Spring 2019

Reading List

The influence of a skilled and thoughtful mentor never wanes

Mental Health Issue

  • by Edward Hundert
  • 9 minute read

Leston Havens

Leston Havens

In the mid-1950s, Leston Havens, psychiatrist, professor, author, patient advocate, and, for me, a mentor extraordinaire, began a residency at what would become Massachusetts Mental Health Center. During his nearly three decades at the center, Les helped define the fledgling field of biological psychiatry, including founding the center’s psychopharmacology unit, serving as chief psychiatric consultant to the Massachusetts Rehabilitation Commission, and directing the medical student clerkship, where he introduced generations of medical students to psychiatry as a career. Later, during his appointment at Cambridge Hospital, Les directed its psychiatry residency for many years.

His academic career was centered at HMS, where, in 1954, he began as a teaching fellow in psychiatry and, by 1971, earned the rank of full professor. In 2008, he became a professor emeritus of Harvard University. Havens died in 2011.

Threaded throughout these many legacies is the legion of psychiatrists who, as medical students, took a month-long one-on-one elective that we called Reading with Les. It was an experience that not only dramatically influenced my understanding of the history of psychiatry, but also led to almost ten years of monthly faculty club lunches during which Les would encourage me, prod me, and always leave me with the feeling that I could accomplish so much more than I ever thought possible.

I learned about his reading elective from a fellow student as we were waiting for a conference to begin. Les was coming to interview a patient from whom none of the residents or students could get even a basic history: the woman’s experience was completely filled with terrifying hallucinations. Les entered, pulled his chair up next to hers, and within a few minutes, to the astonishment and awe of the students and residents in the room, proceeded to have about a half-hour long, rather normal conversation about who she was and her life. I still remember how she talked with him about her work as a clerk at the MIT Coop and her memory of selling the last slide rule in inventory. Calculators were coming in.

Afterward, Les took questions. A resident asked why he thought that patients who hear voices so often think it’s the voice of God that they hear. He paused, then said, “You know, there are lots of kinds of suffering. Physical pain, for example. But the kind of suffering our patients experience really is the worst kind of human suffering, and God doesn’t talk to just anyone.” He left it there.

When next I spotted him on the ward, I raced over and asked if I could sign up for one of his reading months. He said he would look forward to it and later let me know that I should read in advance the book we would discuss at our first session: Karl Jaspers’s General Psychopathology. After we discussed Jaspers for what turned out to be two hours, he assigned me John William Miller’s In Defense of the Psychological, which affected my thinking more than any single book I’d ever read.

These meetings with Les were like classic Oxford tutorials: the wise tutor listens to his young charge discuss the last reading assignment, then chooses the next reading assignment based both on an appreciation of the student’s ongoing misconceptions and an insight into which texts will best challenge the student’s growth to the next level of understanding.

It was during our discussion of In Defense of the Psychological that I confided to Les that I had a contract with Oxford University Press to write a book on various approaches to the mind. He replied, “Well, in that case, next week we should discuss a little effort I cobbled together with that same title about ten years ago.”

We moved on to his Approaches to the Mind—and my life was changed.

When I was in college, I had a double major in math and the history of science and medicine. I thought I had some understanding of the way the history of science and medicine unfolded. In science, the paradigm is always physics, chemistry, or biology, where the Kuhnian revolutions of deeper levels of understanding don’t merely build upon but ultimately replace the older ones. Newtonian physics supplanted both Aristotelian physics and Ptolemaic epicycles, Einstein supplanted Newton, and so on.

That linear view is usually what medical students are taught, too. Darwin’s theories make so many others obsolete, and the discovery and study of bacteria or DNA relegates previous theories about black bile and other humors to history books instead of medical books.

But Les didn’t see the history of psychiatry that way. He believed, and taught, that each school of psychiatry—psychodynamic psychiatry, biological psychiatry, interpersonal psychiatry, existential psychiatry, and so on—brings a different and complementary truth to the table. One does not supplant the next. Instead, each uncovers different sets of fact that should never be understood as contradictory.

In psychiatry, he once wrote, “There can be no separation of facts and methods. Each fact is secured by a particular limited method, and each method is scientific only insofar as it secures consistent facts.” Then he added, “These points should not be overlooked if one hopes to grasp the whole universe of mental phenomena with a few methods and facts.”

I think Les was a master teacher in part because he had a deep understanding that no one school of psychiatry represents an all-inclusive method for understanding mental phenomena. In the introduction to his Approaches to the Mind, Les talked about how each school of psychiatry is convinced it is the psychiatry: “Students shop among the schools, and the public asks psychiatrists and psychologists what kinds they are … new varieties come and go like fashion styles.” Beginning students can feel they are, as he put it, “prisoners of a point of view.”

While some people interpret this viewpoint as nihilistic, Les didn’t intend it that way. Indeed, he devoted all his remarkable powers to celebrating the plurality of perspectives and tools that each psychiatric school brings to bear. Elsewhere in the introduction to Approaches, he wrote, “Many of us enter psychiatry and psychology seeking a bridge between science and the arts, a unity of knowledge and experience … certainly not their fragmentation. We wanted to carry all our life’s experience, as well as the intuitions and colors of art, over into science and the practice of therapy.”

Then appears one of my favorite sentences among the millions he wrote: “We wanted to be as much whole persons in our professional lives as elsewhere, to have each part serve every other part, whether personal, social, or professional.”

This integrative view of the history of psychiatry is indeed more like the history of art than the history of science. Yet it’s important to recognize that the conclusion that Les reached was not that psychiatrists should be what is often described as eclectic: “… the psychiatrist or psychologist does not want to be merely eclectic, that is, borrowing whatever pleases him from various sources. He wants to be pluralistic, able to use all the methods and make the critical observations himself, and to be capable of grasping when and with whom each method should be applied.” Only in this way, he said, can we speak of an inclusive or pluralistic psychiatry, concluding that “having painted our portrait from more than one angle, we may be closer to objectivity.”

Most people don’t make the connection that Les was interested in getting closer to objectivity, instead thinking of him as the guru of clinical work, as someone deeply interested in the phenomenology of mental life and mental illness, as someone who was able to align his subjectivity with the inner life of the patient and make contact with them in a way few other people could.

What most people also don’t know is that he did a residency in internal medicine to prepare himself for studying the relationship between mind and body. Furthermore, many of his awards were for biological research. The first award he ever received was for diagnosing a patient who was considered psychotic as having liver disease instead. Les proved that the patient had elevated blood ammonia levels and that it was his liver, not his psyche, that needed medical attention.

The subtitle of Approaches to the Mind is Movement of the Psychiatric Schools from Sects Toward Science. According to Les, that movement did not follow the scientific historical trajectory in which inferior theories are disproven as we move closer to objectivity. He taught us that the way we move closer to objectivity, the way we can be scientific in psychiatry, is to embrace seemingly contradictory theories and become pluralistic psychiatrists who can paint patients’ portraits from multiple angles at once.

I didn’t learn all of this in my four weeks of reading with Les, but that was where my education started, as it did for so many of us throughout the decades of conversations with him in offices, during walks along the Charles River, and over lunches at the faculty club. I think just about anyone in the Harvard orbit who trained in psychiatry during the last third of the twentieth century was affected, directly or indirectly, by the view that Leston Havens had of psychiatry, its history, and its potential for the future.

Edward Hundert, MD ’84, a psychiatrist, is the HMS dean for medical education and the Daniel D. Federman, M.D. Professor in Residence of Global Health and Social Medicine and Medical Education.

In 2018, The Leston L Havens MD Teaching Site: Constructing Livable Lives was launched. This free teaching website, developed by Susan Miller-Havens, EdD, brings together the books, papers, photographs, correspondence, and audio/video recordings of lectures and patient interviews of U.S. psychiatrist, psychotherapist, author, researcher, and Professor Emeritus, Harvard University, Leston Laycock Havens, MD. The website was donated to the Center for the History of Medicine at the Francis A. Countway Library of Medicine by the Havens family. The Center has made the website available at http://wayback.archive-it.org/4908/20180426152139/https://www.lestonhavensmd.com/

Image: S. Miller-Havens, 2000