In epidemiological research, self-rated health is an independent predictor of mortality, cardiovascular diseases, and other critical outcomes. It is recommended for clinical use, but research is lacking.To investigate what happens in consultations when the question ‘How would you assess your general health compared with others your own age?’ is posed.Authentic consultations with GPs at health centres in Sweden.Thirty-three planned visits concerning diabetes, pain, or undiagnosed symptoms were voice-recorded. Dialogue regarding self-rated health was transcribed verbatim and analysed using a systematic text condensation method. Speaking time of patients and doctors was measured and the doctors’ assessment of the value of the question was documented in a short questionnaire.Two overarching themes are used to describe patients’ responses to the question. First, there was an immediate reaction, often expressing strong emotions, setting the tone of the dialogue and influencing the continued conversation. This was followed by reflection regarding their functional ability, management of illnesses and risks, and/or situation in life. The GPs maintained an attitude of active listening. They sometimes reported a slight increase in consultation time or feeling disturbed by the question, but mostly judged it as valuable, shedding additional light on the patients’ situation and making it easier to discuss difficulties and resources. The patients’ speaking time increased noticeably during this part of the consultation.Asking patients to comparatively self-rate their health is an effective tool in general practice. In epidemiology, self-rated health is measured as an individual’s subjective answer to a question about their general health  or their health compared with others their own age (comparative question), and has a strong association with significant medical outcomes such as death, diabetes, coronary heart disease, functional ability, and depression.2A seminal review and several epidemiological studies recommend self-rated health for clinical use.8The formulation of the question is of minor importance in relation to outcomes such as mortality in epidemiological studies.12This study aimed to investigate what happens when the question ‘How would you assess your general health compared with others your own age? Is it better, about the same, or worse?’ is posed to patients in authentic consultations with GPs.Eight experienced colleagues interested in consultation skills were invited to participate. Six accepted, and two of the authors also participated. The participants received an outline of the study design and brought a recorded pilot consultation to an introductory meeting with all participating physicians. At that meeting, the epidemiological background of self-rated health and the aim of the study were presented, and discussions were held on how to perform the study. The question was to be posed when convenient before the physical examination; the exact wording could be varied, but the words ‘assess’, ‘health’, and ‘compare with others your own age’ were important. Emphasis was not to be on pinpointing comparisons, but on attentive listening to the patients.The consultations were scheduled, non-emergency appointments with new as well as established patients. In keeping with previous research, patients with diabetes mellitus type 2 and chronic non-malignant pain were chosen, adding also patients with undiagnosed symptoms. Patients were aged ≥18 years and able to speak Swedish. The aim was to obtain a wide age spectrum and a balanced number of females and males, accomplished through feedback to the participating GPs. No further selection was deemed necessary. Thirty-three consultations were judged to be sufficient; the last recordings did not change the main findings of the study.Knowledge of self-rated health is based on epidemiological studies. Self-rated health is a comprehensive summary of several factors important for health, it is predictive of critical medical outcomes, and has been recommended as a clinical tool. The application of this epidemiological concept to clinical situations has scarcely been studied. This qualitative study reports what happened in authentic consultations in general practice when patients were asked to self-rate their health.Patients were informed that the study concerned how doctors can improve dialogue with patients. All patients gave written informed consent to participate.The consultations were voicerecorded. One author listed topics covered in each consultation and established which portions concerned the question. Consultation time as a whole and the overall apportionment of speaking time between doctor and patient were measured and specifically during the discussion of self-rated health. Time used for administrative tasks such as writing prescriptions was not included. Decisions on how to delineate topics, and that pauses >1 second were signs of cognitive processes, were informed by the Roter interaction analysis system.The authors separately made a written summary of the portion of each transcript devoted to the question. Further analysis was informed by the method of systematic text condensation (STC).15Immediately after each consultation, the doctors completed a questionnaire asking: ‘Did the question of self-rated health affect the consultation and/or your understanding of the patient’s health situation, yes or no? Describe how’. The answers to the ‘describe how’ question were used in the final analysis as a means of mirroring the STC analysis of the transcriptions.There were 33 participants in the study: 17 females and 16 males, aged 18–83 years, median age 60 years.Reasons for consulting are listed in The participating GPs, three males and five females, were aged 44–61 years and had been working as physicians for 16–34 years. The consultations took place between May 2013 and November 2013 at community health centres in northern Sweden, located in towns as well as small municipalities.Time used for the consultations ranged from 12 minutes to 46 minutes (median 23 minutes). Time for discussion of self-rated health ranged from 30 seconds to 15 minutes, (median 2 minutes). In the consultation as a whole, the patients’ speaking time varied from 21% to 85% of the total speaking time. In the portions covering self-rated health, patients’ speaking time ranged from 49% to 90%. The increase was most prominent in the consultation where the patient had only 21% of the total speaking time. When discussing self-rated health, the patient’s speaking time rose to 64%. Generally, the apportionment of time was associated with the doctor’s consultation style.Physicians stated that the question had affected the consultation and/or their understanding of a patient’s health condition in 30 of 33 consultations. On two occasions, incorporating the question and/or being recorded was experienced as distracting. On two other occasions, the question had made the consultation slightly longer. The remaining comments are integrated into the results below.Doctors did not always use the comparative words ‘better’, ‘worse’, or ‘about the same’, and even if they did the question did not always elicit a distinct answer. In total, 12 patients indicated that their health was ‘worse’ than others in their age group, 13 replied ‘better’, and eight ‘about the same’.The question was often followed by silence lasting several seconds; some patients sighed or made a tentative attempt to respond; some asked the physician to repeat the question. In response to such confusion, physicians sometimes made the question more transparent by providing the three alternative answers.This process suggests that the question was unexpected. Once patients had understood it, many responded emotionally (referred to below as ‘reaction’), and subsequently more thoughtfully (referred to as ‘reflection’).‘Well, I do have a spare tyre.’ [embarrassed laugh]Many patients interpreted the question as referring to lifestyle matters — diet, weight, and exercise — and for most this brought on feelings of guilt and shame. One such immediate response was:When patients conveyed guilt and shame the physicians reported that they became more sensitive in discussions of lifestyle issues. Some patients, in contrast, reacted with pride and delight, asserting that they were in better shape than others. The physicians experienced such responses as ‘lightening things up’.‘Some people just feel so damned good!’Another emotion that came out was grief, sometimes expressed as anger, about poor health and the limitations this entailed, or being so much worse than others. These feelings were often expressed in strong language, whereas profanity did not otherwise occur in consultations. One patient burst out:Even with established patients, a powerful emotional reaction could make the physician view their situation more clearly: ‘Things were worse than I’d realised’. Other reactions provided entirely new insights; debilitating symptoms that the physician did not know about; no peer group for comparison revealed isolation despite an apparently normal social life.‘I don’t know, there’s sure to be someone who’s in even worse shape than I am’.However, there were also patients who stated that they felt pretty good, despite their current symptoms. Even a serious chronic illness might sometimes, in comparison, seem tolerable:According to the physicians, the emotional responses gave an on-the-spot account of the patient’s situation and had an impact on the atmosphere in the room and the direction of follow-up discussion.In discussions that followed, focus was on the patients’ thoughts and reflections about their health, past and present. They expressed insights that seemed to evolve or coalesce during the conversation. The physicians responded with encouraging murmurs and by repeating or summarising what the patients had just said, making it easier for them to continue. The conversations focused on the patients’ functional ability, their ways of managing symptoms, illnesses, and risks, and how their life circumstances affected their experience of ill health.Patient:‘As I said at the beginning, I’m a bit disabled because of my legs.’GP:‘Yes, right.’Patient:‘Don’t have much strength ...’GP:‘Mmm.’Patient:‘My balance is worse, and … But other than that, I think overall I’m doing better than many … A lot of others are dead and … I’m clear in the head, after all.’Illnesses and symptoms were clearly correlated with functional ability in daily life after the question was posed. Some patients thought they felt better than before, physically, emotionally, or in general. Others began identifying what they were able to do despite everything, and things they could enjoy and afford. Comparisons with others who were more limited by illnesses made some look more positively on their own situation, even those who initially had answered ‘worse’. An 83-year-old male who no longer could go hunting because of difficulty walking was one of these. When, towards the end of the consultation, the doctor returned to the question, the patient responded:This type of shift in perspective made it easier to discuss the patient’s resources. As one physician wrote: ‘It stimulated me to try to inspire change’.However, for other patients illness and its negative consequences continued to be the central focus. Such exchanges could give physicians a deeper awareness of the patient’s problem, insight into the gravity of the illness, or the risk of continued ill health. On rare occasions, physicians reported that the question only made the patients ‘start thinking even more about how miserable they were’.The patients also considered how they attempted to manage their ill health. Many described having begun, after great struggle and internal resistance, to accept their situation: ageing was inevitable, illnesses required medication, and they had to make the best of it. Reflections like this incorporated a degree of detachment or self-irony, and occasionally the tone became joking.Patient:‘… when I realised that my son and I never could go to the movies on our own, or go shopping or walk around town on our own …’GP:‘Mmm.’Patient:‘… well, that’s when I pulled myself together and ... started, what do you call it, working through it.’Work and taking responsibility were among the resources and deliberate strategies that patients brought up. One retired patient helping a friend at his firm stated that this made him ‘forget his troubles for a little while’. A female suffering from chronic pain and agoraphobia after being raped described having realised that she had to face up to her fears for her child’s sake:The physicians commented that conversations like this made both participants aware of the obstacles the patient had dealt with. Other patients emphasised, in ways the physicians had not anticipated, being ‘bull-headed’ in their determination to overcome physical disabilities. These attitudes could be useful when discussing treatment.Patient:‘They say I have to eat the right food, I have to exercise, I have to blah blah blah.’GP:‘Mmm.’Patient:‘I was supposed to lose some weight, but I haven’t … You know, I just don’t get around to it … it’s just that it’s so hard to deal with ...’Many patients emphasised their attempts to ‘live a more healthy life’, and some had succeeded. Others were well aware of what they needed to do but failed continuously. The burden of responsibility and inability to live up to expectations weighed heavily on them. A 60-year-old male, worn down by multiple illnesses and answering ‘worse’ had lost his ‘go’:When patients could express their sense of futility aloud, physicians felt it became easier to provide support.‘Well, I’ve been sitting and thinking about this, if it could be something like … having too little to do … that I spend too much time alone, and then, well, I brood about it consciously, or brood about it unconsciously, about my situation, I mean the way things are, you see.’The patient’s circumstances in life and their impact, for better or worse, on symptoms and illness came up in many discussions. A 71-year-old male began reflecting on his isolation:Patient:‘Well, it’s like he feels cut off or something.’ [laughs]GP:‘I see.’Patient:‘He’s like, “Oh, are you off to the stable again? When will you be back?”’GP:‘Mmm.’Patient:‘… it’s not as much fun.’Several females described difficulties in relationships with partners. One female was not taking her painkillers because her husband made disdainful comments about her dependence on them. Another female with chronic pain enjoyed being at the stable with her daughter, but her pleasure was diminished because her husband ‘wasn’t so crazy about it’.The patients’ reflections about their life circumstances gave the physicians a more complete picture of them as individuals and the challenges they faced.In most consultations, asking patients to comparatively self-rate their health had an impact, including on the tone of the discussion. The patients’ speaking time increased, while the physicians’ role shifted to encouraging them to talk. The first reaction to the question, often spontaneously emotional, was followed by a reflective discussion in which patients weighed various reasons for their self-assessment. These reflections gave a telling description of the patients’ functional ability, life circumstances, and resources for or obstacles to managing symptoms and illnesses, that the physicians could follow up. With some exceptions physicians thought the question had improved the consultations and their understanding of the patient.This study is based on authentic consultations involving a number of GPs at various healthcare centres in Sweden and patients of widely ranging ages, in diverse life situations, and with different diseases. Topics brought up often concerned delicate personal matters and emotional reactions were common, suggesting that voice-recording had minimal restraining effect on what was said. The doctors were unfamiliar with asking about self-rated health, however, and it was sometimes difficult for them to use the question.The research material consisted of audiorecordings, verbatim transcripts, and answers to a short questionnaire. For the analysis, STC was used, alongside time measurement and simple counting of yes/no answers in the questionnaire.Despite the limited size of the study and the specific Swedish setting, it is believed that the findings are credible and transferable to other settings.The allotment of speaking time between patient and doctor shifted noticeably after the question was asked and more time was used by the patients. This increase is in keeping with the observation that focus was on the patient’s thoughts when the question was posed. Discussion of self-rated health was incorporated within the timeframe of regular consultations at Swedish healthcare centres, which ordinarily last 15–30 minutes.3Self-rated health is a relatively stable construct, established early in life.In their reflections, patients attempted to understand or explain their spontaneous responses. Sometimes, but not always, this prompted reconsideration of their situation. Opportunities for reflection are few in an ordinary GP consultation, which comprises informational discussion of care and treatment, social chit-chat, or questions and answers.The question about comparative self-rated health constitutes a feasible tool in general practice, particularly to solicit information on risk and the patient’s feelings related to an illness or disease, and to encourage the patient’s active reflection on functional abilities, life situation, health, and health strategies. Self-ratings are not to be seen, however, as a standard procedure in all consultations.There is a need for professional training in using self-rated health questions. Further research is also needed in general practice in different countries about comparative self-rated health and the effects of reflection on health and health care.22


What unites these three very different thinkers is a concern over habitual, automatic and involuntary behavior, which in all three cases has a distinctly neurological dimension. Beckett’s writing explores the Bergsonian notion, informed by medicine and experimental psychology, of the limitations of agency, of “the deep-seated recalcitrance of matter,” and of the human as always already inflicted by the mechanical, a fact that is poignantly highlighted by the case of Samuel Johnson. Through his encounter with Johnson, Beckett registers a paradigm shift in the understanding of subjectivity. Whereas Bergson aims, throughout his career, to  This article analyses the work of the twentieth-century late modernist Samuel Beckett, in light of the turn-of-the-century anti-rationalist Henri Bergson (1859-1941) and the eighteenth-century neoclassicist Samuel Johnson (1709-1784). What unites these three very different thinkers, I will argue, is a concern over habitual, automatic and involuntary behaviour, which in all three cases has a distinctly neurological dimension.Laughter: An Essay on the Meaning of the Comic, first published in 1899. Beckett had recently returned from a two-year period (1928 to 1930) as Lecteur at the École Normale Supérieure where he would have had ample exposure to Bergson’s ideas.1 It is unclear whether Beckett would have felt compelled to read Bergson during his residence in Paris, for Bergsonism was just beginning to wane in the period of Beckett’s appointment at the École Normale (See Addyman 2012). French literary criticism, however, was predominantly Bergsonian in outlook, and during his brief period as Lecturer in French at Trinity College Dublin, from 1930 to 1931, Beckett made ample references to Bergson in his undergraduate lectures on French literature, for instance distinguishing ‘between Bergson’s conception of time and Proust’s  and between Bergson’s attitude to language and Gide’s’ , as the lecture notes of Beckett’s former student, Rachel Burrows, in Trinity College Dublin archives reveal. Furthermore, in October 1930, Beckett wrote to his publisher, Charles Prentice, informing him that he wanted to add some pages to his book on Proust, published in 1931, ‘in part to separate Proust’s intuitivism from Bergson’s’ .2 Beckett’s reading notes on Bergson have not been recovered, but I will argue that Bergson’s thinking did have a lasting influence on Beckett’s work. His publisher, John Calder, recalls conversations with Beckett about Bergson from the mid-1950s until Beckett’s death in 1989 that Calder says, “went on all night” .Samuel Beckett’s interest in the work of the French philosopher, Henri Bergson, began in or around 1930 when he read Laughter, was substantially influenced by medical discoveries and especially the performative and often spectacular culture of late-nineteenth-century neurology. In 1862, Jean-Martin Charcot had been appointed head physician at the Salpêtrière Hospital in Paris. Under his directorship, the hospital underwent numerous reforms, including the laicization of its nursing staff, an increase in the number of beds, “better salaries for ancillary staff, improved bathing facilities, as well as laboratories, a museum, a new lecture hall” and, from 1882, a Service des hommes . By the second half of the 1870s, Charcot’s famous Tuesday lectures, which attracted the public in extraordinary numbers, were a central feature of “Parisian intellectual life” . At the lectures, Charcot exhibited his patients and developed his case studies before admiring crowds. In 1882, he inaugurated the first neurology clinic in Europe. At his clinic, Charcot and his many eminent students made important discoveries in the understanding of such conditions of the nervous system as Parkinson’s disease, epilepsy, Tourette’s syndrome and hysteria. These were brought to public attention at the Tuesday lectures and in the many journals founded in the period of the Third Republic such as Le Progrès médical, in which Charcot published a number of his lectures. La Nouvelle iconographie de la Salpêtrière, the hospital’s own publication, distributed images of epileptics, hysterics and sufferers of other neurological conditions; it ran from 1888 to 1918 and had George Gilles de la Tourette as one of its founders. Knowledge of Charcot’s discoveries entered even the popular newspapers and magazines, and a number of Charcot’s patients became celebrities in their own right. So pervasive was Charcot’s work and so profound was its impact on the popular imagination that it rapidly influenced the performance style of the Parisian cabaret and vaudeville “with a new repertoire of movements, grimaces, tics and gestures” , which mimicked the comportment and disposition of the Salpêtrière patients. Comedians in particular sported convulsive and marionette-like gaits and movements, and mime troupes and singers followed suit in performances that seemed to cast doubt over received notions of the body’s functioning and by implication, the wider questions of agency and free will. Many cabaret and music hall performers went on to have successful careers in silent film, which, as a genre, adopted the frenetic, convulsive and automatic performance style of vaudeville and cabaret. As Rae Beth Gordon writes: “There is a continuous line and directing force running from the cabaret and café-concert performances of the last quarter of the nineteenth century, through the films of Méliès and the musicals of Ernst Lubitsch […].The uniting element is hysterical gesture and gait” . Bergson’s Le Rire was itself centred around the notion of “automatic gesture and word,” and one can trace a direct genealogy between Charcot’s work, the popular culture of the period, and Bergson’s theory of comedy. So fashionable and intriguing did hysteria and neurological disorders prove around the turn of the century that they generated, besides a new performance style, a number of songs and literary works such as Guy de Maupassant’s short story, “Le Tic” (“The Spasm”) from 1884 or T. S. Eliot’s poem “Hysteria” from 1915.Bergson’s extended essay, Laughter was anxiously indebted to neurological discoveries and especially the dyskinesia and the various automatisms that presented in neurological disorders and that figured so prominently in the performance culture of the period. Bergson argued in his book that “The attitudes, gestures and movements of the human body are laughable in exact proportion as that body reminds us of a mere machine” . Humour, Bergson reiterated, arises from “Something mechanical encrusted on the living” (37), for “a comic character is generally comic in proportion to his ignorance of himself” (16). This makes the subject appear as if deprived of his or her essential freedom:The soul imparts a portion of its winged lightness to the body it animates: the immateriality which thus passes into matter is what is called gracefulness. Matter, however, is obstinate and resists. It draws to itself the ever-alert activity of this higher principle, would fain convert it to its own inertia and cause it to revert to mere automatism. It would fain immobilise the intelligently varied movements of the body in stupidly contracted grooves, stereotype in permanent grimaces the fleeting expressions of the face, in short imprint on the whole person such an attitude as to make it appear immersed and absorbed in the materiality of some mechanical occupation instead of ceaselessly renewing its vitality by keeping in touch with a living ideal. Where matter thus succeeds in dulling the outward life of the soul, in petrifying its movements and thwarting its gracefulness, it achieves, at the expense of the body, an effect that is comic. (28-29)Bergson’s What neurological conditions such Parkinson’s disease, Tourette’s syndrome and epilepsy had in common and what was seen as a source of black humour in cabaret and early cinema was the body’s seemingly-mechanical capacity to act outside of the realm of conscious control. Neurological disorders which informed the performance style of music hall, vaudeville, cabaret and film, and as a consequence, Bergson’s work, questioned notions of agency and intentionality and hence cast serious doubt over received notions of subjectivity, suggesting that the mechanical, the automatic and the involuntary were in fact integral to the self. These pathologies “raised serious questions about the philosophical viability of the doctrine of free will” , something that Charcot and his students suggested was a mere metaphysical construct. Of relevance here was also Charcot and his students’ anti-clericalism, which permeated not only their political views but also their research .Time and Free Will: An Essay on the Immediate Data of Consciousness, from 1889, reveals. It is crucial, for instance, to his notion of duration (durée), whose flow is constantly threatened by habit, repetition and automatism. Bergson in fact appears determined to defend the faculty of free will to the point where his work frequently unveils a deep-rooted anxiety over its limitations. In his essay, Laughter, habitual, mechanical, ossified comportment, as we have seen, appears as a source of humour, but it is also a locus of intense anxiety, which persists throughout Bergson’s writing. In the essay, Bergson conceptualises laughter as “a bursting out of life and elasticity in the face of the intolerable stiffening of life into automatic or repeated gestures” (Connor 2008). As Bergson puts it, “rigidity is the comic, and laughter is its corrective” . However, as he often acknowledges, laughter itself can function mechanically, as an involuntary somatic reaction beyond intentional control. Steven Connor writes:…in laughing at what is inhumanly inelastic, we actually mirror the condition that is said to be comic. This confusion between stimulus and response, or between the laughable and the laugh, runs through Bergson’s account. “[I]nvoluntarily I laugh,” he writes ; and when he asserts that “it is really a kind of automatism that makes us laugh [une espèce d’automatisme qui nous fait rire],” it is not certain whether he means that we laugh at automatism or that we laugh as an instance of it. The question of free will is a central concern in Bergson’s work, as the title of his doctoral thesis, and his first published book, Happy Days (1961), but his work nonetheless retains his interest in the mechanized and ossified structures of comportment as late plays such as Footfalls (1975), Rockaby (1980), Quad (1982) and What Where (1983) so clearly attest. In these plays, Beckett’s characters “sometimes seem to be losing species, regressing to the subhuman, trying to rehearse the figures of instinct but botching the job,” as Daniel Abright has put it .Certain aspects of Beckett’s humour, as well as his attitude to repetition and compulsion owe much to his reading of Bergson’s work. Although Beckett rejects Bergson’s Cartesian division into spirit and matter, his influence can be said to be pervasive, for it is not merely Beckett’s humorous works that are infused by Bergsonian ideas. The humour, after all, begins to recede from Beckett’s writing after élan vital so central to Bergson’s thinking – are also lurking at the very heart of language itself. Bergson writes of language that,We feel it contains some living element of our own life; and if this life of language were complete and perfect, if there were nothing stereotype in it, if, in short, language were an absolutely unified organism incapable of being split up into independent organisms, it would evade the comic as would a soul whose life was one harmonious whole, unruffled as the calm surface of a peaceful lake. There is no pool, however, which has not some dead leaves floating on its surface, no human soul upon which there do not settle habits that make it rigid against itself by making it rigid against others, no language, in short, so subtle and instinct with life, so fully alert in each of its parts as to eliminate the ready-made and oppose the mechanical operations of inversion, transposition, etc., which one would fain perform upon it as on some lifeless thing. What is perhaps most pertinent to Beckett’s work, however, is Bergson’s attitude to language. For the ossified and rigid habits that everywhere threaten to stunt vitality – the Creative Evolution (1998), Bergson makes the even bolder suggestion that “The most living thought becomes frigid in the formula that expresses it. The word turns against the idea. The letter kills the spirit” (127).The machinic, rigid and automatic qualities of language, in other words, haunt Bergson’s oeuvre, and the assumption that language might function mechanically becomes progressively more pronounced in his thinking. In Degeneration , which he read in the 1895 English translation. Nordau, a doctor of Hungarian origin, had himself – upon his arrival in Paris in 1880 – undertaken medical research under the tutelage of Jean-Martin Charcot and after defending his thesis in 1882, had remained closely involved with the Charcot circle . Beckett’s ‘Dream Notebook’, now held in the University of Reading Beckett Archive, contains his reading notes on Nordau’s book. Amongst them is a quotation from Spinoza that Beckett copied from Nordau: “If a stone flung by a human hand could think it would certainly imagine that it flew because it wished to fly” . Nordau goes on to elaborate: “Many mental conditions and operations of which we become conscious are the result of causes which do not reach our consciousness. In this case we fabricate causes a posteriori for them, satisfying our mental need of distinct causality, and we have no trouble of persuading ourselves that we have now truly explained them” . Although Nordau’s thesis expresses an anxiety about social, cultural and biological degeneracy, his observation is pertinent to the findings of nineteenth-century neurology, which he frequently references, as well as to the problematisation of free will by Charcot and his many eminent followers. One of the neurological conditions Nordau references is Tourette’s syndrome, as Beckett’s notes record. His notebook registers two of the symptoms of the syndrome: “Echolalia (word & sound repetition)” and “corprolalia ” . Beckett read the following passage in Nordau’s book: “Gilles de la Tourette has coined the word ‘corprolalia’  for obsessional explosions of blasphemies and obscenities which characterise a malady described most exhaustively by M. Catrou, and called by him ‘disease of convulsive tics’” . Nordau, who repeatedly attacks Émile Zola in the book, goes on to say that “M. Zola is affected by coprolalia to a very high degree” .3 Although Nordau’s claim about Tourette’s as an example of degeneration is deeply objectionable, his book does repeatedly draw attention to the close proximities between poetic language and language pathology, which would no doubt have captured Beckett’s imagination. The coprolalia of Tourette’s syndrome, after all, lends force to those qualities of language that escape conceptual definition, such as “volume, timing, tone, rhythm, emphasis, and patterns of sound repetition” . For this reason, cursing not only embodies language, it enters “the realm of play and the nonreferential, which is also the realm of poetry, nonsense, and comedy” . In Tourette’s, as in poetic language, it is the rhythms, rhymes, puns, sound qualities and polysemy of language that are foregrounded.In 1931, shortly after reading Bergson, Beckett turned his attention to Max Nordau’s maladie de Gilles de la Tourette was, in other words, from its early conceptualisation, seen as a disorder of the will. In this new understanding and following Paul Broca’s localisation of speech in 1861, language, the supreme marker of agency and intentionality, proved at least in part to be mechanistic and self-generating. More recent neurological research has indeed suggested that Tourette’s is a disorder of “the very highest parts of ‘old brain’: the thalamus, hypothalamus, limbic system and amygdala, where the basic affective and instinctual determinants of personality are lodged” . This also implies that certain functions of language are “overlaid on sensorymotor systems” that evolved to control motor functions and affect and that continue to do so now . The obscenities of Tourette’s syndrome function as “material articulations of language that gather up the power and emotions of seeming subcortical primal cries within discourses,” for obscenities are associated with “more or less automatic emotional responses” . Tourette’s as a disorder problematizes the distinction between voluntary and involuntary action, for like peristalsis, Tourettic tics can be suspended but not suppressed altogether, as Oliver Sacks (1985) has shown in his essay, “Witty Ticcy Ray”. In the phonic and verbal tics and utterances of Tourette’s, Brown and Kushner argue, the body itself becomes “a set of physiological impulses that are at once aberrant and self-seeking, expressive of the speaker’s circumstances while escaping his intentions” .Although Tourette’s syndrome now bears the name of Georges Gilles de la Tourette, he was not the first nineteenth-century physician to publish on the seemingly-disconnected and diverse symptoms of the syndrome. In 1847, Ernest Billod had published his “Maladies de la Volonté” which, as the title suggests, saw the condition as a pathology of the will. In 1883, a book by the same title was published by Theodule Ribot, who described the symptoms of the Parisian Marquise de Dampierre – who suffered from Tourettic motor and verbal tics – as a case of “the idiocy of the will” . The condition that in 1885 came to be known as The Vanity of Human Wishes (1749), a poem which, like much of Beckett’s own work, might be characterised as a dramatisation of failure. Beckett’s fascination with Johnson is evinced by the three substantial exercise books that he filled with notes on his reading from this period.Another equally decisive factor in Beckett’s awareness of language pathologies, however, came a few years later and originated not in nineteenth-century but in eighteenth-century medical discourse. From 1936 to 1937, Beckett intensively researched the life of Samuel Johnson for a play he intended to write about the great eighteenth-century lexicographer. In a period of just over a year and mostly in the National Library of Dublin, Beckett read more than a dozen books about Dr. Johnson for his prospective but never completed play, "Human Wishes". Beckett’s play took its title from one of Johnson’s most acclaimed works, Whoroscope Notebook”, which dates from the 1930s, and at his death, Beckett owned a copy of the eighth edition (1799) of Johnson’s Dictionary of the English Language, which he had acquired during his formative years in Dublin . He consulted the dictionary regularly and was often bemused by Johnson’s definitions. In fact, according to Dirk Van Hulle and Mark Nixon, “the largest number of books in Beckett’s library” at the time of his death was “dedicated to the work of Samuel Johnson” . Beckett’s library also contained copies of three of the most important books he consulted in 1936-1937, namely James Boswell’s Life of Johnson, Mrs. Thrale’s Anecdotes and C. E. Vulliamy’s Mrs. Thrale of Streatham, and the fact that he purchased the Boswell and Thrale volumes in the 1960s and 1980s respectively, attests to his enduring interest in the life of Samuel Johnson .Beckett’s interest in Johnson seems to have begun even earlier, in fact, for in a letter of 8 September 1934, he makes a reference to “the Lexicographer kicking the stone”  – a story reported in James Boswell’s famous biography of Johnson “striking his foot with a mighty force against a large stone” in an attempt to refute Bishop Berkeley’s thesis of “the non-existence of matter, and that every thing in the universe is merely ideal” . Beckett also quotes a number of Johnson’s books in his “Beckett’s original idea for his “Johnson blasphemy” – as he called his prospective play – focused on the unconsummated relationship between Johnson and Mrs. Thrale. His first “Human Wishes Notebook” is faithful to this idea although it tellingly contains far more notes on Johnson than on Mrs. Thrale. By the second notebook, however, Beckett’s interest has shifted from the relationship to Johnson himself with whom Beckett clearly identified and empathised. Frederik Smith has pointed out that “the figure of the declining Johnson became for him a sort of metaphor of Western man, academic and witty, alone, afraid of dying and yet intrigued by his own physical deterioration” . Indeed, in his second “Human Wishes Notebook,” Beckett takes nine pages of notes on Johnson’s medical conditions including his dropsy and its many symptoms, his asthma, his endocrine disorder, his depression (melancholy) and the attack of aphasia Johnson suffered at the age of seventy-three, after a minor stroke in the middle of the night on 17 June 1783 (Beckett 1936-1937). According to Mrs Thrale, Johnson composed a prayer in Latin immediately after the stroke in order “to satisfy himself that his mental powers remained unimpaired, and to keep them in exercise that they might not perish by permitted stagnation”  – something Beckett’s notes also record. In the morning, Johnson wrote to his physician, Dr. Heberden: “It has pleased God by a paralytic stroke in the night to deprive me of speech” . While suffering from aphasia, Johnson continued to write letters but had no power of vocalisation. From one of the letters, we know that Johnson perceived his aphasia to derive from a problem of “the organs of speech” rather than from the brain. Through a close analysis of the nineteen letters written by Johnson after his stroke, Macdonald Critchley has concluded that Johnson suffered from dysphasia with symptoms of dysarthria as well and that his speech disorder was most probably Broca’s aphasia (aphemia) .Letters and Diaries, Beckett notes:In 1777: His mouth is almost constantly opening and shutting as if he were chewing. He has a strange method of frequently twirling his fingers & twisting his hands. His body is in constant agitation, see-sawing up and down; his feet are never a moment quiet, +, in short, his whole person is in perpetual motion .Tellingly, Beckett also took copious notes on Johnson’s nervous disorders, jotting down from Boswell’s biography that “’Such was the heat and irritability of his blood, that not only did he pare his hands to the quick, but scraped the joints of his fingers with a pen knife [sic], till they seemed quite red & raw”’ . Most crucially, however, Beckett writes that “Miss Lucy Porter [Johnson’s stepdaughter] mentions his ‘convulsive starts & odd gesticulations’ + Fanny Burney” . Quoting from Fanny Burney’s too, too, too: all this accompanied sometimes with a thoughtful look, but more frequently with a smile. Generally when he had concluded a period, in the course of a dispute, by which time he was a good deal exhausted by violence and vociferation, he used to blow out his breath like a Whale. .…while talking or even musing as he sat in his chair, he commonly held his head to one side towards his right shoulder, and shook it in a tremulous manner, moving his body backwards and forwards, and rubbing his left knee in the same direction, with the palm of his hand. In the intervals of articulating he made various sounds with his mouth, sometimes as if ruminating, or what is called chewing the cud, sometimes giving a half whistle, sometimes making his tongue play backwards from the roof of his mouth, as if clucking like a hen, and sometimes protruding it against his upper gums in front, as if pronouncing quickly under his breath, Boswell suggests in his biography that Johnson’s odd gesticulations appeared “to be of the convulsive kind, and of the nature of that distemper called St. Vitus’s dance,” affirming that “in this opinion I am confirmed by the description which Sydenham gives of that disease” . Beckett makes a note of this passage although as a number of twentieth-century commentators have pointed out, the symptoms of St. Vitus’s dance (Sydenham’s chorea) are temporary, and since Johnson suffered from motor and verbal tics all his life, his symptoms are unlikely to have been caused by the condition. Beckett would also have read in Boswell’s biography a rather striking passage focusing on the motor and vocal tics for which Johnson was famous:Johnsonian Miscellanies in 1937. In it, he would have encountered Miss Francis Reynolds’ recollections of Johnson’s “extraordinary gestures,” of “his head, his hands and his feet often in motion at the same time” . Reynolds’ description is worth citing at some length. She recallsany doorway. On entering Sir Joshua’s house with poor Mrs. Williams, a blind lady who lived with him, he would quit her hand, or else whirl about on the steps as he whirled and twisted about to perform his gesticulations; and as soon as he had finish’d, he would give a sudden spring, and make such an extensive stride over the threshold, as if he was trying for a wager how far he could stride, Mrs. Williams standing groping about outside the door, unless the servant or the mistress of the House more commonly took hold of her hand to conduct her in, leaving Dr. Johnson to perform at the Parlour Door much the same exercise all over again.…his extraordinary gestures or anticks with his hands and feet, particularly when passing over the threshold of a Door, or rather before he would venture to pass through But the strange positions in which he would place his feet  are scarcely credible. Sometimes he would make the back part of his heels to touch, sometimes the extremity of his toes, as if endeavouring to form a triangle, or some geometrical figure, and as for his gestures with his hands, they were equally as strange; sometimes he would hold them up with some of his fingers bent, as if he had been seized with the cramp, and sometimes at his Breast in motion like those of a jockey on full speed; and often he would lift them up as high as he could stretch over his head, for some minutes. But the manoeuvre that used the most particularly to engage the attention of the company was his stretching out his arm with a full cup of tea, in his hand, in every direction, often to the great annoyance of the person who sat next to him, indeed to the imminent danger to their cloaths, perhaps of a Lady’s Court dress; sometimes he would twist himself round with his face close to the back of his chair, and finish his cup of tea, breathing very hard, as if making a laborious effort to accomplish it. We also know that Beckett read Birkbeck Hill’s 4 The emphasis in these descriptions on Johnson’s obsessive-compulsive behaviour only strengthens the hypothesis, for Tourette’s is frequently accompanied by the symptoms of OCD.5 As Beckett’s notes on Johnson acknowledge, the lexicographer never talked about his verbal or motor tics. However, Johnson’s was one of the early dictionaries to include examples of use exclusively from written sources, and as Laura Davies has recently argued, the “Preface” to Johnson’s Dictionary makes a clear distinction between speech and writing, associating the former with flux, decay and contingency and the latter with stability, constancy and permanence . It is not difficult to see how Johnson’s own inability to control his verbal tics might have resulted in this privileging of the written word. Furthermore, Johnson was suspicious of regional variation in language and, although he accepted the inevitability of linguistic change, he lamented it, noting that “tongues, like governments, have a natural tendency to degeneration,” but that just as “we have long preserved our constitution,” we should “make some struggle for our language” .Present-day commentators on Johnson concur that, judging by the many detailed descriptions of Johnson’s phonic and motor tics, he most probably suffered from Tourette’s syndrome.Watt (1953), in the protagonist's idiosyncratic gait:Watt’s way of advancing due east, for example, was to turn his bust as far as possible towards the north and at the same time to fling out his right leg as far as possible towards the south, and then to turn his bust as far as possible towards the south and then at the same time to fling out his left leg as far as possible towards the north, and then again to turn his bust as far as possible towards the north and to fling out his right leg as far as possible towards the south, and then again to turn his bust as far as possible towards the south and to fling out his left leg as far as possible towards the north, and so on, over and over again, many many times, until he reached his destination, and could sit down. Beckett’s early interest in dyskinesia and language pathology, in part filtered through his reading of Bergson and his fascination with the cultures of music hall and early cinema, may also be said to account for his life-long interest in Samuel Johnson – an interest that leaves its mark on his own writing. Accounts given by Boswell, Mrs. Thrale and others of Johnson's gesticulations and tics are indeed distinctly Beckettian: the "antics" of Johnson's hands and feet recorded in Hill's book, for instance, find a humorous echo in Watt so clearly indicates, is rarely transparent in Beckett’s writing. It is frequently stilted through the maiming of the body or permeated with limps, falls and crawls. Movement is frequently presented as unintentional in nature, for Beckett’s work contains numerous instances of involuntary movements such as shaking, tics and convulsions. Malone, in the novel Malone Dies (1956), for instance, observers that “My arms, once they are in position, can exert a certain force. But I find it hard to guide them. Perhaps the red nucleus has faded. I tremble a little, but only a little” . Voluntary movements are here compromised, while the involuntary trembling is foregrounded.Motility, as the example from Molloy (1951), which takes place at the police station after Molloy has been arrested. The protagonist is handed a tray of “greyish concoction which must have been green tea with saccharine and powdered milk” with “a thick slab of dry bread” . Once the tray is in Molloy’s hands,The liquid overflowed, the mug rocked with a noise of chattering teeth, not mine, I had none, and the sodden bread sagged more and more. Until, panic-stricken, I flung it all far from me. I did not let it fall, no, but with a convulsive thrust of both my hands I threw it to the ground, where it smashed to smithereens, or against the wall, far from me, with all my strength. Johnson’s habit of manoeuvring his teacup, recorded by Birkbeck Hill, in turn brings to mind a scene from Beckett’s novel Not I:…whole body like gone . . . just the mouth . . . lips . . . cheeks . . . jaws . . . never – . . . what? . . tongue? . . yes . . . lips . . . cheeks . . . jaws . . . tongue . . . never still a second . . . mouth on fire . . . stream of words . . . in her ear . . . practically in her ear . . . not catching the half . . . not the quarter . . . no idea what she’s saying . . . imagine! . . no idea what she’s saying! . . and can’t stop . . . no stopping it . . she who but a moment before . . . but a moment! . . . could not make a sound . . . no sound of any kind . . . now can’t stop . . . imagine! . . can’t stop the stream . . . and the whole brain begging . . . something beginning in the brain . . . beginning the mouth to stop . . . pause a moment . . . if only for a moment . . . and no response . . . as if she hadn’t heard . . . or couldn’t . . . couldn’t pause a second . . . like maddened . . . all that together . . . straining to hear . . . piece it together. . . and the brain . . . raving away on its own . . . trying to make sense of it . . . or make it stop This Johnsonian, Tourettic or convulsive aesthetic is everywhere present in Beckett’s writing, extending to the very texture of the language, which is repeatedly staged as speaking itself. The Unnamable, for instance, observes, “I seem to speak, it is not I, about me, it is not about me” . The line anticipates the Unnamable’s female counterpart, Mouth, in Beckett’s 1972 play, Mouth’s monologue is staged as involuntary, convulsive, and beyond intentional control. Its Tourettic logorrhoea takes place in the “nearest lavatory . . . start pouring it out . . . steady stream” . The association between enunciation and peristalsis is, in other words, made explicit. In a letter of October 1972 sent to Alan Schneider, the foremost American director of his plays, Beckett writes that he is making a distinction “between mind & voice” in the play and goes on to add that Mouth’s speech is “a purely buccal phenomenon without mental control or understanding, only half heard.” Beckett defines it as “Function running away with organ” .It isn’t Boswell’s wit and wisdom machine that means anything to me, but the miseries that he [Johnson] never talked of, because unwilling or unable to do so. The horror of annihilation, the horror of madness, the horrified love of Mrs. Thrale . . . The opium eating [erasure] dreading-to-go-to-bed, preying-for-the-dead, past living, terrified of dying, terrified of deadness, panting on to 75 bag of water, with a hydrocele on his right testis. How jolly. We might conclude that what Beckett responded to in Johnson’s chronic condition was a sense not so much of the unbearable exceptionalism of the lexicographer’s predicament but rather what it unveiled about language and the body in general. In a letter to Mary Manning of 11 July 1937, Beckett responded eloquently and empathically to the dread and misery of Johnson’s unspeakable habits and habitus:The letter suggests just how deeply Beckett was influenced by Johnson, but it also suggests that it is the man and his convulsive condition more than the writing that was to leave the most lasting impression on him. There can be little doubt that the body image of the typical Beckett character owes much to Johnson the man – to his wit, intelligence, erudition to be sure, but also, and more pertinently, to his many physical predicaments, including his compulsive verbal and motor tics.contest the mechanical, habitual and automatic that threaten to encrust themselves upon the living, in Beckett’s often uncannily Johnsonian writing, the habitual and the automatic become progressively more central, until in the late works, habit and mechanical behavior constitute a tenuous, fraught and primitive ontology, the residues of an agential self.As the Bergsonian notion of the “ready-made” and mechanical nature of language in general recognises, the characteristics of so-called pathological language are also present in non-pathological language use, over 40 % of which is constituted by non-propositional speech acts such as clichés, idioms, and phatic communication. And it is this intrinsic pathology of language that is foregrounded in Beckett’s writing. Beckett’s shift to French in 1946 and the subsequent decision to straddle two languages may itself have been a magical gesture against the “rigid, the ready-made, the mechanical” , which Beckett’s writing simultaneously manages to perform, to exemplify and to evade. While Beckett’s writing is far from Cartesian in its stance, it nevertheless explores the Bergsonian notion, informed by medicine and experimental psychology, of the limitations of agency, of “the deep-seated recalcitrance of matter,” and of the human as always already inflicted by the mechanical, a fact that is poignantly highlighted by the case of Samuel Johnson. Through his encounter with Johnson, Beckett registers a paradigm shift in the understanding of subjectivity. Whereas Bergson aims, throughout his career, to 1 Beckett is also likely to have learned about Bergsonian concepts from Alfred Péron, who was the exchange lecturer at TCD from the École Normale (1926-1928). The character of Chas in Dream of Fair to Middling Women (1932/1992) is partly based on Péron. In the novel, Chas talks to a group of students about Bergson: “The difference, then I say, between Bergson and Einstein, the essential difference, is the difference between a philosopher and a sociologist […] And if it is the smart thing nowadays to speak of Bergson as a bit of a cod […] it is that the trend of our modern vulgarity is from the object […] and the idea to sense […] and REASON” .2 On 14 October 1930, Beckett wrote to Prentice: “Would you let me add 5 or 6 pages to the last 9? Or would that make it too long? I would like to develop the parallel with Dostoievski and separate Proust’s intuitivism from Bergson’s” .3Nordau’s claims so disturbed Émile Zola that he voluntarily underwent a medical examination in order to prove that he did not suffer from neurological disorders.4 See, for instance, Wiltshire 1991, 29-32.5 See, for instance, Towbin 1988.


With his article “Normative preconditions for the assessment of mental disorder” Stier  is presemethods or strategies of preventing, ailing, or curing mental disorders. These strategies in turn are interrelated with methods of properly explaining and diagnosing such disorders. In contrast, whatever psychiatrists or their critics hold on the level of ontology or epistemology seems relevant to psychiatric work (only) in so far as it determines outlooks on methodology—especially in interacting with patients and in treating their disorders. When it comes to the latter, matters of causation play the crucial role. And here, I urge, one should distinguish between two questions: (i) how mental dysfunctions  is/can at all be “caused” by brain dysfunction; (ii) how relevant systemic brain dysfunction is caused by neurobiological processes on lower levels—e.g., on the levels of circuits, cells, or genes.Making use of Ayala's  influentThe first question points to the central and perennial problem of the mind-brain debate and from here cuts throughout psychiatry  and by isolating them from as many relevant background conditions as seems fruitfulStier holds that “mental disorders cannot be completely reduced to neuronal or molecular processes” (p. 1). His justification for this “anti-reductionist claim” is the above stated “main thesis” which holds that in the field of neuropsychiatric disorders, the borderline between health and disease is value-laden. Unable to argue for this in any detail, I wholeheartedly agree with the view that the concept of mental disorder is partly normative. Being mentally diseased means (or should mean) to be in some or other dysfunctional and unwelcome mental state that thus should ideally be prevented or treated. Imprecise as these stipulated evaluative criteria and their originators are, I also agree with the view that individual and social value judgments cannot be read off from mere neurobiological factsgeneral, for disorders within and without psychiatry? For so-called somatic disorders, this might not always be as obvious as in the realm of psychiatric diseases. Take an infection that, if untreated, would rapidly lead to death without any other adverse symptoms. One might argue that premature death is a purely descriptive term independent of it's being unwelcome to most people. But the same could be said about neuro-psychiatric disorders that lead to permanent coma or benign delusions. Where single disorders, in the mental as well as in the non-mental sphere, seem to be explicable without recourse to values, the gist of the whole concept of disease refers to unwelcome malfunctioning (including the functions of living or being conscious) and can be traced, I think, in each of its sub-types. Unable to further argue in favor of a partly normative concept of disease at this occasion, let me at least emphasize that this is one of the standard views  in the contested field of theories of health and disease  without giving a complete explicit definition. In the literature, MM is indeed a commonly used paradigm; it is seen, however, to allow for “minimal and strong interpretations” , but also by Stier himself. He clearly admits that “[… ] it is not that bodily diseases are value-free whereas psychiatric disorders are value-laden. Both rest on normative assumptions.” But then he continues: “In one field we simply share them, in the other we don't” (p. 5). Both observations of the last sentence seem questionable: Quite a number of “bodily” conditions are contested with regard to their “diseasedness”—e.g., limited reproductive or sexual functions, moderately decreased hearing, or moderately diminished memory capacities in “normal aging.” Arguably, it is normative aspects that will determine demarcations. In any case, MM does not seem committed either to value neutrality in the concept of disease, or to the indisputability of the underlying values. On the other hand, value dissent in the psychiatric domain is by no means ubiquitous. After all, delusions, anxiety disorders, depression, or addiction do not appear very attractive, neither from inside nor from outside.rightly holding a thoroughgoing non-exceptionalist view toward the explicability of psychiatric disorders. This view indeed seems to be the main stream position in neuroscience. It implies optimism with regard to neuroscientific contributions to diagnostic and therapeutic progress in psychiatry. But, again, it does neither imply viewing the concept of psychiatric disorder as value-independent nor viewing the mental realm as eliminable by neurobiological approaches.Hence, contrary to Stier, MM should in my eyes be properly understood as specific psychiatric diseases, one of them called Z; (3) valid indicators and tests for Z; (4) positive testing for indicators of Z in the concrete patient. Each of these steps has its problems. But only (1) seems value-dependent in the way described by Stier, i.e., relative to human flourishing and human interests. With regard to (2) there is malleability and ongoing change in both the bodily and the psychiatric dimension of medical practice: fine-tuning and re-tuning according to some symptoms or other, to locations, or to (assumed) underlying causal paths. The main values that reign nosology are coherence and therapeutic success, I think. (3) is, again, an ongoing process according to medical evidence, having repercussions to (2) and being reigned by the very same values of coherence and therapeutic effectiveness. Finally, diagnosing a given patient should involve testing her according to best available parameters, with results of presuppositions (1) to (3) in the back. Hence, in psychiatry, a patient showing up with certain behavioral symptoms could conceivably be tested for neurobiological indicators, resulting in the diagnosis Z—without loosing sight of the mental. Determining a mental disorder in this way is not guilty of any problematic reductionist credo.Suppose, you diagnose an individual patient with certain symptoms as suffering from mental disorder Z. In an idealized nutshell this presupposes: (1) a multi-dimensional demarcation between mental sanity and mental diseasedness, where those symptoms indicate disorder; (2) a taxonomy of Granting potential causal relevance to a multitude of external influences, psychiatrists would finally be ill advised to look for brain function in isolation rather than in context. But turning external effects—e.g., psychologically stressful life events—into background conditions of pathogenesis, does not imply neglecting their causal role. Nor does it imply ignoring the importance of preventing such adverse factors in the first place, or excluding psychotherapy from the agenda of psychiatry. Likewise, nothing in a methodologically reductionist approach to psychiatric research compels scientists or doctors to ignore or belittle the enormous importance of patients' conscious experiences. If such unfortunate “practical reductionisms” nevertheless occur, they can neither legitimately be nobilized nor criticized as a sequel of biological psychiatry.From all we know and foresee, detailed knowledge about one's inner mental life needs first-person experience or, as a weak approximate substitute, third-person encounter. Listening to psychiatric patients' directly or indirectly describing their subjective experiences thus seems irreplaceable for assessing the subjective impact of mental disease as well as for an understanding interaction with patients. Nevertheless, using neurobiological tools for diagnosing and monitoring treatment might in principle be possible and helpful.Stier holds that the classification of certain mental states as disorders is value-dependent and therefore cannot be read off from neurobiology. Contra Stier, however, this plausible view does in no regard discredit the medical model (MM) as “the one and only bedrock of psychiatry” (p. 1). Rather, MM is uncommitted to a naturalist theory of disease. As Stier himself admits, values can be seen as indispensible also in demarcating bodily diseasedness. Some of these diseases and values might be as contested as in psychiatry. MM's upshot is a non-exceptionalist view on the explicability of psychiatric disorders—and subsequently on their diagnostic and therapeutic in-principle accessibility on a biological level.anti-reductionist view, is both unusual and misleading. Affirming such constructivism should not get confounded with common and problematic objections that blame biologically oriented psychiatry as metaphysically or methodologically reductionist. Yet another distinct problem might be an unfortunate practical negligence of patients' inner life within modern psychiatry. Such “practical reductionism” can and should be defeated within a neurobiological orientated psychiatry.Finally, framing and selling a partially constructivist position regarding  disease as an The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Incontinence is a common problem faced by family caregivers that is recognized as a major burden and predictor of institutionalization. However, few studies have evaluated the experiences of family caregivers caring for stroke survivors with incontinence.To describe experiences of caregivers managing incontinence in stroke survivors.This qualitative descriptive study employed a grounded-theory approach.Semi-structured in-depth interviews with ten family caregivers of stroke survivors with incontinence were conducted during 2011. Audiotaped interviews were transcribed and analyzed using content analysis.Data analysis identified four themes: chaos, hypervigilance, exhaustion, and creating a new life. There were nine related subcategories: fluster, dirtiness, urgency, fear of potential health-hazard, physically demanding and time-consuming, mentally draining, financial burden, learning by doing, and attitude adjustment. Together, these described a process of struggling to cope with the care of stroke survivors with urinary/fecal incontinence. Of the four categories, “creating a new life” developed gradually over time to orient caregivers to their new life, while the other three categories occurred in a chronological order.The research highlighted unique caring experiences of family caregivers of stroke patients, which focused solely on the ‘incontinence issue’. Understanding these experiences may help nurses provide better support and resources for family caregivers when caring for stroke survivors with incontinence. Stroke is a disabling illness that is prevalent in both developed and developing countries . In TaiwBowel and bladder control are associated with a person’s privacy, self-esteem, and dignity. Loss of bowel or bladder control is linked to feelings of personal incompetence, embarrassment, and shame, in addition to being a social stigma. Patients with incontinence require help from relatives, which impacts emotional, physical, and social well-being of both patients and caregivers –10. PatiThe literature relating to the experiences of caring for stroke survivors is now relatively extensive. However, although several qualitative studies have focused on the issue of incontinence among non-stroke patients , 18–20, We used a qualitative design with a grounded theory method described by Corbin and Strauss . The groCaregivers were purposefully selected from contacts obtained by outpatient staff at clinics of the National Taiwan University Hospital. Participants were included if they were adult family caregivers of stroke survivors who had cared for relatives with urinary, fecal, or dual incontinence for at least 1 month. Semi-structured, face-to-face, tape-recorded interviews were conducted with 10 adult family caregivers (two men and eight women) with home-based caregiver responsibilities. The characteristics of family caregivers and their relationship to the stroke survivors are presented in The stroke survivors had a median age of 74.5 years  and half were men. All stroke survivors had limitations in their activities of daily living (ADLs) with the majority being totally dependent (n = 9). Seven stroke survivors presented with an initial National Institutes of Health Stroke Scale (NIHSS) score ≥16  and dual incontinence. The mean time since the stroke was 18.9 months .Data were collected from April to August 2011. An interview guide was developed and then refined through discussion by the research team. The interview began with a broad central question regarding the caregiver’s experience: Tell me what it is like to care for a close relative who has incontinence. This question was discussed in all interviews and followed up by probing and follow-up questions in relation to this caring experience . The first author (CNT) carried out all the interviews. The interviews were conducted in a quiet room of the outpatient clinic and lasted 35 to 75 minutes. All the interviews were tape-recorded.The interview data were transcribed verbatim and transcripts were compared with audiotapes to verify accuracy. Following Corbin and Strauss’ guidelines, data collection and data analysis took place simultaneously . Every iThe rigor of this qualitative study depended on the ability to capture and accurately represent the reality of the experience of caring for incontinence from the caregiver's perspective. Toward that end, a wider purposeful sampling allowed for interviews from of a broad spectrum of family caregivers, increasing the range of information and depth of knowledge. Obtaining data from different types of family members, rather than relying on a single type of relative, can provide a larger variety of caregiving experiences. Two investigators, CNT and MFL, reviewed the coding together to ensure that codes were data-driven. Differences were discussed until consensus was reached.Ethical approval for the study was granted by the Research Ethical Committee of the National Taiwan University Hospital (No. 200809056R). Each participant was informed of the purpose and design of the study and assured that participation was voluntary. Caregivers were required to provide signed informed consent prior to their inclusion. Confidentiality and anonymity were also ensured.Analysis of the interview data identified four core categories that describe the family caregivers’ experiences of managing incontinence: chaos, hypervigilance, exhaustion, and creating a new life. Nine related subcategories further describe their experiences: fluster, dirtiness, urgency, fear of potential health-hazard, physically demanding and time-consuming, mentally draining, financial burden, learning by doing, and attitude adjustment .Taken together, these describe a process of struggling to cope with the care of stroke survivors with urinary or fecal incontinence. Of the four main categories, “creating a new life” appeared to develop gradually over time in an attempt to orient caregivers to their new life, while the other three categories were present continuously and seemed interminable .Chaos describes the absence of order or the confusion that resulted from caring for the stroke survivor’s incontinence, compared to the caregiver’s previous life. The care of incontinent patients requires significant levels of attention and concern. Inexperienced family caregivers initially face chaos due to feeling flustered by the unpredictability of incontinence and the dirtiness that requires a significant amount of cleaning. Caregivers need to overcome the chaos, so that they may go a step forward to adopt other strategies for coping with further challenges without the concerns of being contaminated, disturbed, or anxious.I thought that I should wear the gloves but it just happened so fast… I was flustered and wanted to clean up all the mess as soon as possible”.Fluster is a feeling nervousness or pressure due to multiple skills and procedures needed, including changing positions safely, cleaning, and changing diapers. Caregivers often felt it was hard to get used to all of these tasks, which caused additional problems. For example, they must not only change a diaper but may also need to clean bed sheets, floors, and even the whole room. More tasks led to greater levels of fluster. For example, one son-in-law said, “Changing diapers sounds easy, but anything may happen. I was always nervous and flustered whenever an unexpected situation happened when dealing with incontinence”.A son noted, “I have to lift him up while wiping and doing lots of tasks at the same time…sometimes feces spreads … and we even change the bed sheets”. Furthermore, these tasks are often repeated again and again. One daughter said, “The stool is uncontrollable; it came out just after you thought it’s over”.One wife described her situation by stating, “The uncontrollable pee and poo make the room smell bad and uncomfortable…dirtiness makes me feel upset”. Another daughter mentioned, “I felt dirty in the beginning … I did find it disgusting… If you do not change in time, the urine will spread all over the bed… the room will smell bad and dirty and it’s hard to bear”.The unpleasant smell of feces and urine, and incomplete cleaning that can leave the environment feeling dirty, disgusting, and uncomfortable was the subcategory of dirtiness. For example, one son-in-law responded, “When caregivers had no knowledge of how to provide care and deal with incontinence and solve unexpected problems, they experienced fluster and anxiety.Caregivers not only have to overcome the concerns of dirtiness and fluster, but must also pay attention to the feelings and health of the stroke survivors. Therefore, caregivers must remain alert, so that they can act immediately and keep the stroke patients clean and comfortable. Moreover, being alert helps caregivers avoid unnecessary care work, such as washing pants, sheets, blankets, and floors, which can prevent potential complications such as bedsores or infection.After the stool passage, she cannot wait…I should deal with it quickly and leave other things behind…other daily living care could be arranged, and followed my schedule, but not incontinence…”. A granddaughter responded, “She did not know (about the stool passage) and tell us…so, we should deal with it as soon as possible, because the longer you left it there, the harder it was to clean it up…”.It is imperative that incidences of incontinence be cared for immediately; urgent intervention is required and cannot be delayed. If caregivers cannot provide immediate care, the patient is left in an uncomfortable state. Therefore, urgency was a factor that necessitated caregivers’ hypervigilance. One son-in-law noted, “I should change things immediately after he urinates or defecates, or else his buttocks will get red and injured… I can feel his pain… If you miss once or twice, his skin will be injured and that will be an additional problem you have to deal with….The hypervigilance was also driven, in part, from the fear of potential health complications associated with not cleaning fecal incontinence promptly. These included the possibility of an increase in patient discomfort, impaired skin integrity, infections, hospitalizations, medical costs, and caregiver loading, and a decrease in the quality of the caregiver’s life. For example, a wife stated:The urgency and fear of the potential health-hazards of urinary and fecal incontinence created increased nervousness and alertness in the family caregivers, and ultimately, a state of constant hypervigilance.Exhaustion describes the state of feeling tired-out—physically, mentally, and financially—due to hard caring work. Physical care is a trifling “around the clock” job. It was more difficult for caregivers dealing with both incontinence and physical dependency.… for stool cleaning and diaper changing… I feel soreness and numbness of my hands at night. I had back pain and I get more frequent headaches now…I wake up several times a night to check his diaper and don’t get enough sleep…It’s tiring.The necessary care tasks for stroke survivors are complicated and physically demanding, particularly for caregivers that are not professionally trained. Consequently, the physically demanding care that is required was cause for caregivers’ experience of exhaustion when managing incontinence care. One wife described her experience by stating:“Although I am a male, changing diapers consume lots of energy. Every time I finish the diaper changing I feel my back pain…”.One son said, In addition to diaper changing, I also need to wash his pants, clean his body, and even shower him. There are so many things waiting to be done after his urination or stool passage”.The arduous management of incontinence is also time-consuming, which adds to the exhaustion. Patients must use the toilet several times throughout the day and night, leaving family caregivers with little time for themselves. A granddaughter observed, “Caregivers experienced physical problems, such as sleep deprivation, back pain, headaches, and fatigue that led to physical exhaustion, which was compounded by the time-consuming nature of the care and subsequent activities.I’m worried about not being able to provide proper care for her, and whether she will have complications or infections…I have to offer both money and energy and I’m mentally fatigued…”. A daughter-in-law also responded, “I feel pressured and worry about whether I can handle this or not, whether she will be all right under my care or not…The invisible stress is huge…”.Constant worrying about the patient’s condition caused caregivers to experience mental stress. Common problems were fear of being unable to offer good care, feeling frustrated, and depressed. One daughter mentioned, ““Diapers are more costly because I change them whenever she urinates or defecates … for her good, I cannot save this money… I worry about money. These are really huge costs…”. Another daughter said, “We now feed her the special milk designed for lactose intolerance to prevent diarrhea. It costs us more, and we have to buy one can every three days. This is really costly”.Management of incontinence is expensive, resulting from the costs of nutrient supplements, diapers, pads, and other supplies, and adds an additional burden to family caregivers. A son-in-law noted, Stroke survivor’s physical disability requires a substantial amount of assistance from caregivers on several levels. Incontinence was associated with a lack of control, repetition, and physical dysfunction that contributed to physical demands, consumption of time, mental stress, and financial cost among caregivers.Most caregivers needed to learn how to perform each care task, and sought professional assistance for instructions. To handle incontinence, caregivers not only tried to accumulate experience by doing, trying to complete every step smoothly, but also needed to change their perceptions toward excrement by adjusting their attitude and thinking positively. All of these changes meant creating a new life for themselves.My daughter-in-law had experience of caring for elders and kids … I learned how to deal with urination and defecation from her … Besides, I read and ensure that food is rich in fiber, which affects bowel movement. Now she defecates regularly and smoothly.Caregivers tried to learn the required skills from professionals or other sources, such as books and people with similar experiences. One daughter engaged in problem solving activities, noting,In the beginning, I was a novice and knew nothing at all. If nurses only tell me and do not show me what to do, the help was limited … I learn from doing, because only doing can make me understand the process … I learned how to turn him and change his diapers … I learned from nurses and accumulated my experience gradually. I had to discuss with nurses to understand the reasons, and to learn skills for saving time and energy or making him more comfortable…One son said,The first time, I may be new to the skills, but I’m more sophisticated after a few times of practice. Now I have few problems dealing with her”. A daughter responded, “…I learned (to) handle it…Now I’m good at this and I feel the situation is not so hard anymore… I will no longer get poo everywhere … I do it smoothly”.Over time, caregivers learned to become experienced and familiar with caring tasks. This made them confident and flexible when meeting different incontinence-related conditions. A daughter-in-law said, “If I am too rushed to get gloves, I just think that we are family, so it doesn’t matter… I can wash later. It’s all right and I am used to this situation … I do not feel flustered or dirtiness anymore”. One wife also described a similar feeling “Now I only worry about whether he can be cured or not, and not about whether it’s dirty or not”.Caregivers must overcome the feelings of discomfort when providing incontinent care. They must change how they perceive excrement, which is often associated with dirt and bad smells. They must therefore learn to clean the mess quickly without thinking about the dirtiness. A daughter-in-law mentioned “There is pressure, indeed, from taking care of her. But I think that this is just the way that life is now. All I can do is give as much as I can, so that I can say I did my best”. A wife also remarked “We should change … and try not to … think of sad and painful situations. We should look at the bright side of everything because that’s the life we’re in. We cannot change it, so the only way (forward) is to accept it and move on.Besides seeking external assistance, caregivers also adjusted their attitudes to move on and appreciate life more. A son-in-law said,Caregivers prepared themselves to overcome their challenges and tried to change their thinking to maintain mental balance. Their goal was to create a new life with acceptable conditions.This study highlights the unique experiences of family caregivers of stroke survivors with incontinence. It was designed to provide a deeper understanding these caregivers’ experiences and their challenges. We identified four categories that reflected the progress of physical and mental reactions to the care of stroke survivors with incontinence. These were chaos, hypervigilance, exhaustion, and creating a new life. These categories revealed a mix of different feelings and emotions among family caregivers when dealing with incontinence.Our results are consistent with several previous qualitative studies revealing that family caregivers of patients with strokes experienced hypervigilance –24 and eCaring for stroke survivors with incontinence is physically demanding, mentally draining, and financially burdensome to family caregivers. Almost all caregivers mentioned drains on their mental health, personal time, physical health, and financial resources, particularly the latter two. The physical aspects of incontinence care of elderly stroke survivors with immobility, and their greater dependence and 24-hour care requirements, led to back pain, sleep deprivation, and fatigue. This suggests that family caregivers may require, and benefit from, respite care, consistent with the finding of previous studies exploring the needs of stroke caregivers . We propI do not have enough time to sleep; how could I have the energy to understand the complicated application process for social welfare”. Hence, we suggest that the government not only offer sufficient allowances for family caregivers but also ensure adequate information is publically available about the application process and available support. The use of pamphlets or the mass media could improve access and reduce caregiver burdens, thereby increasing the effectiveness of the social welfare system.Financially, the extra expense of incontinence care is high, such as nutrient supplements , diapers, pads, hospitalizations, and emergency visits for incontinence-related complications. Many family caregivers commented on the financial impact of caring for stroke survivors with incontinence. As reported by Cassell and Watt, family caregivers require financial support from the government . In manyIn this study, caregivers reported using various strategies to deal with incontinence, despite lacking the knowledge and skills needed to provide incontinence care. The categories of chaos, hypervigilance, and exhaustion were associated with this lack of information, knowledge, and skills about how to deal with incontinence. Caregivers are inexperienced and often insufficiently prepared to take on such responsibilities. Our findings indicated the lack of well-organized training and educational programs, as well as the absence of ongoing support, left the caregivers vulnerable. Simultaneously, family caregivers also seemed to need access to professionals that could be resources of information and skill building. As noted in other studies , 25, 28,In addition to feeling high levels of burden, caregivers described how they tried to deal with patient’s incontinence problem by learning and making attitude adjustments to create a new life. Specifically, they often tried to develop more positive attitudes towards their situation. Family caregivers needed to overcome the sense of chaos and adopt strategies to cope with their challenges without the concerns of being contaminated, disturbed, or anxious. This experience was confirmed in a recent study  in whichDespite its contributions, this study had some limitations. The caregivers in this study were recruited from one medical center, and the sample size was small. The research focused only on the incontinence aspect of stroke for family caregivers in Taiwan. Thus, the results may not be transferred to other settings or caregiver populations. The family caregivers were asked to recall their experiences of caring for close family member survivors with incontinence, which may be influenced by recall bias. Furthermore, the caregivers interviewed in this study were not followed, and the differences in incontinence care could not be further described. We suggest that prospective studies be conducted, utilizing both qualitative and quantitative research designs, to understand changes of caring experience across different stages. Extending the scope of investigation to the impact on other issues such as changes in familial relationships and careers for caregivers could provide deeper understanding of care-giving phenomena.This study focused on the unique caring experiences of family caregivers of elderly stroke survivors with incontinence. Family caregivers described reactions to urinary/fecal incontinence as a sense of chaos, hypervigilance, and exhaustion, and of the need to create a new life. Using various resources, family caregivers were able to develop the skills and techniques required to deal with the complexities of stroke and incontinence. In most cases, learning was through experience. Moreover, adjusting their attitudes to be more positive and forward-looking helped caregivers bridge their difficulties and continue providing care. Caregivers were eager to gain technical support from healthcare professionals and financial support from the government. Recognizing the physical and emotional reactions of family caregivers caring for stroke survivors with incontinence may help nurses provide better support and resources to meet the needs of caregivers and patients alike.


These range from a BBC article, ‘Spotting the Royal stalkers’,The spectrum of today’s search results for this 88-year-old emeritus consultant psychiatrist of Royal Liverpool University Hospital, fellow of the Royal College of Psychiatrists, member of its Council for over 20 years and Court of Electors for 8, due shortly to publish his autobiography, offers just a glimpse of the diverse tales Dr Enoch might relate, should you be lucky enough to meet him.With a surname meaning ‘he who walks with God’, Morgan David Enoch was a sixth-form student due to read theology at the end of World War II. David’s mother, who worried about his sister attending a hairdressing course in Swansea, 8 miles from the family home, was shocked when, after a letter from the King of England, he was soon serving with the British army in India’s north-west frontier, ‘facing the forces of the Faqir of Ipi at the very place where fighting has been heaviest for the [past] 10 years’, aged 18. Later, following a War Office Selection Board, he trained at the Indian Military Academy, ‘the Sandhurst of India’ at Dehra Dun, was commissioned into the Royal Artillery and posted to the second Indian (Sikhs) Field Regiment in 1947.During this time, he says ‘while angry with God for obstructing my chosen path, I had four exciting years in India. I heard Jawaharlal Nehru and Mohammed Ali Jinnah address vast crowds: I witnessed the birth of two great nations and the process of India’s violent partition’. Playing rugby for the British Army in India, David returned to Woolwich Arsenal on leave, expecting to continue playing but was indignant to be ordered back to India to complete his outstanding months’ National Service. He says the physical and mental suffering he observed during his army career is what called him to medicine. After eventual military discharge, he ‘went around the London teaching hospitals and liked St Thomas’ Medical School. I think the uniform helped at interview’.Qualifying in 1954, following house jobs Dr Enoch returned to Wales to work at St David’s Mental Hospital, Camarthen, as his father, ‘a hewer of coal in 2 feet 9 inches’ was dying of silicosis. Of his first years in psychiatry, he recalls the routine use of the hypnotic paraldehyde at night, prescribing ‘quite effective’ Drinamyl , deep insulin coma therapy and, for the first time, an antipsychotic: chlorpromazine.6Following his father’s death in 1958, he returned to London, then ‘the supreme place to train’, obtaining a medical registrar post at University College Hospital, working for Professor Baron Max Leonard Rosenheim, Dr Roger Tredgold and Dr Desmond Pond, later president of the Royal College of Psychiatrists. In the mid-fifties, after the Institute of Psychiatry course and obtaining his Diploma in Psychological Medicine, Dr Enoch witnessed the introduction of antidepressants, beginning with imipramine and amitriptyline. He later obtained a senior registrar post divided between the London Hospital  and Runwell Mental Hospital, Essex, which opened after World War II in response to shell shock – the last mental hospital built in Britain.Dr Enoch recalls Runwell’s physician superintendent, Dr Rolf Ström-Olsen, as ‘one of the best physicians I ever met. He was Norwegian, abrupt and highly intelligent’. He recollects Runwell’s units divided into neurosis and psychosis, conferences clouded in cigarette smoke, treating patients for the first time with out-patient electroconvulsive therapy and the introduction of newer antipsychotics, like haloperidol. This dynamic clinical, educational and research environment was to prove instrumental in inspiring his future writing, yielding a lifelong dedication to evidence-based improvement in clinical practice.Dr Enoch recalls presenting a patient at Runwell Hospital, whose complaint was that ‘my wife’s an impostor’. Phrases began to occur to him describing the psychodynamic processes at work: ‘His wife was ”the fallen idol”, hence the delusion of doubles. How do you resolve loving and hating someone at the same time? By splitting. Is apperception not a wonderful word? To perceive with feeling. That is the essence of Capgras psychopathology.’Acta Psychiatrica Scandinavica in 1963,7 the same year he won the Gaskell Prize. He developed an increasing interest in rare presentations, from De Clérambault’s syndrome, to folie à deux, Tourette’s and more, which yielded his first book. The first edition of Some Uncommon Psychiatric Syndromes, a bestseller, was published in 1967, with further editions in 1979, 1991 and 2001. Dr John Pollitt, President of the Section of Psychiatry of the Royal Society of Medicine, predicted that it ‘well deserves to be placed as a classic’;8 it has been translated into French, German, Turkish and Japanese.After further research, Dr Enoch’s paper on Capgras syndrome won the bronze medal and prize of the Royal Medico-Psychological Association in 1962 and was published in cause célèbre status. ‘I never thought, for example, that patients with Munchausen syndrome by proxy would become so important. They became huge’. The diagnosis was questioned publicly, after several child killing convictions were overturned, including that of lawyer Sally Clark. In these cases, the diagnosis was used inappropriately for paediatric assessment, without involvement of a psychiatrist. By contrast, high-profile cases incorporating psychiatrist assessment, such as that of nurse Beverley Allitt, now detained at Rampton Secure Hospital, demonstrated the contemporary relevance of the diagnosis.Dr Enoch expected his ‘uncommon syndromes’ to remain rare and was surprised by their later Uncommon Psychiatric Syndromes from around the world; he remains fascinated by delusional disorders. ‘I’d like to know far more about emotions. How can feelings affect thought? Psychodynamics remain all important. This book has been lived’. Although he never met Ian McEwan, who referenced the text in Enduring Love, Dr Enoch ‘approved’ of the novel, unlike the film Fatal Attraction , which did not depict true De Clérambault’s syndrome, because ‘the protagonists had an initial affair: usually there is no contact’.To this day, Dr Enoch receives telephone calls from readers of Uncommon Psychiatric Syndromes, Dr Enoch wrote other well-received books, including Healing the Hurt Mind: Christian Faith and Psychiatry.9 Now in its 11th edition, its title was inspired by a patient’s letter, kept to this day, stating that ‘Dr Enoch was the first person who listened to me and asked me how I am. Healing began for me today’. In the most recent, I Want a Christian Psychiatrist,4 he returns to his theological roots. ‘You don’t necessarily need a Christian psychiatrist: you need a competent psychiatrist who must respect your faith’.After the success of Uncommon Psychiatric Syndromes.Dr Enoch recalls obtaining his first consultant post at Shelton Hospital, Shrewsbury, after debating Ganser syndrome with Professor Sir William Trethowan, foundation chair of psychiatry at the University of Birmingham, at interview. He would later invite Trethowan to contribute to the chapter on Ganser syndrome and Dr John C. Barker that on Munchausen syndrome, in the first edition of Sans Everything: A Case to Answer.10 He remembers ‘feeling encouraged’ at the time by the Sunday Times’ article series on care in the community by Marjorie Wallace, who later founded the mental health charity SANE, with telling photographs by Lord Snowden.It was at Shelton Hospital that Dr Enoch introduced regular teaching, therapeutic communities and care in the community. He recalls meeting Enoch Powell, then expounding de-institutionalisation as minister of health. He worked with Barbara Robb on a national campaign for elderly care in hospitals, contributing a chapter to her book, 11Dr Enoch was later head-hunted to take on the new post of consultant psychiatrist and senior clinical lecturer at the new Royal Liverpool University Hospital’s ‘superb’ department of psychiatry, later including beds at Rainhill Mental Hospital. He is still remembered as a dynamic and enthusiastic teacher, as evidenced by Dr Gamal Hammad’s description of him as ‘a charismatic guru, a wonderful mentor and a visionary’.He always enjoyed encouraging the next generation of psychiatrists and made a point of involving students and nurses in ward rounds: ‘I wanted the doctors and students to see the full range of psychiatric disorders. I used to remind them, ”Rare things rarely occur”.’ At the opening of Shelton Hospital’s replacement, the Redwoods Centre, in 2011, his second wife, Anne, a retired headmistress, recalls him being treated ‘like a celebrity... they’d all read his book’.Above all, Dr Enoch strove to teach and practise psychiatry as a holistic discipline, examining each and every patient: ‘I liked psychiatry because it deals with the whole person: their body, mind and spirit. I wanted to do something exciting while staying true to my faith. A good psychiatrist is prepared to listen, know their stuff and gather it all together into a diagnostic formulation. It doesn’t mean you have all the answers, but the diagnosis is the first step to management and treatment.’Dr Enoch is a staunch supporter and advocate of psychiatry as a compelling specialty with much still to be discovered: ‘It’s a new frontier of medicine... We know so little about the human brain: the heart is a pump, but you love with the hypothalamus. We thought that scans would give us clear-cut answers but they have not. What is consciousness? I have thirty books on it but no one can say where, how, what. It is remarkable what can arise from the unconscious. I thought that fMRI would locate jealousy, De Clérembault, because those syndromes are so specific: monomanias with one delusion. The fact that we cannot locate them suggests that the brain’s connections hold the answers. But can this brain really have the capacity to understand itself?’The specialty remains compelling for Dr Enoch, even after more than 50 years; he continues to advocate keeping psychiatric wards within medical hospitals: ‘Psychiatry is the most intriguing of all specialties: you deal with the wholePatients come to you broken psychologically and emotionally, intent on suicide, and get better. Is there anything more helpful in society than to heal pain: physical and psychological? Psychiatric illness is an illness like any other: treatable and curable despite what even doctors may think. You need maturity to choose something so difficult, though. You will need hope, positivity and graciousness.’Having seen his last patient on 31 December 2012 and survived a coronary artery occlusion of ‘99%’, Dr Enoch remains active, lecturing at Cardiff University Medical School until recently. In addition to his forthcoming autobiography, a book of Welsh essays is due for publication in 2014, with several exploring the relevance of the Ten Commandments today. Although he never did complete that theology degree, he has continued to preach from age 16 until today, in between spending time with his wife, son and four grandchildren. Considering his rather uncommon life, he reflects that: ‘I have been greatly blessed. I am very grateful for a very exciting life; it’s still exciting. I have enjoyed psychiatry’s riches in helping people in great depth.’When we last met, Dr Enoch was looking forward to meeting recipients of the Royal College of Psychiatrists’ Pathfinder Fellowships, considering the next generation with excitement – and a little envy: ‘this is going to be the century of the brain’. Above all, it is the pursuit of learning which he most fervently advocates for us all: ‘I spent 65 years in the game, to realise how little I know. I would love to be starting again, with the knowledge I have now’. His wife adds, ‘He is as enthusiastic today as when he was twenty’. All taught by Dr Enoch, exposed to this enthusiasm, may count themselves truly fortunate. His last piece of advice? ‘Gather your materials from everywhere, but be your own architect.’