Gilbert Farie, (pronounced fairy) you will not have heard of, for he is a forgotten village Pharmacist who practiced back in Victorian days. Gilbert Farie was the dwarf pharmacist, hunched, red cheeked and monocular in vision, who each day dispensed from his pharmacy the cough medication for the boy who was Robert Louis Stevenson.
Gilbert Farie could sell anything, and literally did. He monopolized the Spa town of Bridge of Allan, made a fortune and married an heiress. He was widely unpopular as his only pursuit was of self advancement. No wonder he crept into the nightmares of young Robert Louis Stevenson. By now, you will have gathered, that Gilbert Farie was the counter of Dr Jekyll. Yes, Gilbert Farie was Mr Hyde.
Our family shares no DNA, not even one helical twist with Gilbert Farie. You may conclude then that the following chapter is a forensic anomaly amidst a collection of family stories.
Today, Gilbert Farie’s pharmacy still runs, and with an interior that is largely unchanged, still dispenses to our family. Through Gilbert Farie’s window it is possible to capture the passage of time and perhaps also the narratives collected here. It is of course a glimpse captured through one window only.
This chapter will stumble into a philosophical world of mental suffering. To give some sure-footedness to such faltering steps I have taken liberty in employing the writings of Robert Louis Stevenson. In my revisits to Gilbert Farie’s pharmacy I will offer ten reconsiderations: each carried by the title of one of the works of Robert Louis Stevenson.
A couple of general reminders should be made. First you will recall that my older sister is called Catriona and she has suffered more than her fair share of mental suffering. The second reminder is that Gilbert Farie (the pharmacist) lived with Dr John Stewart Rutherfoord our first village doctor (and my forebear of many generations back) one of the resurrectionists that provided bodies in Edinburgh for the anatomist Dr Robert Knox.
I offer here ten considerations made in my revisits to the pharmacy that once belonged to Gilbert Farie. A pharmacy still busy dispensing to our village.
- The strange case of Dr Jekyll and Mr Hyde – considers extreme or polar views
- Catriona – considers what psychiatrists still term the ‘subjective-objective’ divide
- Kidnapped –asks if the humanities have capitulated to our biology?
- The body snatcher – considers Darwin, ourselves and medical understanding
- The wrong box – looks at a world as if minds are disembodied
- The suicide club – considers medicalization beyond Ivan Illich
- An inland voyage – suggests that cognition matters: as much as matter itself
- Memories and portraits – considers biological ageing
- A child’s garden of verses – looks at how the world ‘sees’
- Treasure island – where we find reason not gold.
(1) The Strange Case of Dr Jekyll and Mr Hyde: considers extreme or polar views
My earliest memory is the vantage I had from my princess pram: peering out from the merimo hood I could see above the Buckstone pharmacy a large gold pot pulled-in at the waist. Just above was the gold handle of a golden pestle for a golden mortar. For the last 40 years I have tried to spot such surviving symbols of the alchemist. Certainly they are now rare unlike the need for remedies which are not. In a way the golden mortar and pestle have come to represent to me misunderstanding. You see I thought the golden pot was a container of sweeties and I was baffled why it was kept well out of my reach! Over time I have understood that this pram journey was the start of an exploration of the world in which I found myself. It took Gilbert Farie to reveal to me what was important and what was not.
One of our villagers, now deceased, wrote a poem about Gilbert Farie: he called it ‘There are furies’. As I shall explain, my fury is against Jekyll and Hyde thinking: polarised thinking that reaches to silly extreme. There are so many examples, and I shall explore some of them below.
C.P. Snow in his 1959 Rede Lecture at The University of Cambridge maintained that there was an unhealthy divide between the humanities and the sciences. Subsequently published as The Two Cultures and The Scientific Revolution Snow later commented ‘‘if you hit a nerve hard and get an instantaneous response from a large number of people in the world, then you must have said what a lot of people have been thinking.’’ For medicine this divide has had consequences as this chapter shall reveal. In more recent times Leon Eisenberg has suggested that what has ‘hampered progress is too narrow a view of the sciences’ relevant to medicine. The concepts and methods of the social sciences he argued must be integrated into medical education if doctors are to be enabled to respond effectively to illness as a human experience. I am reminded here of the Charles Dickens narrative, A Dinner at Poplar Walk. In this work both cousins are absurd but neither is wholly unsympathetic, and the drama bites, without villain or hero. Order and muddle are set against each other. This also returns to a concern that will probably always needs reconsideration: the classification of mental suffering.
I am as guilty as any other of what I term as ‘Jekyll and Hyde thinking’. Another doctor has helped me here and that is Professor Michael Rutter who recently suggested that we remember: “Progress in science – clinical science and basic science – has to come from questioning the given wisdom of the day and doing so in a style that builds constructively to a better understanding.” It is helpful here to return to philosophy, for in terms of a current medical understanding and the over-arching paradigm that is evidence-base, going at least by debates in all the major journals, we are beginning to realise that evidence base is necessary to progress our understanding but in itself it is not sufficient.
What should be obvious may not be and this returns us to Jekyll and Hyde thinking. With technological advance, it is understandable why mankind has chosen to view life through the paradigm of illness, when actually what we seek is health. Wholesome humanity must not today approach this back to front, or the result will bring harm. Extreme medicalisation runs the risk of causing harm: are one in four of us really mentally ill? Where do our definitions of illness stop? Where does ageing fit in? Might there be unforeseen consequences? And then, and it is usually the last consideration, what about stigma? These are but a few questions brought about by extreme thinking.
As a citizen of Scotland who was started on an antidepressant during the 1990’s “Defeat Depression Campaign.” I was interested that it was recently affirmed by a leading professor in psychopharmacology that as a result of this campaign “the quality of care has improved, and even suicide rates may have dropped as a consequence” However, Melissa Raven and Jon Jureidini presented both epidemiological and philosophical argument why we cannot yet be certain that antidepressants have reduced suicide rates. One General Practitioner’s experience of the Defeat Depression Campaign in Scotland was starkly different: “you will note the large rises in depression diagnosis in the young, rising quickly in the mid nineties, sustained for 7 years and then declining rapidly in 2003. I worked through out this period and anecdotally will tell you what happened. We were berated for under-diagnosing depression and so treated patients. After 5-6 years it was patently obvious that this wasn’t the case and we were over prescribing medication. We lost faith. We had simply medicalised normal reactive behaviour and denied young patients the opportunity to develop coping skills. This is what happened, I was there.”
Proportionality of understanding comes in words as well as numbers and this is another example. Numbers versus words; the quantitative and qualitative: here we all risk Jekyll and Hyde thinking. Let us return to that General Practitioner: “The number of antidepressants prescribed by the NHS in the United Kingdom almost doubled during one decade. There is no evidence that our mental health has improved over this time and plenty to say it hasn’t. I do not celebrate the ever increasing consumption of antidepressants but mourn the poverty of our thinking.”
This section is about extreme views. Paul Valery, and his Monsieur Teste was the embodiment of just such. Valery is mentioned here in terms of the extreme divide between science and the humanities. Paul Valéry French poet, essayist, and critic, ceased writing verse for twenty years to pursue scientific experiments. Throughout his life Valéry filled his private notebooks with observations on creative process and his own methods of inquiry. He insisted that the mental process of creation was alone important: the poems were a by-product of the effort. “Enthusiasm is not an artist’s state of mind“, stated Valéry. T.S. Eliot has compared Valéry’s analytical attitude to a scientist who works in a laboratory “weighing out or testing the drugs of which is compounded some medicine with an impressive name.”
Examples of Jekyll and Hyde thinking abound, such as the idea underlying modern neuroscience, that nerve impulses can journey towards a place where they become consciousness. I am with Dr Raymond Tallis that such is plain ‘barmy.’ Whilst I am less skeptical of neuroscience than Raymond Tallis, I agree with him in the frankly BOLD conclusions made from voxel colours on functional MRI experimentations: fMRI that separates brain from both the body and the world that the body lives in. There are good reasons for doubting one of the assumptions on which many fMRI studies are based: that neural mechanisms are always and everywhere sufficient for cognition. Mark Sprevak suggests that in the case of the mechanisms underlying psychiatric disorders, this assumption should be doubted. Mark Sprevak does not dispute that a malfunctioning neural mechanism is likely to be a necessary component of a psychiatric disorder. His question is whether a story only in terms of these neural mechanisms is sufficient to explain the mechanism of a psychiatric disorder.
One dramatist returns us directly to Jekyll and Hyde thinking and that is Stephen Poliakoff. He is a director who has acclaim, yet who has also been assailed for his obsession with the past. I must be honest; I feel an affinity with Poliakoff that perhaps rules out proper scrutiny. I was first brought to his work through Sian, my wife, after she recorded his 1999 production ‘Shooting the Past.’ I was captivated by the imagery, music and surreal characterization. The oddball archivist and custodian, Oswald, was metaphorical of my need to find meaning in the past. However, in subsequent productions, Poliakoff was to stick rigidly to a world of grand pretension with characters that were no longer surreal but unreal. However, it seems to me, Poliakoff should be charged with inconsistency rather than wholesale rebuke. Indeed, his critics are as badly polarised as his doe-eyed following. I would urge you to watch Poliakoff’s 2003 production ‘The Lost Prince,’ telling the heartbreaking story of the ‘monster boy’ Prince John. Through the detached eyes of the autistic and epileptic Prince, we see infact that it is the preposterous world around him that is the Monster. The vantage of the boy Prince, looking out from behind a half-opened door, reminds us of a Jekyll and Hyde world of divide.
Scientists and artists alike, in reading this, do not be too frustrated for we are all, by some degree or other, bound by Jekyll and Hyde thinking. Both scientists and artists like metaphor (in doubt? Read Richard Dawkins). I like the writings of a Scottish writer called Andrew Greig, in his book Electric Brae he posits: “I sit and watch our ship with two captains and no crew move hesitantly into the open sea.” In the Shipping News of Thursday 9th August 1866 we learn:
A bottle containing intelligence of the ill-fated Monarch of the Sea was found in the stake-nets on Burntisland Sands at two p.m. on Saturday last by Mr. James Baird, lessee of the salmon fishings. The message from the sea was as follows: “Ship Monarch of the Sea, from Liverpool to New York, sinking rapidly; no hope. – J.Jones, passenger, 2nd April, 1866.” The bottle is marked “Gilbert Farie, chemist, Bridge of Allan,” and the paper is a blank leaf torn from a pocket cash-book. The writing is in pencil, in a firm and practised hand.
(2) Catriona: considers what psychiatrists term the ‘subjective-objective’ divide
Recently I asked my wife Sian why I carried some anger towards the profession that I love and am honoured to be part of. I knew the answer but I was struggling to articulate it. The answer was Catriona, my older sister.
A professional colleague once told me that in talking about my sister my words ‘were wasted’ for doctors find ‘heart-on-sleeve’ words ‘uncomfortable’ and ‘inappropriate’ from a fellow ‘professional’.. So in this section I am not going to talk about my sister Catriona but you may get the impression that I am!
It was by magpie chance that I found a 150 year old news report about an extraordinary narrative where a young man of the name of Higgins, who, though ‘fully endowed with the power of speech’, would never speak to his father. I mention this as it is not as extraordinary as it sounds and because it reminds me that families function in the land and the hinterland of interactions. Dr Hoare, the ‘respectable surgeon’ looked hard at Higgins but was dumfounded as no medical cause could he find for the child’s specific aphasia. One conclusion, though obviously whiggish, may be made, is that perhaps Dr Hoare might have better spent some time looking at the formative relationships behind Higgins?
There is a writer today that has written on the subject of how we accommodate ourselves in the family. Dr Alan Rappoport’s paper is on what he calls ‘co-narcissism’ and it has, in my experience, bearing on many who grow into adulthood tussling to maintain mental health. Here we consider the world the adult-to-be has lived in: for example with parents who struggles to ‘see’ or ‘feel’ beyond themselves and as a result their child works harder to please, to defer opinion, and adjusts to fear being selfish or in fear of being assertive. Occasionally a narcissistic parent battles with a narcissistic child: the resulting tug-of-war can pull one or other over into a muddy pool of cess. Here we have Barclay’s elephant (see below).
When I employ the elephant in my films generally it is to suggest through symbolism what science can miss. Here I am generally talking about the world round about us, our interactions with one another and the passage of time that perhaps narrative gets closest to representing?
The elephant above was gifted to Dr Knox’s Anatomy museum thanks to Dr Barclay. However with Knox’s ‘notoriety’ the elephant disappeared. In our case the notoriety might be reductionist medical understanding.
In 2008, Dr Ben Goldacre published ‘Bad Science’ and it has since become a bestseller.
Two chapters in this book are worth considering when it comes to Catriona, my sister whom I am told by fellow professionals I should not talk about amongst them. The first is ‘How the media promotes the public misunderstanding of science.’ We are used to journalism that reduces the horrid reality of mental suffering, yet perhaps it is also true that many of us, when in trouble, seek simplified diagnostic understandings. There is a cost here (and I am not here referring to stigma) and that is by reducing too much of suffering to a diagnostic ‘entity’ risks reducing the very understanding of that suffering. Here I do think of my sister Catriona. The chapter in Bad Science that resonates here is where Ben Goldacre suggests reasons ‘why clever people believe stupid things.’ In terms of evidence-based research he argues that we: ‘tend to seek out confirmatory information on any given hypothesis.’ My sister rests in all this, and whilst I refuse to generalize her case I cannot help wondering if we seriously wish to ‘scientifically’ understand Catriona and her mental suffering that we need to include her journey from childhood and the world she has lived in.
Mental understanding it seems to me, is like the golfing metaphor Andrew Greig, gave us in his novel ‘In Another Light’: “The game you struggle with all your life, but never ever master, that will always humiliate.”
As a nine year old child my older sister was in hospital under the care of Dr Sula Wolff. Catriona had her ninth birthday party in hospital and her birthday was medicalised into (what I recall, but cannot easily put into words) as baboon-salavation-reward to ‘treat’ her extreme starvation. I do not recall Dr Sula Wolff and in mentioning her I am not substituting blame. I have however found it fascinating, that the same year that Catriona was hospitalized for her anorexia, Dr Sula Wolff wrote Children under stress. Such a title would suggest an insightful approach to children, formative relationships and the family world of interactions that surround the child. In my sister’s case such insight – and I am sure it was there – was fully distanced by the model of care that made Catriona the subject. If at the time I had been asked, and I was not, I would have replied like Peter Pan in this conversation with Wendy:
(3) Kidnapped: asks if the humanities have capitulated to our biology?
I would say that they have, at least through my window. I try hard to resist ‘Jekyll and Hyde thinking’. As a graduate of Science, and as a graduate of Art, I refuse to be disciplined by either! In July 1856 Mr Snape, the Medical Superintendent for Surrey Lunatic Asylum was prosecuted for the alleged manslaughter of a patient named Daniel Dolly. I see metaphor here. When considering Professor Snape, thanks to Harry Potter, we are today more familiar with the master of Hogwarts portrayed as an embodiment of all that is sinister, yet ultimately revealed special for his humanity.
This year is the bicentenary of the birth of Charles Dickens. It is worth considering what shaped his humanitarianism: “John Forster, who was the first to be told the whole story more than twenty years later, believed that it had given Dickens his exceptional determination and energy to ride over obstacles, with ‘a sense that everything was possible to the will that would make it so’, and also a cold, fierce aggression that burst out occasionally, quite at odds with his normal generosity and warmth” “. . . but if the experience did some damage it strengthened his character too.” It is hard not to identify with Pip in Great Expectations, for he survived so many childhood adversities and was damaged; yet despite this he managed to do good to those around him. But Pip was not glorified and we gradually appreciate that the best we can hope for him is to end his days with a measure of self-knowledge. Perhaps, in this way, Great Expectations is the truest of Charles Dickens novels?
Pessimistic biologism dovetails with other intellectual trends and it should be no wonder that this is the rallying call of many of today’s philosophers. Here I am with Raymond Tallis who has stated: “Fortunately, we don’t have to be either dishonest or muddled or self deceived to challenge the biologistic picture of humanity. Our questioning must begin with a critical look at the assumption that consciousness is identical with brain activity so that observations made by neuroscientists are casting light on the very nature of the human mind.” It occurs to me that there are so many ways of putting this, none of which deny our biological basis. A major feature of Western culture, and still gathering pace, has been how medicalised ways of thinking have come to dominate explanations for the vicissitudes of life, and the vocabulary of distress. The concept of a person now emphasises not resilience but vulnerability. This is a momentous shift that has no biological basis.
“A science of consciousness does seem to be rather like the famous ouroboros: a serpent that was able to swallow its own tail. Indeed, it would be a super-ouroboros that swallowed its entire body and the world that it inhabited, re-describing it as a model made out of nerve impulses.”
In the British Journal of Psychiatry of summer 1993, R.H. Cawley insisted that Psychiatry is ‘More Than a Science’: “I propose that psychiatry is an applied science and in addition something more. I believe the advances in its scientific content, over the last four decades, may have dazzled us into blindness, or at least made us inarticulate, about the dimension which does not fall within the boundaries of science. If that is true, the future of the subject is threatened by the neglect of one side of its foundations.” I am with those who say that history has revealed Dr Cawley to have had valid concern.
Let us reaffirm: this section asks if the humanities have capitulated to biology? Today we need only look at the deliberations over the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The fifth edition of this has been much delayed and the reasons for this will be explored.
However first we need to return to Victorian Scotland to meet Dr David Skae (1814-1873) the Superintendent of Edinburgh’s asylum for the insane. I discovered this springtime when I visited Dr Skae’s grave that his adoring students had carved on his tombstone: ‘How good, how kind and he is gone’ as. In July 1863 Dr Skae gave his keynote address to the British psychiatric establishment, it was entitled ‘A Rational and Practical Classification, of Insanity’ and in the introduction to his lecture he defined mental suffering as a “disease of the brain affecting the mind.”
Let us stop and consider: “a disease of the brain affecting the mind”: can such a classification be valid? At the time it was ridiculed by several of the leading psychiatrists of the day and in particular by Dr James Crichton-Browne. In death, Skae was not remembered in the way his students so wished, rather he was remembered for his classification as deemed misguided and false. Yet today, if one looks through the categories of diagnoses in either of the major classifications of mental disorders one finds that Skae’s premise has re-appeared as the authoritative one. Perhaps one day science will help us here but only if it considers our biological selves, our cognitions as understood through the world in which we live. This is the truth, the reality, of the humanities. I am with those who argue that neuroscience is trying to create a theory of everything that it simply isn’t qualified to offer. In short, I am terribly worried about reductionist explanations of human nature.
It is our very need to ease suffering that brings great passion to debate. Understanding requires that we must see the real world through more than our own window: today’s mental biologism is not enough: it is necessary but not sufficient. Equally quantitative evidence base is necessary but requires qualitative understanding.
“He knew there was a problem. But he also knew he could never explain his culture to her, nor why you could no more extract it than you could fillet the backbone and expect the fish to swim.”
(4) The Body Snatcher: considers Darwin, ourselves and medical understanding
Darwinitis is a frightful contagion that has spread beyond science to infect sociology, politics, literature, and more. Darwinitis has snatched our bodies and carried them back only to resurrect them in the Pleistocene age.Many academics today are convinced that Darwin’s science is a universal solvent that can sort out the most recalcitrant problems of society, consciousness, politics, literature, and more. They mislead themselves. Great philosophers are those who enable us to see the world differently. Mary Midgley, in her eighties, writes about subjects that are both complex and important. One of her targets has been the claims about human nature made by evolutionary biologists such as Richard Dawkins and EO Wilson. Her argument is simple that whilst an evolutionary appreciation is necessary for understanding our biology it is not sufficient.
Today there are devotees to Evolutionary Medicine, like Randolph Nesse, who demand that an evolutionary framework should be the ‘over-arching’ framework to our mental ‘architecture.’ I have discovered from my philosophical readings that I am not alone in dismissing this as Pangloss.
You will recall from chapter five that our first village doctor, and my genetic forebear, was a student of the monocular populist anatomist Dr Robert Knox. My forebear admitted to his daughter that along with medical student pals he had been a ‘Resurrectionist’ (a body snatcher) for Dr Knox. With the 1828 scandal of Burke and Hare he decided his best ploy on graduation was to leave Edinburgh behind and become a ship’s doctor. Only two years later, after the terrible hoo-ha had died down, and Burke had been executed, did my forebear dare return to Scotland. It was then that he returned home to our village where Gilbert Farie was soon to establish his pharmacy.
It is no wonder that I share Robert Louis Stevenson’s fascination with the body snatchers, and such curiosity brought me to seek out the lost ‘tounship’ of Carlindean, which lies on the gentle hills above Carnwath. Today any visible history of Carlindean isn’t even ‘ankle high’ yet it was here that Burke and Hare found employment for one autumn season. Burke and Hare lodged with a woman with a curved spine and then murdered her at Carlindean before they left. Dr Robert Knox, the Edinburgh Anatomist, had since his student days, a deep fascination with spinal curvature.
There is something most twisted about body snatching (Darwinitis). It strangles cultural life (our lives so lived) out of our bodies. Even Gilbert Farie understood this and he himself was an ankyloid kyphotic.
I recently wrote a piece on another village doctor who served generations of my family in the time of Darwin. Dr Daniel Rankin was a favourite eccentric in Carluke, a rural Scottish village, where he was regaled for his long flowing hair, massive torso and awkward but yet kindly temperament. He spent all his non-doctoring moments collecting fossils and supplied them to the HunterianMuseum and met with the ‘Bulldog’ but not Darwin himself. Anyway Dr Rankin used to wear a long coat, and for reason presumably only to shock, used to greet returning ‘heart-sink’ patients by standing on his head! This has left me wondering what his Pangloss coat revealed underneath: presumably a man living and shaped as much by his culture and family, as he was by the evolution that he helped understand.
The most important talent for a darwinian is to know where his subject stops.
(5) The Wrong Box: looks at a world as if minds are disembodied
This year, the northern lights, the aurora borealis, have been more spectacular than any other that I can remember. Mica, in the novel ‘In Another Light’ put this more prosaically with added observation of her own: “it happens quite a lot in winter,’ she said quietly. ‘Some things you can see properly only if you live away from the bright lights.” This section is going to talk about the bright lights of the voxel-based coloured-lit neo-phrenology of functional magnetic resonance imaging (fMRI). The wrong box may be the fMRI scanneror it may be, as I intend it here to be the cranium understood for the brain only, without body or the environment within which the person so lives.
Maurice Merleau-Ponty was a thinker steeped in neuroscience but able to resist capitulating to it. His view was that to be a conscious person we engage in complex relations with objects, and these relations depend on the whole human being, not simply on the brain: a disembodied brain could not be said to have conscious experiences of objects, but only to provide some of the necessary, but not sufficient conditions for the conscious experiences.
The science of Phrenology taught us you can read a person’s character from feeling the bumps on their skull. It was a dumb science that achieved greater public authentication than Darwin’s theory of evolution. Edinburgh, the Enlightenment capital of the world, was also capital of phrenology thanks to the brewer’s son Andrew Combe (1797-1847). Nobody did more for disinterment than Combe: skulls all over Scotland were dug up and examined for their bumps: even our greatest heid, Rabbie Burns, had his skull disinterred for this ‘science’. It is impossible to imagine that Burn’s skull could reveal more about him than his words.
Physicalism comes in ever so many guises: Londonderry August, 1898, “Photography as an aid in the diagnosis of insanity,” and today it comes in bright fMRI lights. Understanding the biological basis for ourselves is fine (I support the advance in imaging, and the science of this), but as Dr Saad Ghalib has quietly recommended: we need ‘physics to come to our rescue’ as not everything that is real has an appearance.
Raymond Tallis in his book ‘The Kingdom of Infinite Space’ managed the impossible, to study the head but avoiding discussing the brain! I go along with Tallis that science needs a “bit of corrective action” for we have indeed had too many headless brains. Perhaps we could teach the parrot that belonged to Dr Juvenal Urbino to voice this for mankind?
“He was a deplumed maniacal parrot who did not speak when asked to but only when was least expected, but then he did so with a clarity and rationality that were uncommon among human beings.”
(6) The Suicide Club: considers medicalization beyond Ivan Illich
‘This is not yesterday’ serves as one family exposé that DNA is over-rated in understanding. I write so boldly “because I was nearly dead once . . . and I’m trying to live with that I return to over-medicalization because I believe we have seen monumental changes in our approach to life and in ways that the sociologist Ivan Illich could never have predicted. I am careful in my writings not to blame medicalization per sae but cannot help myself considering the potential of unforeseen consequences that such an approach may have for society at large.
“Here’s your arsenic, dear.
And your weedkiller biscuit.
I’ve throttled your parakeet.”
Despite a lack of supporting evidence, the claim that one in four people will have a mental health problem at some point in their lives is a popular one. For journalists, quoting a high prevalence of mental disorder helps illustrate the newsworthiness of stories about mental health. It is important that people know that mental suffering is common and that our collective goal must be to reduce this, but it is not clear that championing a poorly supported prevalence figure is the way to achieve this.
Often today we are seduced by so many familiar assumptions: newer is better; widely used procedures are all proved; a registered drug must surely be a safe one. But perhaps the unhealthiest fallacy of all is the popular conviction that early detection is always for the best. A number of medical researchers are now suggesting that overdiagnosis is one of medicine’s biggest problems, causing millions of people to become patients unnecessarily, producing untold harm, and wasting vast amounts of resources.
I am naturally wary of wolves.
‘What is it. Peter?` she cried, running to him, thinking he was ill.
‘It isn`t that kind of pain` Peter replied darkly.
‘Then what kind is it‘?’
(7) An Inland Voyage: suggests that cognition matters: as much as matter itself
Daniel Dennett in the book where he did not explain consciousness famously said: “There is only one sort of stuff, namely matter – the physical stuff of physics, chemistry, and physiology – and the mind is somehow, nothing but a physical phenomenon. In short, the mind is the brain . . ..” Dennett does not shy away from expressing his wisdom as one of the ‘Bright’ club: and he will be pleased that he illuminates my brain coloured fMRI bright. I do however share Dennett’s naturalistic view in the sense that I see no need for mystical explanations. Where I differ is his neuroevolutionary view. Such a view lacks patient sense. In this section I will briefly try and explain why.
When Charles Dickens looked back on his early years, he remembered himself as a delicate and sometimes lonely child, unable to join the games of the local boys. As a result he later told his friend John Forster that “he grew used to watching, and being set apart from those watched.” I have no common ground with Charles Dickens other than this. As I have grown older I have learned to trust my observations and especially when I feel discomfort or dissonance with what is being offered as understanding, scientific or otherwise. In my sanctum sanctorum I try to express this in a creative way. I feel that it matters even if others do not.
“But no other room displayed the meticulous solemnity of the library, the sanctuary of Dr Urbino until old age carried him off”
In the year before he died the Nobel prize winning neurobiologist, Roger Sperry wrote a paper entitled “The impact and promise of the cognitive revolution.” His main argument was that he believed that a ‘cognitive revolution’ in psychology would lead the way among the sciences to a new and improved, more comprehensive, adequate, and valid conceptual foundation for scientific as well as for all causal explanation and understanding. Sperry felt that other (non-biological) disciplines, even physics, were beginning to agree and join in, discovering and adopting new less reductive a and emergent insights. Unfortunately in the twenty years that have passed since Sperry’s death the ‘hard sciences’ have rallied in the opposite physical direction. Indeed Peter would say that today we live in a world weighed down by mighty materialism.
In a recent head-to-head debate on the future of psychotherapies in the British Medical Journal I was struck by the degree of ‘Jekyll and Hyde thinking’ and left saddened given that nothing has helped me more in my life than in gaining cognitive insights. The sort of cognitive approach that I would espouse is: integrated with drug and other therapies; open to empirical investigation of efficacy and mechanism of action; teases out the ways in which social stress impacts on the developing psyche via difficulties in relationships; and helps clinicians understand the ways in which their decisions may be adversely influenced by forces of which they and their patients are unaware.
It was during a similar head-to-head debate celebrating George Bush’s ‘Decade of the Brain’ that Steven P.R. Rose said “Bridging the gap between biological and social psychiatry must be an aim for us all; but it cannot be done by retreating into entrenched positions, or by insisting that the social is subservient to the biological.”
Shortly before he died, Leon Eisenberg, author of ‘Mindlessness and brainlessness in psychiatry’wrote me a note of thanks. I had written to him that this, his 1986 paper, still held up today. In review of this current head-to-head Leon Eisenberg might have said that those against the argument were rather ‘mindless’. Let me rephrase this, in Gilbert Farie terms: ‘Jekyll and Hyde thinking’ has surely only served to damage the further understanding of biological and cognitive science.
“But as I keep saying you live your life forward and you understand it backward. I was slowly discovering things about myself. And one of the profound discoveries I did make, was that I on the whole prefer people to institutions and if rules get in the way of people I will break the rule. I am not recommending that to everyone . . . as it upset a lot of people.”
(8) Memories and Portraits: considers biological ageing
Our media daily deals with ageing but not necessarily in a way that best serves us. I suspect this is not the media’s fault but one of which we should all take collective ownership. As I have aged my views have changed but my self probably has not left behind the boy who observed a world from behind a half-closed door. Letters and narrative still move me in just the way they did when first read. I still treasure the letters of Maggie Boag who wrote as a 16 year old friend of my grandmother removed by three generations. This was 1830 and the fear of cholera was visceral: our village was in panic. In her letter’s Maggie voiced this with frightening innocence.
My favourite book, by a mile’s stretch, is Love in the time of cholera in which we are introduced to an old doctor and an unrequited love-affair. The doctor dies when he falls off a ladder whilst trying to retrieve his parrot from the courtyard tree. Just before he died Dr Juvenal Urbino contemplated his situation: “he had slowly discovered that even the oldest people were younger than he was and that he had become the only survivor of his generation’s legendary group portraits. But what disturbed him most was his lack of confidence in his own power of reason: little by little, as in an ineluctable shipwreck, he felt himself losing his good judgment . . . with no scientific basis except his own experience, Dr Juvenal Urbino knew that most fatal diseases had their own specific odour, but that none was as specific as old age.”
“Time passes. Listen.Time passes”
As I write, ‘compassion’ is in the news. The broadcaster announces that we have lost the time to do this and suggests that today’s solution is for us to be trained in this. I had sort of hoped that such a ‘cognitive revolution’ was a little less algorithmic? The news broadcast continues: “It is now well established that Scotland is facing a declining and ageing population. The ageing demographic in Scotland means that the current pathways of care are becoming unsustainable.” It is at this point, even and in spite of being a doctor for the elderly, that the language of this new plan, the ‘CHANGE PLAN’ loses me:. today it seems we have need for ‘metrics dashboard and scorecard allied to a system wide metrics, visual controls and benchmarking’. It is recommended that we ‘improve dementia care through synergies with Dementia Demonstrator Site’. To carry out the recommendation medical professionals were encouraged to ‘map and then redesign the pathway of care’ and complete ‘Staff training to embed the ethos of re-ablement.’
I was made aware of John Betjeman’s rallying call against unnecessary bureaucracy when I studied Landscape Architecture in Edinburgh. I have often had Betjeman walking through my films to remind us of silly talk. ‘The Planster’s Vision’ captures remarkably the sort of voice never before heard in a sonnet. This is the voice of a town planner anxious to erase the symbols of history and replant the landscape with a Maoist vision of collective banality. Betjeman fulminates against a dystopic future in which church bells are silenced by loudspeakers indoctrinating the masses until they have become brainwashed drones.
A colleague of mine, with whom I am to share a keynote address this October has suggested that we consider two hypothetical models of ageing. One is the model of a master clock (or indeed multiple clocks) inside the organism that gradually run down. As the clock advances, the organism ages. A natural thought to prolong life is to somehow slow down, or stop, the internal clock. An alternative model is based on an analogy with how elderly cars age. The thought is that small failures inside a car’s mechanism may, by themselves, be un-troubling, but these small failures get exacerbated by repeatedly coming into contact both with each other, other components of the car, and an uncooperative environment. The on-going interaction between these elements can grow what initially seem to be small failures in large and unexpected directions, and place them beyond the ability of a repair mechanism to fix. The malfunctioning here does not involve a single localisable internal failure, but is the result of any number of internal abnormalities that are supported by, and reinforced by, the feedback the car receives from its environment.
The fMRI dream of psychiatric imaging follows roughly the master-clock model. Psychiatric disorders are a matter of one (or more) neurological functional failures. The dream is that taxonomising, diagnosing, and treating the disorder can be done in terms of taxonomising, diagnosing, and treating the underlying neurological failures.
An embedded account of psychiatric disorders would follow roughly the elderly-car model. Psychiatric disorders may not have a single identifiable internal malfunction. Rather, they are the product of small, perhaps otherwise un-troubling, internal misfunctions, that jostling together, and being reinforced by an uncooperative environment, snowball, and contribute to wider breakdown.
Getting older is too often presented in an ageist way. As if the process of ageing, that we all face, is riddled and inherently diseased. The Mental Health Foundation recently commented on the negative language used in the general media regarding dementia. I have heard medical professionals refer to dementia as the ‘new cancer’ and indeed to state that they fear a diagnosis of dementia more than cancer itself. Mary Midgley, who as a philosopher she did not start publishing until she was fifty was recently interviewed:
“I wasn’t confident enough in what I might have said. I think it’s terribly hard that young academics are forced to publish all the time, whether they know what they want to say or not, and I think it often happens that people are rather slow to form opinions, but anyway it certainly did happen to me.”
When her interviewer asked if the experience of raising three children helped her mind, Midgey replied: “Greatly, yes indeed, they’re very educative things, our children.”
(9) A Child’s Garden of Verses: looks at how the world ‘sees’
To some extent or other we all compete with one another in our vision of the world that surrounds us.
There are windows in every moment of all 7 billion of us. My own window, I keep trying to clear dust and dirt from, but through it I see a special world that faces all sorts of challenges. I am not interested in celebrity or power but I am interested in improving our collective understanding and here my endeavour will stop only on my death. As a child I did not have a voice. I guess this is why as a boy who has grown into a man, who tries to bridge the sciences and humanities, I have turned to more expressive art-forms such as film-making, story telling and garden poetry.
“Poems appeal to the engineer in me – such great size to power output ratio, wondrous wee gleaming machines, the best of them inexhaustible.”
Like most film-makers I employ symbolism in my films, and this section gives me an opportunity to explain such symbols most briefly.
Wolves I use to represent medicalisation. I must stress here that I do not blame Dr Sula Wolff for my sister’s problems; however I do think the strict medical approach that focused only on Catriona made matters worse for Catriona, her parents and siblings.
Elephants are used in my films to suggest what might be missed by science. Principally here I consider the world of interactions that shapes us, and our social and cultural worlds which are too easily ousted from much of scientific endeavour.
The teddy bear is called Hale Bopp. He was bought for Andrew on the day of his birth. The teddy bear represents the intrinsic brightness of my children in the world. My family make my world the wonder that it is.
The multi-headed Hydra monster is used for stigma. I guess we have all faced stigma in our lives! Chop off one head of the Hydra monster and another grows. It is not the simple case that giving a ‘diagnosis’ reduces stigma. Research in its beginning supports my ‘feeling’ that such is fallacy.
Recently, a film of mine caused a stir because it approached a subject that has troubled me as a doctor. I find the idea that doctors should not be free to say things which some people may find uncomfortable troubling. In issues like this I would chose Richard Smith, former Editor of the British Medical Journal as guide and mentor. Richard Smith had the maturity to see where the British Medical Journal had become moribund and so blew some fresh air into several areas of medical publishing, for example the obvious need perceived nowadays for ‘patient participation’. It saddens me to tell you that there is no similar patient participation with the Royal College of Psychiatry. Here, the listening profession is not listening! I am left wondering if this is why some eminent thinkers have talked about a lack of reality in today’s prevailing psychiatric determinism?. Is this the subjective-objective divide in action? Here we should return to Mary Midgley, who when asked if psychiatry as a profession had become ‘unrealistic,’ replied:
“Well, the hope of dealing with mental illness entirely by physical means, which psychiatrists have been very dedicated to. The idea that consciousness is just an epiphenomenon, something floating on the top. It’s obviously much easier and less disturbing to the people who have to do the work to think that there’s a physical process they have to carry out, and if they haven’t found the solution yet, they soon will and everything will be quite all right, than it is to have to enter imaginatively into the state of the people who are in trouble . . ”
(10) Treasure Island: where we find reason not gold.
As a trustee of Mavisbank House I have come to appreciate the optimism of the 18th century Enlightenment which consisted in a belief in reason, science, universal moral ideas, and human progress. Today we have lost some of this roundedness and C.P Snow was correct to draw our attention to the divide that has opened between science and the humanities. Fortunately however my belief is that we practise continually an almost unconscious revision.
Nevertheless, quite a fundamental shift of stance that is required here and I am one of those increasing number who insist that it is time for philosophy to reassume its fundamental duty: to look critically at the conceptual framework and presuppositions within which contemporary thought operates.
“Amazing the difference a wee shift of stance makes.”
The dominant myths of science are atomism (the view that the world is divisible into basic units), reductionism (the view that the world is only properly understood in terms of these basic units), and materialism (the view that the world is both ultimately analysable in terms of physical science and that there is no spiritual, i.e., non-physical aspect to reality). Mary Midgley argues that these guiding principles, are “either derived from or greatly supported by powerful metaphors that are not themselves the result of scientific investigation but are, rather, metaphysical presuppositions.” I am not sure that I am prepared to generalize to this degree but I do think that to accept science as the last word on the mind is to overlook that which made science possible: the mind itself.
I have quoted Andrew Greig and his philosophy (of narrative) several times already, but this thought of Dr Alexander Mackay in the novel In Another Light made me laugh out loud: “Sandy considers it, as he has often, though he doesn’t believe in anything so irrational as luck. There are reasons for everything, though some are pretty damn mysterious.” The discovery of penicillin by Fleming illustrates Pasteur’s dictum that chance enters only the mind that is prepared. Many people, including Pasteur himself, must have seen their culture plates contaminated by moulds, but only Fleming saw the significance of the sterile ring surrounding the spot of contamination.
“. . . the only affinity between the two was their addiction to chess understood as a dialogue of reason and not as a science.”
To consider science as a whole it is crucial to gather all available evidence-base, but also not to dismiss a collective narrative less quantifiable. Medicine, as a branch of such a tree, should accept that numbers (that which is quantifiable) and words (the qualitative) are equal forms of measurement. It is disappointing that we need reminding of this essential evidence and that the individual story risks being lost in pursuit of ever greater denominators.
In a rather fine essay that summarized the evolution of modern therapeutics Langdon-Brown reminisced about his time as a medical registrar at Bart’s where the post-mortem book was still labelled “Register of Complete Cases.” In a sense this is the end-pont of reductionism where you have no complete case until post-mortem! Perhaps here we should remind ourselves of the first book of Plato’s Republic, where Socrates avers that: “Medicine does not consider the interests of medicine, but the interests of the patient.”
It is time to close this chapter. I have given you ten considerations that will always need reconsideration. Think of me giving more thought to them as I revisit Gilbert Farie.
“Even when he did find the right path, there was still a long way to go before he could hope to establish himself professionally. But his pursuit of various goals was so energetic, and he demonstrated such an ability to do so many different things at once, and fast, that even his search for a career had an aspect of genius.”
Before closing one interviewer asked Mary Midgley why she used the word imagination so much in her writing and why she gave it so much weight. Midgley replied: “Coleridge and Wordsworth got this right for us, didn’t they? They said there’s a fancy, which is just for fun, and the imagination which works. It is the form in which our feelings go through to our thoughts by recollection – emotion recollected in tranquillity. You can’t, as it were, use raw feeling directly. It’s got to be processed and brought into relation with the rest of your life and made into thought and then it will come out.”
 Eisenberg, Leon. Science in Medicine: Too Much or Too Little and Too Limited in Scope?
 Rutter, Michael. Challenging psychiatry. Interviewed by Mathew Billingsley. BMJ Careers. 9th February 2011
 Isacsson, Göran, & Rich, Charles (For) Jureidini, Jon & Raven, Melissa (Against). IN DEBATE: The increased use of
antidepressants has contributed to the worldwide reduction in suicide The British Journal of Psychiatry (2010) 196: 429-433.
 The primary form of fMRI uses the blood-oxygen-level-dependent (BOLD) contrast
 6 Sprevak, Mark. Neural suffciency, reductionism, and cognitive neuropsychiatry. Commentary on ‘Conceptual challenges
in the neuroimaging of psychiatric disorders’
 Gordon, P. Personal comment: It is worth emphasising that I am not saying that brain malfunction does not play an essential role in mental illness, or that fMRI cannot enhance our understanding the mechanisms of mental illness. My claim is that fMRI may only be part of the story by uncovering the brain-side mechanisms involved in mental illness
 Personal comment. I mention this uneasily, but do so as I am serious about stigma
 Goldacre, Ben. Bad Science. Fourth Estate (Oct 2008)
 Tallis, R. Aping Mankind. Page 341
 Greig, Andrew. In another light, page 254
 Gordon, Peter “I am a ‘good Darwinian,’ an atheist, and I am utterly persuaded by Darwin’s accounts of our origins at a biological level”
 Brockman, John. Beyond the scientific revolution: The Third Culture. 1st Touchstone Ed edition. May 1996
 Dobbs, David: “fMRI scanning overlooks the networked or distributed nature of the brain’s workings, emphasising localized activity when it is communication among regions that is most critical to mental function.”
 Mathews, Eric. The philosophy of Merleau-Ponty
 Vul et al. Puzzlingly High Correlations in fMRI Studies
 Márquez, Gabriel García. Love in the Time of Cholera Page 22:
 Greig, Andrew. ‘In Another Light’ Page 357
 Thomas, D. Under Milk Wood
 BMJ, Medicine and the media. “One in four” with a mental health problem: the anatomy of a statistic. Published 22 February 2012. BMJ2012;344:e1302
 Moynihan, R. Overdiagnosis and the dangers of early detection Published 23 February 2011. BMJ2011;342:d1140
 Dennett, D. Consciousness Explained, 33.
 This was the name Walter Scott gave to the study of The Antiquary
 Márquez, G.G. Love in the Time of Cholera, page 21
 Sperry, R. The impact and promise of the cognitive revolution. American Psychologist. August 1993
 Does psychoanalysis have a valuable place in modern mental health services? Published 20th February 2012 BMJ2012;344:e1211
 Eisenberg, L. Mindlessnessand brainlessness in psychiatry. British Journal of Psychiatry. 1986
 Holloway, R. Quote by him on BBC Radio Scotland. March 2012
 Thomas, Dylan Lord Cut-Glass in Under Milk Wood
 The Scottish Government. The Change Plan. 2012
 Sprevak, M. Neural sufficiency, reductionism, and cognitive neuropsychiatry: Commentary on Conceptual challenges in the neuroimaging of psychiatric disorders. Philosophy, Psychiatry & Psychology
 Williamson T. ‘Living Death’ Mental Health foundation 16 Feb 2012
 Greig, Andrew. In Another Light. Page 84
 B Rüscha, Nicolas et al. Biogenetic models of psychopathology, implicit guilt and mental illness stigma. Psychiatry Research 179 (May 2010) 328-323
 Greig, A. Electric Brae. Page 6
 Greig, A. In Another Light. Page 71
 Márquez, G. G. Love in the Time of Cholera Dr Juvenal Urbino and Jeremiah de Saint-Amour play chess
 Langdon-Brown, W. The evolution of modern therapeutics January 1945
 Tomalin, C. A quote about Charles Dickens. Page 50. A Life.
Films about Gilbert Farie:
[to play these films please click on the associated image]