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‘We are today in need of more humility in how we frame geographies of the mind,” says Gavin Francis, a GP and travel writer. In his new book he attempts to combine both disciplines as he treks the uncanny topography of mental illness.
The journey is divided into chapters that explore various genres of human anguish – clinical anxiety, trauma, bipolar disorder, depression and psychosis – as well as autism and ADHD. He attempts to summarise each condition’s history in roughly 20 pages, evaluate past and contemporary theories, and weigh up the efficacy of treatments. To call this ambitious is to break new frontiers in understatement.
When recounting specific events and people, Francis is rarely less than excellent, his prose cadenced, vivid and crackling with telling details. He describes one professor as “short, neat, taciturn; he had a reputation for civility, and was rumoured to make all of his own clothes by hand”. As a student, his work dissecting human corpses is “an education in glory: on arrival I’d switch on the radio, don an apron and gloves, unwrap the shrouds over the cadaver I was working on and begin the revelation”.
Anonymised stories about patients add welcome colour, such as his phone conversation with “Helena”, a woman in her 30s experiencing a manic episode. Her pressured speech leaps from UFOs to snowflakes to Superman to cathedrals in a freewheeling poetic monologue that, weeks later, when the mania has passed, she’s able to dismiss with a laugh.
One of the hardest to read is the story of Max, who comes to Francis as childhood memories of sexual abuse begin to resurface. “Memories of those terrorised years were thickening around him – he could hardly breathe for them.” Francis refers Max to a counsellor, but arrives at work one morning to find that he has taken his own life.
These are more than dry case studies. Each is a real, irreplaceable human life. Francis foregrounds the person over the symptoms, viewing his role not as that of an impersonal diagnostician, but as a healer.
Sadly, the book’s breadth leaves little room for this kind of tender, detailed biography, and these first-hand encounters are fleeting and fragmentary. The moment he widens the aperture, all the acuity and crunch – and, crucially, the author’s rhetorical authority – fall away. Instead, we get whistle-stop histories of each condition, peppered with quotations from a motley array of sources – including, jarringly, me.
Any of these chapters could have been a book on its own, and probably should have been. Francis takes a generalist approach to the better part of human psychic dysfunction; the result is necessarily superficial, like trying to cram years of therapy into a 15-minute doctor’s appointment. Throughout, an odd, semi-articulated scepticism bubbles beneath the surface. Francis characterises contemporary models of brain function that involve neurotransmitters as “a recasting of the old idea of the four humours”; he compares psychiatrists to a priestly caste.
He even devotes a page to David Rosenhan’s infamous study, On Being Sane in Insane Places, as evidence that psychiatrists cannot tell the difference between schizophrenics and the clinically normal, only to concede, via an asterisked footnote: “There have been doubts raised about the authenticity of the fine details of Rosenhan’s account.” Well, yes, if by “fine details” you mean whether any of it happened at all. Thanks to Susannah Cahalan’s painstakingly researched book The Great Pretender, the overwhelming modern consensus is that Rosenhan made most of it up.
Francis would know this had he interrogated his own assumptions with the same epistemic humility he encourages in others. He argues diagnostic categories have become “too rigid … too blindly accepted” – and he’s right that our current labels are, at best, provisional shorthand. By contrast, he believes his training as a GP allows him to call on “the implicit part of the mind, where intuition can take over”, bringing to bear the “dynamism and flexibility” of his “experience and wisdom”.
In practice, this manifests as a grab bag of folksy, common sense remedies: depressed and anxious people should exercise, get more sleep, see friends. He claims that “for the vast majority” of low mood sufferers, antidepressants are not only useless, but “potentially harmful”, citing as proof a study that is not about antidepressants, but control groups receiving – as its authors explain – “a range of treatment options”. Intuition, it turns out, is no substitute for reading the actual paper.
In the final chapter, Francis shares the closest we get to an overarching thesis: “Life can be difficult for everyone … The happiest people I’ve met have found ways of enduring or making peace with those hardships – no easy task.” Fair enough, but not exactly the “re-evaluation of mental illness” promised in the blurb.
“Life is a balance of energies, good and bad, up and down.” “Though we can’t change the past, we can always influence the future.” If these conclusions feel to you like vital, revelatory contributions to the discussion about mental illness, The Unfragile Mind will prove good medicine.
The Unfragile Mind: Making Sense of Mental Health by Gavin Francis is published by Wellcome Collection (£18.99). To support the Guardian, order your copy at guardianbookshop.com. Delivery charges may apply.
