“Be not solitary, be not idle. Unhappy ones, have hope; happy ones, be cautious.” So wrote the priest and scholar Robert Burton in his treatise The Anatomy of Melancholy, published in 1621. It’s great advice and despite the astonishing medical advances of the subsequent 400 years, nobody has improved on it all that much.
Innovations from psychotherapy to Prozac have made lofty claims about reducing psychological suffering, but Britons are now reporting the highest levels of mental ill health yet recorded. We have sent probes to Mars and created artificial intelligence, but it seems we are still clueless when it comes to our happiness.
So what is going on? Are we, despite the relative material luxury of our lives, more unhappy than ever before? Or have we just invented new ways of classifying and reporting our distress? What can we actually do to look after ourselves and the people we love?
In his fascinating and beautifully written book The Unfragile Mind, the GP Gavin Francis addresses these questions with a winning combination of pragmatism and compassion. His message is that mental health is more cultural and social, and less medical, than we often think.
He starts by emphasising that a human mind is not a problem but a thing of wonder that no science or technology has even begun to understand. “Our minds are not brittle or rigid,” he writes in his opening chapter. “They are dynamic, resilient and adaptive: they are not fragile, but unfragile.”
Francis introduces us to the mind first through his experience as an anatomist, dissecting the web of nerves and tissues that somehow — nobody has any idea how — facilitate consciousness. Emotions might seem abstract, but they take a physical form; he uncovers the fibres behind the eye that govern weeping, “this tangle of nerves where thought or feeling becomes water”. Later, he notices that in one of his cadavers — covered with prison tattoos — the muscles needed for a smile have withered while those that pull the forehead into a frown are strong and thick.
He prefers metaphors for the mind that have a mystical or organic quality: it is a galaxy, a rushing river, an “enchanted loom”. This is not the language of mainstream psychiatry with its ever-expanding lists of disorders and dysfunctions. The first iteration of the American asylum manual, published in 1918, included 22 potential diagnoses — the most recent, The Diagnostic and Statistical Manual of Mental Disorders, has 400 categories of mental disorder.
Psychiatry’s obsession with labelling and classification might be helpful for insurance companies, but is less so for humans. Although sometimes naming a problem can help a patient, Francis says, “this might be at the cost of a more dynamic and hopeful perspective on their state of mind”. It also cultivates an unjustified sense of certainty in the professionals. When it comes to minds we need to get comfortable with doubt.
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Francis uses case studies inspired by patients in his Edinburgh general practice to bring the complexities of mental health care to life. The GP’s-eye view is unique since it is they, more than the specialists, who deal with most of society’s distress. “My education hadn’t prepared me for just how ubiquitous anxiety is, or paranoia, or depression, or insomnia — often among people who are pretending to everyone else in their community that they are doing fine… only a minuscule proportion of sufferers ever make it into a psychiatrist’s office.”
“Our minds are not brittle or rigid. They are dynamic, resilient and adaptive”, writes Francis
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To anyone who has recently tried to access mental health care through their GP, Francis’s account of his consultations might seem unfamiliar. He sees one anxiety sufferer “once or twice a month for a year” and discusses some sophisticated stuff like helping his patients to understand the impact of childhood trauma. Perhaps things are different in Scotland, but where I live a patient will be lucky to see the same doctor twice and will almost invariably leave with a prescription for antidepressants.
This in itself is depressing because, as Francis makes clear, the evidence is that they don’t work. Between 75 and 82 per cent of any benefit obtained from antidepressant drugs is believed to derive from the placebo effect. They don’t reduce the suicide rate and some studies suggest that they actually slow down recovery: 85 per cent of depressions that are untreated recover on their own within 12 months. Even so, GPs are still “prescribing more than ever before but mental illness rates continue to rise”.
Would talking therapy be better? Not necessarily. While there is no doubt that trusting relationships are essential for good mental health, it doesn’t seem to matter much whether you go for psychoanalysis, CBT, counselling or less formal support networks. As far back as the 1960s a study compared the results of sessions with senior psychotherapists and those with laypeople who had had just a couple of years’ training: it found that the laypeople’s results were as good as the psychotherapists.
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The inconvenient truth is that our healthcare system is set up to treat individuals and mental health is intimately bound up with wider society and culture. As Francis writes: “The West’s 20th-century focus on individualism has led to us creating maps of the mind that have many blind endings.” Outcomes are much better for schizophrenics in countries including Ethiopia and Sri Lanka than they are in the West probably because it’s more possible for them to retain their community connections.
Even a problem such as anxiety manifests differently in different cultures. In Korea hwa byung is described as a constriction in the chest, in Nigeria ode-ori is characterised by a feeling of heat in the head. In south and east Asia there is an anxiety syndrome linked to semen loss and in Afghanistan the many varieties of anxiety include deltangi (“the space that occupies my heart becomes smaller”).
Our minds are inescapably, thoroughly social. Newer scientific approaches are confirming that “our wellbeing is about more than chemicals or cells — it’s about relationships”. Network theory, proposed by the Dutch psychologist Denny Borsboom, is a conception of mental illness that puts the emphasis on symptoms and how to alleviate them rather than causes or diagnoses. Could that kind of approach ameliorate the symptoms of living in a highly individualistic society? It would be good to find out.
The Unfragile Mind by Gavin Francis (Profile £18.99 pp304). To order a copy go to timesbookshop.co.uk. Free UK standard P&P on orders over £25. Special discount available for Times+ members