A conversation about minds and medicine

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Hello,

In The Unfragile Mind: Making Sense of Mental Health (UK edition | US edition), Gavin Francis explores the ways that our minds meet medicine, and specifically how our troubles are diagnosed. The move towards fixed labels, he argues, has done nothing to prevent an epidemic of unhappiness. We need a less rigid approach.

I was curious to read this book, and even a little anxious - after all, an autism diagnosis has been a very helpful label for me. But Gavin's argument is more nuanced than a simple dismissal of labels. He shows how our experience of mental distress has changed over time and across different cultures, according to the ways we picture our problems, and argues that patients deserve to be met with sensitivity and nuance, invited to think more generally about being well.

Gavin is himself a GP, as well as being a prolific author; you may remember him from our Book Club in 2023, when we discussed his excellent book Recovery: the Lost Art of Convalescence. I was curious to ask him more about the thoughts and experiences that led him to write The Unfragile Mind, so below is a conversation we held over email, which I hope you'll find illuminating. I certainly did!

Katherine May: Gavin, it’s lovely to get the chance to roam around the ideas in your latest book, “The Unfragile Mind”. It feels to me like a much-needed, ‘Wait a moment!’ at a time when the language of mental health is everywhere, but it hasn’t made us any happier. Before we get into the details, could you maybe start by giving us a broad outline of your argument?

Gavin Francis: Thanks Katherine - I’m not sure it’s an argument, as much as it is an invitation and an exploration of the kinds of conversations I have every day as a general practitioner. Over a third of the encounters I have in clinic are around mental health. Many of my patients feel as if society has got itself into a bit of a muddle around mental illness, and they come to me for guidance - some believe very strongly in the categories that have been developed by psychiatrists, and would like my help to find out whether they fit into one or another of them, while others have begun to question the authority on which those categories are based. I don’t try to impose one view or another, because in both cases my job remains the same: to try to ease suffering. The book draws on 30 years of helping people with difficulties of thinking, feeling, or even being, and my main intention with it was to reintroduce some humility, kindness, and curiosity back into the way we talk about mental illness.

Katherine: It does feel like a very complex landscape to navigate at the moment. On one hand, we’ve seen a huge change in the conversation about mental health, and a normalisation of issues like depression or anxiety, which we now broadly see as treatable. But there’s still plenty of pushback against people expressing their fragility in the world, and clearly huge budgetary constraints in giving people the support they want and need. This puts diagnosis at front and centre of the change: people reach for a diagnosis not just to make sense of their own suffering, but also because it unlocks support and adaptations, for example in the workplace or at school. I’m curious to know: how does it feel to be the person mediating these diagnoses?

Gavin: The landscape of mental health diagnoses is always in flux - every few years a new system of the DSM (Diagnostic & Statistical Manual) or the ICD (International Classification of Diseases) emerges which takes a different set of views about which distressing thoughts, feelings, and ways of being should be accorded a clinical diagnosis, and which don’t. And you’re right - psychiatric diagnostic labelling has come to the fore in recent years so that it sometimes feels like the only way to make accommodations and adaptations, rather than a more nuanced, needs-based psychological approach which takes individuality into account. I’d love our society to be more accommodating of difference, helping people with their difficulties on the basis of their needs, rather than their diagnosis - which can never define someone’s complexity anyway.

The human brain hasn’t changed much (archaeologists tell us) in the past 300,000 years, but ideas of mental health and illness change all the time. Across the world different cultures take very different approaches, no less valid - we have diagnoses in the West that don’t exist in, say, East Asia, or sub-Saharan Africa, and vice versa. ‘Mediating’ is a good way of describing my job as a GP in the sense that for the more severely affected patients, I am often in the position of having to refer on to specialists, but for the majority of people whose problems are more on the mild to moderate end of the spectrum, I’m exploring with each patient what is going to be the best way to help them. So I regularly find two people with the same symptoms whereby one will benefit from formal diagnosis, and ask for it, while for another that doesn’t help them, and they’re not keen to pursue diagnosis at all.

This is sacred territory, people’s innermost feelings and anxieties, and it’s worthwhile proceeding with care and compassion - slip off your shoes before you enter! That conversation has to take into account the person’s own history, upbringing, ideas of what would be most helpful to them, and the way they approach big questions about the role and value of diagnosis itself, and what their problems are. The first ethical principle of medicine is ‘Do No Harm’ and there’s evidence that the wrong diagnostic label can do a great deal of harm - it can lock someone into a self-fulfilling expectation that is difficult to break free from. But in some cases, the right diagnosis can unlock a feeling of liberation and release from the guilt that accompanies so much mental ill-health. And it can unlock access to a community of others.

You ask how that role feels: and the answer is that it feels privileged, often challenging, but also very rewarding when you can help someone to a better understanding of what their symptoms might mean, and how they might make sense of them. When there’s time to do it, it’s such a wonderful job. Often the value of a GP is that they’ve seen so many others go through similar problems and can offer the reassurance that things can and will get better. One of the chapters in the book is about low mood, and towards the end I quote Robert Burton, who wrote a long book about depression in the 1600s (The Anatomy of Melancholy) - and concluded “be not solitary, be not idle; happy ones, be cautious, unhappy ones, have hope.” That hope is often one of the most powerful elements in the room during these kinds of conversations.

Katherine: What strikes me is that we want so much from doctors when we’re in these situations - but they can only offer some of the answers. I’m thinking about my own experience here. When I went to my GP to explore the possibility that I was autistic (nearly 10 years ago now), I thought I wanted a diagnosis. But by the time the process was complete, I realised that the external diagnosis was almost irrelevant. Yes, it mattered when my GP listened to me, and agreed that it might well be the case; and that the psychiatrist agreed too (although I knew far more about autism in women than he did). The label meant a lot to me, but it was just a starting-point. The biggest change was my own identification and what I did with it - finding my peers, working out how to live my life differently, addressing my own behaviour and assumptions.

I wonder if we’ve lost something in the past few decades as our psychological knowledge has grown - a more ecological sense of ourselves, embedded in a broader society. We focus on medical diagnosis because it’s the only part of the picture that we can access.

Gavin: Yes - I liked what you said about the diagnosis becoming almost irrelevant - almost like it’s a way to think about thinking, which has a time-limited purpose. I quote John Berger in the book, who wrote “Maybe labels are useful early in the morning of a work – when the pile to be shifted seems as high as a little mountain – but by noon the labels should have been discarded.”.

There’s a wisdom in that. It’s also true that our society is highly medicalised in lots of ways, and so it’s natural for us to turn to medicine. That medicalisation has its roots, I suspect, in the phenomenal success of medicine in some realms of human suffering since the 1950s. Through that decade and through the 1960s medicine came up with amazing new antibiotics, chemotherapies, steroids, inhalers, and drugs that can affect mood. And so we began as a society to expect quite amazing things of medicine, and expect it to have the answers even in situations when it doesn’t have either the evidence base or the track record of success.

Medicine can be tremendously successful at breaking things down into parts and figuring out the mechanics of different elements of the body - just look at the transformation of cardiology in the last 30-40 years, and the survival rates from heart attacks and heart disease which have just gone up and up. Or chronic lung disease, with a wonderful array now of complex inhalers and immune modulating drugs that we have access to now, to help the lungs stay open and breathe.

But psychology and mental health are fundamentally different, in the sense that it’s far less straightforward to break down its elements into smaller parts in exactly the way you describe. Mental health requires, as you say, an ‘ecological sense of ourselves, embedded in broader society’. One of the aspects of this I focus on in the book is the huge influence our childhood experiences can have over the long arc of a life, in terms of how we built our sense of the safety and danger, how we learned from those around us to regulate the intensity of our emotional responses, how we learned who to trust and who to be wary of. A lot of that comes through the relationships with the adults who are supposed to take care of us, but caregiving relationships extend and get more elaborate and complex through our lives.

There’s so much to say on this, but I think the last element I’ll focus on is that as a society we’ve developed an overreliance on the idea of breaking things down into categories. That’s something I often see in the DSM and in the expectations of people who come to my clinic - they sometimes wonder which category of feeling their own feelings slot into, which can lose a lot of the subtlety of their individual circumstances and often impressive creative resilience. Broadly, those categories can be helpful, but narrowly they’re much less so, and it’s often far more helpful to think of mental experience in terms of dimensions rather than categories. Most traits that influence our mental health have at their core a tendency that in a different context, or more measured dose, can contribute to our mental wellbeing rather than detract from it.

Autism and ADHD are often mentioned in this context, and for many patients I see their autistic traits or attentional difficulties bring other compensations and even blessings in their life - which isn’t to detract from the suffering brought by them too. But this idea applies to other dimensions of mental experience too. The elation and disinhibition of mania, when not running out of control, can bring benefits both personal and to the community; a little anxiety is necessary to keep us safe; even psychosis hints at our human ability to creatively reinterpret reality and draw connections between disparate ideas and experiences; at the core of depression lies the conviction that life should feel better than it does. The issue in these problems is not the tendency per se, but the dimension of it, the context, the intensity, severity and the impact of them. Health means ‘wholeness’ and that sense of being complete can look and feel very different for different people.

Katherine: How to be whole is the great question of our age! I started my morning by reading the news (war, the manosphere, racist violence, children being recruited as brand ambassadors for cosmetics companies…) and it strikes me that all of these issues are related to our sense of wholeness. There is so little urging us toward balance or equilibrium, or to place our needs in the context of a wider community. Our conversation has made me think that our relationship with medicine is often quite childlike: “Grownup, make me better!” Do you think there’s a pathway back to a view of health that’s based on wholeness? How can we integrate all those incredible medical advances that made our doctors seem so god-like (and therefore so disappointing when they couldn’t meet all our needs), and still seek other means of feeling well?

Gavin: How to feel more whole? What a great question! You’re right in that medicine is only a small part of the story, though our society increasingly turns to medicine for all sorts of things that it’s ill-fitted to respond to. Illness does return us to childhood in a sense, in that it places us in a position of vulnerability and need which for many is an experience most associated with childhood. It’s hard to take charge of our own autonomy when we feel frightened, disorientated, or in pain - which is why it’s so easy for doctor-patient relationships to become paternalistic or maternalistic. Which isn’t always a bad thing, as long as it’s temporary.

It’s reassuring to me that psychology and psychiatry are increasingly realising the importance of context, community, life experiences, lived experience, in understanding distress and mental suffering, rather than focussing only on brain chemistry and ‘wiring’ - which can only ever be a small part of the story. In the book I write that if I had one ambition for the 21st century it would be that we human beings “become more tolerant of uncertainty, more comfortable with paradox, more compassionate and open-hearted about the fuzzy edges of the categories we try to impose on the world”, and that ambition seems relevant to your question. Wholeness, or Health, can mean something very different for different people depending on their own story and circumstances, as well as at different ages in their lives eg. health for an 18 year old and an 80 year old are not the same thing. Our society is very idealising of youth and if you look at our media it’s far more likely to broadcast ideals of youth (and beauty) than ideals of wisdom.

Your suggestion of a greater focus on balance or equilibrium, community and wholeness, is another way of saying, I think, that we’d do well to place a greater emphasis on wisdom - which often means accepting imperfection. One of the wise figures I turn to in making sense of all this is the paediatrician and psychiatrist Donald Winnicott, who a few decades ago created a series of extraordinary books and broadcasts about parenting. He championed the idea of the ‘good enough parent’ - and insisted that aiming for perfection in your parenting is always going to lead to disappointment, and that what children need is to be loved, and for their parent to try to be ‘good enough’. And when I started out as a GP, fresh from hospital medicine, overwhelmed by the enormous variety of the medical and social problems that I was asked to address in 10-minute appointments, one of my mentors told me that I didn’t have to be superdoc, that I should aim to be a “good enough GP”

Humility about the limits of medicine, and compassion, and curiosity, are all elements of that approach. The ‘wounded healer’ is a very old idea that seems worth remembering - that if we allow ourselves to see our doctors and clinicians as less than perfect, as struggling with their own doubts and difficulties, we open up the possibility of a better and even more effective relationship with them, and with medicine.

Thank you for your questions, I’ve loved thinking around these ideas and I hope it can be the beginning of a longer conversation.

Katherine: Thank you so much, Gavin!