autobiographical narratives of psychopathology sufferers can ‘augment’ service providers’ humanity by offering valuable qualitative insights into minds afflicted with a psychiatric disorder. The primary author, a doctor of Middle-Eastern descent practicing in the UK, composed an autobiographical narrative about his personal experiences with oscillations in his mood in an attempt to illustrate the cultural, religious and psychosocial factors that influence disease detection, progression, treatment and outcome. An inordinate amount of misconceptions about mental illness abound. We hope that this manuscript will help to lessen the stigma associated with those who suffer from psychopathology (particularly doctors) and encourage sufferers to engage with the appropriate services.

Background

According to Professor Brian Hurwitz, an eminent scholar in the health humanities, there is a growing perception that science alone provides insufficient overall foundation for the holistic understanding of the interaction between health, illness and disease.1 Echoing this message in an article in the Journal of the Royal Society of Medicine, the Prince of Wales called for wider perspectives on healthcare and for National Health Service clinicians to develop a ‘healing empathy’. Prince Charles beckoned for treatment that “understands…and uses patients’ perspectives and beliefs…”2

Notwithstanding the aforementioned, other myriad issues in modern medicine have also been identified (ie, 5–15% of schizophrenia sufferers experience psychotic symptoms despite medication).3 Over recent years the health humanities has emerged as a distinct entity in attempts to ameliorate the limitations in the provision of healthcare services.4 Autobiographical narratives of those who suffer from psychopatholgy (which includes Jung’s archetype ‘the Wounded Healer’) falls under the remit of the health humanities. One of the aims of this exposition is to explore how autobiographical narrative is gaining popularity among doctors with mental illness both as a form of therapy and as a means to campaign against stigma (figure 1).

Figure 1

Dr Ahmed Hankir MBChB lecturing on Art Therapy at the Doctors Academy International Academic and Research Conference, November 2012, Manchester University Place.

A review of the literature was conducted. First-person narratives of doctors with psychopathology were collated and qualitatively analysed. The primary author, a psychiatry trainee of Lebanese descent practicing medicine in England, also composed his own autobiographical narrative about his personal experiences with oscillations in his mood in an attempt to illustrate the cultural, religious and psychosocial factors that influence disease detection, progression, treatment and outcome.

An inordinate amount of misconceptions about mental illness abound and our intention is to encourage people to deconstruct and reformulate their views on psychiatric illnesses in general. It is our hope that this manuscript will help to lessen the stigma associated with mental illness. Stigma is a motif that we will expand upon in more detail later in this manuscript.

The primary author unashamedly discloses his having bipolar disorder, one of the most persistent and severest forms of mental illnesses,5 for numerous reasons. We are aware that there are employers who do not look favourably upon applicants who have a psychiatric illness and it is an established fact that sufferers of psychopathology are less likely to be employed than those who have a physical ailment (fewer than 4 in 10 employers say they would be happy recruiting someone with a mental illness6 ,7 a statistic that would provoke consternation if it applied to hypertension or gout). Our aim is to increase awareness and dispel myths about psychopathology in general and manic-depressive illness in particular, by elaborating on the primary author's personal experiences and by signposting his own trajectory. In the same vein as the creative poet David Holloway poignantly said in his moving article, My ‘Colorful’ life with Schizophrenia, the primary author “… prays that the perception of psychiatric illness can be altered to that of a renewed awareness which evokes notions of love, peace and harmony.”8

Jung's archetype, ‘The Wounded Healer’

Carl Jung used the term ‘The Wounded Healer’ as an archetypal dynamic to describe a phenomenon that may take place, both positively and negatively, in the relationship between analyst and analysand.9 The ‘Wounded Healer’ remains a powerful archetype in the healing arts. Carl Jung discovered this archetype in relation to himself; for Jung, “A good half of every treatment that probes at all deeply consists in the doctor’s examining himself…it is his own hurt that gives a measure of his power to heal. This, and nothing else, is the meaning of the Greek myth of the wounded physician.”10

Jung traced the origins of the concept of the wounded healer to the epoch of the ancient Greek myths of Chiron, the wounded centaur and his student Asclepius, who later became the god of medicine and healing. The ‘Wounded Healer’ archetype probably precedes this, however. For example in shamanism, traditions have held that a healer must first be wounded themselves before they can be truly effective in helping another heal.

Case presentation

Case study: Dr Ahmed Hankir (a first person account)

In order to restore the human subject at the centre, the suffering afflicted fighting human subject we must deepen a case history into a narrative or tale… Oliver Sacks, The Man Who Mistook his Wife for a Hat11

A special place must be reserved for those colleagues who know and can describe the world of the Parkinsonian with an incomparable authority, from the inside. Oliver Sacks, Awakenings12

I was born in Belfast, Ireland on the 15 September 1982 against a backdrop of increasing tension and civil strife between the Protestants and the Catholics. I then lived in the picturesque city of Dublin for a spell before moving to the idyllic county of Worcestershire where I resided for half a decade prior to being whisked away to the war torn lands of Lebanon, where I am ethnically from.

I returned to the British Isles at the young age of 17. This was a significant mark in my life; from that point on I would be totally dependent on myself in the financial sense but also in the emotional sense in that I would no longer be living in the immediate milieu of my parents. But the UK wasn't like Lebanon where if you don't work, you don't eat and furthermore a good education was your birthright and I'd be damned if I squandered this golden opportunity, this decent shot at life that I had been granted because of the sacrifice that other Britons of previous generations had made in order that I live a better life than them. It didn't take what the Columbia University Scholar C. Wright Mills called a ‘sociological imagination’ that I would later acquire to realise at that time that I had plenty to be grateful and sanguine about.

I enrolled in a sixth form for the A-level assessments since, despite graduating top of the school that I attended in Lebanon, the qualification that I was in possession of was not recognised. Even though I was in full-time employment I still managed to receive straight A's and I was granted admission into Manchester Medical School.

In 2006 reports started trickling in about a war that was being waged upon Lebanon. The sheer abruptness was astounding; Lebanon was only just recovering from a devastating civil war and after many, many years of reconstruction Beirut was now, once again, boasting a spectacular opulence and was becoming a tourist attraction as it had been before the conflict. It only took a matter of days for Lebanon's concrete infrastructure (for Lebanon's abstract fabric is impregnable) to be obliterated. It was around this time that I started to notice the following:

  • “I was dreaming dreams that no mortal ever dared to dream before…”

  • Grandiloquent ideas, racing thoughts, Knight's move thinking evident

  • Pressurised speech

  • Argumentative, irritable, impetuous, over-familiarity

  • Over generosity and spending sprees

  • Reduced need for sleep

  • Increased amounts of energy (subjective 11/10)

  • Affective incongruity (feeling elated despite the fact that my world has turned upside down, but this will soon change…)

Predisposition: both my parents suffer from depressive illness; however, it is noteworthy that my monozygotic twin brother was spared of the disorder highlighting the environmental role played in bipolar disorder (my twin brother has gone on to achieve great feats of his own, obtaining a doctorate from Imperial College London and is presently a postdoctoral research fellow at The Department of Physiology Anatomy and Genetics, Oxford University).

Precipitating factor: war waged upon my country of origin was a major stressor although there were a number of other factors that also culminated and compounded.

Perpetuating factors: refusing to seek psychiatric treatment out of fear that I was ungrateful for all of what I have been given in life and parents living overseas so they were not able to care for me and provide me with the support that they would have wanted to because of logistics.

Protective factors: I did attempt to abide by the tenets of Islam as best as I could and as such I was aware that committing suicide was strictly forbidden. This did confer protection as I was experiencing suicidal ideation while I was in extremis but resisted the impulse to carry out any such act as I realised that this would violate the laws of Islam.

A full-blown mania ensued. When beholden to the spur flights of fancy and notions of romanticism compel you and those who suffer from bipolar disorder can be rendered impressionable to sensationalism as portrayed and depicted in popular culture. For example, I was particularly struck by the actions of the Oxford physician Thomas Willis and I actively sought ways to emulate him which may not necessarily be pathological but can be beyond a demarcated degree.

The aftermath of mania is invariably melancholia… I started to sink into the murky depths of a depressive illness, a depression too dreadful to describe. Suicidal ideation, irregular/disturbed sleeping patterns, socially withdrawn, listlessness, feelings of worthlessness, utter guilt and sheer shame, inability to concentrate and a bleak outlook for the future are all part and parcel of the depressive dimension of bipolar disorder. I was, ironically, rendered homeless consequent to the spending spree as a result of being over generous while manic; for two nights I slept on the hard and cold streets of Moss Side in Manchester (déjà vu?). These were the toughest times of my life and things were not going to get much better any time soon…

While the bridges in Lebanon were burning quite literally, I started to burn bridges in the metaphorical sense with people whom at the time I thought were my closest companions. Champagne to my real friends and real pain to my sham friends… Edward Norton, 25th hour

It is true that my friends became fewer but firmer and my reputation tarnished apparently irrevocably so to the extent that I was ostracised by these so-called ‘sham’ friends of mine. Social exclusion had a deleterious effect on me. I was sinking deeper and deeper into the darkness…

Stigma

Both experiences were horrible… but with breast cancer people ran towards me with open arms and hugged me. With depression people ran away… When I was diagnosed with breast cancer, I was inundated with ‘Get Well Soon’ cards. When news leaked out that I was in a psychiatric hospital following a breakdown, not a peep. And certainly no cards… British television personality Trisha Goddard

A stigma was a scar on the skin of ancient Greek criminals. It was a sign to all that they were unsafe, unclean and unwanted. Stigma stills persists today in the public's attitude towards those who are mentally ill. We see a fundamental divide between the psychotic mind and the asthmatic lung, as if those who suffer from psychopathology do so out of their own making and as such do not deserve the same kind of sympathy we would ordinarily show to someone with another chronic or long-term illness like cancer but instead they are made to endure the howls of derision that are hurled at them…

Treatment

Disclaimer alert: while I have personally experienced oscillations in my mood, the euphoric highs and debilitating lows, this manuscript can never replace the guidance and advice from an expert, that is, a consultant psychiatrist. Evidence proves that the mainstay of treatment for bipolar disorder is medication and it is imperative that patients are informed about this and follow the recommendations and advice from their specialist. There are other medications used to treat bipolar disorder that have been developed that service users should discuss with their doctors since they are reportedly efficacious and have a good side effect profile. Advances in the management of mood disorders have been made and sufferers can keep abreast with progress in this area by consulting the relevant professionals.

Some patients with manic-depressive illness may opt out of popping pills in order to cure themselves (a lot of patients don't believe that there is anything that matter with them in the first place). The reason behind this resistance is that they perceive the taking of medication to be a sign of weakness. Also, manic-depressive illness has a profound effect on a person's identity and some patients believe that taking medication will rob them of their character. There is also the concern of medicalising human emotion. A person with manic-depressive illness can no longer merely be angry any more for any manifestation of human emotion is regarded as symptomatic of his illness.

Citalopram (an antidepressant) was prescribed by the general practitioner (GP); however, the consequences were deleterious. An adverse reaction ensued (antidepressant used to treat depressive illness in patients with bipolar disorder can cause a drug-induced hypomanic or manic episode which is what happened). Citalopram was therefore discontinued.

The antipsychotic quitiapine was then instigated since it has mood-stabilising properties. It is also used as an off license sedative (which is the reason why most patients, including the primary author, refuse to continue complying with this medication).

Carbamazapine (an anti-epileptic drug) was then considered since it is known to have mood-stabilising properties, however, it was not started due to the revelation of unexplained abnormal liver function tests (primary author is a teetotaller).

Lithium has a narrow therapeutic index and is not advocated by some psychiatrists on the grounds of its toxic side-effect profile although it is the drug that has the most evidence to prove its efficaciousness in treating bipolar disorder.5

Outcome and follow-up

Dr Hankir convalesced in 2010 and he has been in full remission ever since without having to take any medication. It is paramount to realise that for the majority of cases, medication has been key to recovery and patients must seek help from their psychiatrists in order to establish what is the best recourse for them.

In April 2010 Dr Hankir conducted an out-of-area special student component in Cambridge University as part of his medical studies (supervised by Dr. Mark Agius and Dr. Rashid Zaman) on the association between the artistic temperament and bipolar disorder. This experience piqued his interest in academic psychiatry, with a particular focus on art therapy in psychiatry. Dr Hankir qualified in 2011 and has been actively campaigning to stamp out the stigma associated with mental illness, particularly in the medical profession. He has presented his research findings in national and international conferences all over the world (New Jersey, Montreal, Tel Aviv, Cambridge, London and Vienna). He has published widely on the portrayal of mental illness in film, literature and the media and has given oral presentations and lectures on his personal experiences with mental health challenges. Dr Hankir is presently a member of the British charity Doctors Support Network (as well as associate editor of their newsletter) and is currently serving an appointment as Health Humanities, Psychiatry and Global Health Lead for the medical education organisation Doctors Academy and is also editor of their official publication the World Journal of Medical Education and Research. Dr Hankir is a published poet and is working on his first book about the portrayal of mental illness in film. Dr Hankir has been offered the National Institute of Health Research Academic Clinical Fellowship in Psychiatry with Manchester University and is progressing well with his foundation training.

Discussion

The mental health of doctors

“Quis custodiet ipsos custodes?” Who will watch the watchmen?

With respect to mental health, the incidence of most psychiatric disorders is higher in doctors than in the general population. Surveys have revealed that up to 25% of doctors have significant depressive symptoms. Suicide rates are also high, with depression, alcohol and drug misuses the significant contributory factors. Specialties over-represented include anaesthetics, GP, psychiatry and emergency medicine. Problems of drug and alcohol dependence may affect as many as 1 in 15 doctors in the UK.5

Barriers to seeking help

Doctors are notoriously bad at seeking help for their own medical problems—particularly psychiatric problems—often only presenting when a crisis arises. Reasons for this include symptom concealment (owing to fears of hospitalisation, loss of medical registration and exposure to stigmatisation), negative attitudes to psychiatry, psychiatrists and people with psychiatric problems and lack of insight being a feature of many psychiatric disorders. All of these factors can conspire and lead to misdiagnosis, delayed referral and doctors not receiving the benefits of early interventions.5

Looking after your own mental health.

“The physician who doctors himself has a fool for a patient” Sir William Osler, 1849–1919.

As enumerated above, psychopathology is common in colleagues, patients and relatives (1 in 4 people will develop a mental illness at some point in their lives).13 The authors urge readers to seek help for their own problems. You are not the best person to plan your assessment, treatment and referral. In the words of the authors of the Oxford Handbook of Psychiatry, “You have a duty to yourself and your patients to act promptly if you feel there are early warning signs that your health may be affecting your performance.”

Developing good habits is vital to preserving a healthy mind and preventing psychopathology from transpiring. Psychiatrists recommend the following: learn to relax, take regular breaks at work if you can, escape the pager, exercise, avoid drugs such as tobacco and other recreational drugs (caffeine and alcohol should only be consumed in moderation). Most importantly, register with a GP! An alarming number of junior doctors (up to two-thirds) have not done this.5

The Merits of the Health Humanities

The medical humanities are described as including medical ethics, medical sociology, social history of medicine, and the application of literature and the arts in general to medicine. It has been argued that the medical humanities can complement medical science and technology through contrasting perspectives of the arts and humanities by… shaping the nature, goals, and knowledge base of medicine14…What is implicit in these arguments is that there is something about the scientific stance that detaches the medical practitioner from the subjective experience of patients and, this argument goes, the arts or the humanities can facilitate the re-engagement of the practitioner with the subjective world of the patient.4

Notwithstanding the above, the strengths of the health humanities are substantial. Professor Kay Jamison’s autobiographical narrative about her personal experiences grappling with bipolar disorder entitled An Unquiet Mind has been perused by sufferers of bipolar disorder all over the world and has been attributed to saving a countless number of lives. In the Royal College of Psychiatrists prestigious yearly Morris Markowe competition, the 2012 prize winner’s article entitled, “Doctors go mad too” revealed through autobiographical narrative how the author’s experiences with mental illness enabled her to be more empathetic with service users thus strengthening and redefining the therapeutic relationship.15 The article also helped to make mental illness among the medical profession more acceptable. The British charity Doctors Support Network (DSN), which is run by a group of doctors with mental health challenges, includes in each issue of its news letters an autobiographical narrative from a doctor who suffers from psychopathology. Readers of the DSN newsletters (fellow medics with mental illness) report deriving solace from shared experience.

The health humanities are beneficial for both service providers and service users. Reading autobiographical narratives of psychopathology sufferers can ‘augment’ and ‘embellish’ service providers’ humanity by offering valuable qualitative insights into minds afflicted with mental illness. Autobiographical narrative is also becoming increasingly recognised as an effective form of adjunctive therapy. A burgeoning number of doctors who have mental health challenges (and who thus become service users) are utilising this form of therapy. They report that the activity itself is both therapeutic and cathartic. In a poignant autobiographical narrative from a parasuicidal medic published in student BMJ the author relates how, “... in the US alone 400 doctors are lost to suicide every year... and that it is only through increasing the extent to which we make it more acceptable to share our experiences of difficulties with low mood that the number of suicides among medics will fall”.16 The authors, particularly the primary author, posit that autobiographical narratives of doctors who suffer from psychopatholgy serve that very purpose.

Learning points

  • There are higher rates of psychopathology in the medical profession compared with the general population.

  • Stigma is a major issue among doctors who suffer from a psychiatric illness and can hamper disease detection, delay referral and result in doctors not receiving the benefits of early interventions.

  • The health humanities are beneficial for both service providers and service users.

  • Reading autobiographical narratives of psychopathology sufferers can ‘augment’ and ‘embellish’ service providers’ and the general public's humanity by offering valuable qualitative insights into minds afflicted with mental illness.

  • Autobiographical narrative is becoming increasingly recognised as an effective form of adjunctive therapy. A burgeoning number of doctors who have mental health challenges (and who thus become service users) are utilising this form of therapy. They report that the activity itself is both therapeutic and cathartic.

Footnotes

  • Contributors AH helped to conduct the literature review and provided the case report. RZ was AH's SSC supervisor and has been providing AH with ongoing supervision with various research projects, including this one in which he conceived the idea for AH to write the manuscript. RZ conducted the literature search, rectified errors in the original drafts and edited the final draft. RZ is Consultant Psychiatrist and Associate Lecturer, Department of Psychiatry, University of Cambridge, UK.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

References

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