The Unfragile Mind: Making Sense of Mental Health by Gavin Francis review: 'sits on the fence'
By taking a “mibbes aye, mibbes naw” approach to some of the big questions around mental health, Gavin Francis’s new book can read as if the author desperately trying to avoid causing offence, writes Stuart Kelly
Gavin Francis has carved out a rather recognisable niche as both a travel writer – his two volumes on the Arctic and Antarctic are commendable – and a writer, who, as a general practitioner, can write accessibly about medical matters. He has also written a book about Sir Thomas Browne, which did not for me quite capture the knottiness of the 17th century polymath (although neither did Hugh Aldersey-Williams’s book around the same time). His medical works include Adventures in Human Being which I admired a great deal, and an exceptional work of convalescence, which I read while recovering from surgery and which was useful as well as interesting. His most polemical book thus far has been Free For All: Why the NHS is Worth Saving, which makes pertinent points acutely. The physician-philosopher Raymond Tallis has written on the same topic with NHS:SOS, a much more trenchant philippic about health funding.
This new book deals with mental health, and perhaps suffers from coming just after a great many books on the topic. Amongst the ones I found most enlightening would be Suzanne O’Sullivan’s It’s All In Your Head and The Age of Diagnosis; No More Normal by Alastair Santhouse; Stephen Grosz’s The Examined Life; and Bessel van der Kolk’s remarkable The Body Keeps The Score. These are all heavy-hitting books, but more importantly they have an argument: in short, they make a case. Concurrently with Francis’s book I read The Only Cure: Freud and the Neuroscience of Mental Healing by Mark Solms. I have some reservations about the details, but the central argument – that Freud, so frequently dismissed, was actually alert to a core dynamic about healing rather than health – is persuasive. Maybe, as Freud said, the goal was to transform “hysterical misery” into “common unhappiness”.
Although this book is relatively slender at 260 pages, Francis attempts to cover a vast amount of ground. The opening chapters are a potted history of psychiatry, with some nice grace notes such as ruminations on pharmacological brand names and the etymology of the name of René Descartes (“born again, of the map”). Later chapters cover anxiety, paranoia, trauma, PTSD, depression, psychosis, schizophrenia, addictions (including self harm), ADHD, autism and more. Any one of these could have been the subject of a whole book, and it tends to conflate a number of conditions that have superficial similarities but whose sufferers might benefit from very different therapies. Francis is alert to how problematic the Diagnostic and Statistical Manual of Mental Disorders – currently on its fifth iteration, DSM-V, is. Earlier versions catergorised things like homosexuality as a treatable condition: now the critique is that the symptomologies are so broad, inclusive and contradictory that almost anyone can be diagnosed with anything. Various research pressure groups push for widened definitions. Discussions are apparently underway about whether DSM-VI will consider grief to be a psychological disorder rather than a natural reaction and consequence to loss. Pathologising is not the same as treating.
Francis is less polemical. Or one might say, he hedges his bets and sits on the fence. In terms of scientific method, agnosticism is always preferable to conviction, but the “mibbes aye, mibbes naw” approach can read as if the author was desperately trying not to offend anyone. To be clear, I do not think that complex conditions have singular and simple causes. But take this passage: “Anorexia is often mysterious in its origins: some people become addicted to the airy, light-headed feeling they experience when they’re starving; for others its roots seem to go deep into ideas learned in childhood of nourishment, and ambiguity over whether food is good. Or it can be about controlling the boundaries of the self, or it can be disguised self-harm. I’m often struck by how many adolescents who self-starve show a surface indifference to whether they live or die, as if at core they’ve lost a sense of themselves as someone worth feeding”. There is a lot to unpick in this, although firstly it might be noted that the focus on “adolescence” plays into one cliché – later, it also skirts around the gendered nature. But is the condition willed or involuntary? Is it caused by nurture or inheritance? Is it a cry for help or a yearning to disappear? Perhaps having the testimony of those who suffer rather than a panoply of possibilities might be more empathetic.
Francis states, in terms of neurodiversity, held in inverted commas like tweezers, that “As a GP I cannot take sides in what is becoming a polarised debate”. I rather think that as a GP one does have to take sides, or run the risk of diagnosing two people with identical presentations with different diagnoses. It is strange that we live now in a culture where people want to be told there is something “wrong”, as if the label precludes taking responsibility.
Towards the end, Francis lists owning pets, “being in green space and among green smells”, watching the sun rise, volunteering, rereading great stories and many other things which all might be lumped together as “living”. As are grieving, being sad and anxious, being lonely, being angry and so much else. Francis stresses the need for kindness. Fair enough, but kindness always to me seems patronising, like pity: something that can be gifted or withheld. Most people, I suspect, want to be respected, believed and understood.
The Unfragile Mind: Making Sense of Mental Health, by Gavin Francis, Profile / Wellcome, £18.99
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