I learned of Lawlor’s book in an engaging essay in a recent issue of The New Yorker. She is Henry Waldgrave Stuart Professor of Philosophy at Stanford University. The review was intriguing and a book only 213 pages long sounded plausible. I am here to confirm that it is a beautifully written book, one that does not pull punches and that does not hide behind academic terminology. It is of the moment and I hope it gets wide circulation and readership.

Let me explain why. The force driving Lawlor’s book is to analyze the relationship between rational and reasonable thinking and to make the case for restoring value and prestige to the second cognitive style. Lawlor addresses the difference in multiple contexts – in law, in personal identity, and social values. Rational man has had several names including Homo economicus and has been studied in clever models such as the response to the Prisoner’s Dilemma (read the book for details). She points out that greater emphasis was traditionally placed on being rational, namely, making intellectually valid decisions about ourselves and the world around us. Reasonableness was dismissed as a lesser virtue, one that was poorly defined and incapable of promoting good behavior.

The book is rich in stories. Lawlor starts the book with a court case that occurred in Louisiana in 1992. A 16-year old Japanese exchange student was invited to a Halloween party but unfortunately went to the wrong house. After a confused and ominous exchange with the owner, even though the student started walking away from the door, the owner of the house became anxious for his safety and well-being and fatally shot the student. A criminal jury acquitted the homeowner and considered the shooting a reasonable response to a perceived threat to life. A driver in Ohio is issued a summons for exceeding 85 miles per hour in his vehicle, above the reasonable limit. Governor Pataki and Mayor Guliani argued whether it was reasonable for the mayor to violate the standing law and run again as a candidate for another time after the September 11^th attack.

Lawlor’s book begins with the standard view, namely that a rational person is “logical, smart, and unemotional” while a reasonable person is “honest, kind, and fair.” But her central thesis is that this characterization overstates the value of rationality and misrepresents the importance of reasonableness to meaningful interpersonal interactions and the stable function of society. She assembles a wide selection of psychological data and real and theoretical circumstances to redefine the meaning of reasonableness and to identify its key components. She makes a compelling case that to be reasonable means to be sensitive to the needs and views of others, be willing to recalibrate one’s own view in response to the concerns of others, and to be willing to change your course of action if pressed by someone who thinks differently from you. These are not features that are generally invoked when describing a rational person and she makes the claim that this indicates that reasonableness is more important than rationality in grounding society.

The link to the current political environment is clear and acknowledged. Without mentioning any names, Lawlor vividly chronicles how loss of reasonableness is the underlying defining feature in our polarized argumentative world. The fact that political parties articulate programs that fail to account for the needs of the other and the inability to acknowledge any value to the views of others are signs of rampant unreasonableness. It is unclear whether reasonableness has a biological basis and whether it was favored by evolution. But anyone reading the news or monitoring the policy objectives of the current administration cannot escape the notion that reasonableness is a “misunderstood” and clearly undervalued virtue.

One gap in Lawlor’s narrative is medicine. She does not have a chapter on reasonableness in patient care. To me this is an area in need of attention. A case can be made that the movement towards evidence-based medicine is a move to incorporate more rationality into medical care. To be sure, incorporation of the patient voice and patient-related outcomes in the assessment of treatment efficacy is a sign of attention to the other and recognition of the need for reasonableness. But I fear that this information may be prone to quantitative analysis that undermines a genuine commitment to listen to the patient and treat that person on their own individual terms. Clinical research is urgently needed to learn whether exciting novel therapies are being utilized in a reasonable way, namely with genuine attention to the needs of the patient, a willingness to change the plan if the clinical course does not meet expectations, and a realization that medical care is just one component in the total scope of social wellbeing. That research team would be wise to include Lawlor as a consultant.

In closing, books often have an impact because they are read by a receptive reader at just the right moment time. In the beginning of May, I was on vacation with my wife. After a day biking and hiking, I accidentally fell and suffered a head injury. I lost consciousness for two days and needed to be hospitalized in an unfamiliar place for six days. On my return to New York, I was cared for by wonderful people and I think, or should I say I hope, that I am getting back to “normal.” But one thing was clear to me. I am not sure how I usually think and behave but over the last two months, I am sure I was not as reasonable as I should be. But one good and reasonable decision I made was to read this book. It has helped me appreciate what I lost and offered guidance about what I should pay attention to as I get back to myself. I cannot think of higher praise for any philosophy book.

Being Reasonable: The Case for a Misunderstood Virtue
Krista Lawlor
Harvard University Press, 2026. 213 pp 

Web image by Medhum.org.

Despite Virginia Woolf’s (12) famous proclamation that a “poverty of the language” exists in the description of illness, the most common form of pathographies is likely literature. Woolf’s essay On Being Ill argues that illness, compared to topics such as grief and love, remains rarely written into narratives due to the vocabulary itself. Yet, Carel’s work focuses on a more acute limitation. Language in books inherently offers limited bearing on temporality and pacing. While it is true that skilled authors can decide the pace of paragraphs, quickening tension with staccato and parataxis, the reader is ultimately given control regardless. As Roland Barthes (11) writes in The Pleasure of Text, “the author cannot predict tmesis: he cannot choose to write what will not be read.” In other words, the writer’s intentions matter little if a reader decides to skim over what they deem to be unimportant. Thus, the act of writing itself involves a willful relinquishment to the reader, and this act of surrender betrays a core tenet of the illness-experience: removal from control, particularly over time and space.

Video games complicate this dynamic, since some strip the very control Barthes describes back out of the player’s hands. Perhaps no game better exemplifies this removal of player control, especially over time, to depict illness than Before Your Eyes., released in 2021 by GoodbyeWorld Games. Before Your Eyes is not a typical video game. At no point does the player use their hands to control the game. Rather, the opening minutes require the player to set up an eye-tracking system, which lends itself to a simple conceit: with each blink in real life, once a metronome-object appears, time passes rapidly within the video game.

The first half of the game acts as a type of memory play. The main character, Benjamin, whose eyes the player inhabits, awaits judgment after death and must recount their life story to a mythical Ferryman to continue to the afterlife. The scenes begin playing out. Blink – Benjamin, as a baby, playing with rubber ducks. The scene plays out, then a metronome begins ticking down. Blink – watching parents argue about money. Blink – a piano recital. Blink – nervousness about talking to a crush. Evoking how memories work in real-life, each of these moments has a fleeting quality to them, as these scenes can only last if the player does not blink. Life goes by in a blink of an eye, literally.

While this perspective on memory alone makes Before Your Eyes an intriguing musing on memory, the second half of the game recontextualizes what comes before it in the context of medical humanities. As the scenes continue to play out, eventually Benjamin becomes a highly successful musician and artist, garnering worldwide acclaim. Yet, the story increasingly becomes fantastical, until it’s revealed that the story up to this point has been false. Rather, Benjamin died at 12 years old due to an unspecified terminal illness. The game plays out again; this time, the scenes are of Benjamin confined to his hospital bed. Blink – a growing illness. Blink – his parents visiting him at the hospital. Blink – dreaming of playing the piano. Blink – a fading interaction. In this second half, the scenes become ever more fleeting as the metronome signaling the scene is ready to pass appears more rapidly, triggering in the player a desire to avoid blinking. Often, before a moment can conclude, one blinks; time progresses, closer to death.

Before Your Eyes demonstrates the ability of other mediums, particularly video games, to use interactivity to disrupt typical temporality. This technique is not unique to Before Your Eyes by any means; the works of Samuel Beckett employ a similar technique of stripping audience control to simulate the constricted present Carel describes. For example, Beckett’s Not I (1972) features a disembodied mouth that delivers a fragmented monologue about past trauma at a pace too fast for an audience to fully process, let alone control. In video games, Red Dead Redemption 2’s protagonist, Arthur Morgan, develops tuberculosis over the game’s final chapters, which alters gameplay mechanics, including reducing stamina. As Marshall McLuhan famously argued, a medium’s structure shapes the way it delivers experience, independent of its content. Removing description of illness in favor of depicting its phenomenology, whether that is through Beckett’s compression of time or Red Dead Redemption 2’s diminishing of gameplay abilities, aims to cause the audience to experience illness. Before Your Eyes heightens both of these experiences, for time and space are tied to the player’s physical body, as occurs in sickness. In binding the passage of time to the player’s own involuntary blinking, the player’s body becomes a mechanism of failure. Thus, the player is made to inhabit Carel’s claim that illness is lived from within the body rather than observed from outside it. While literature can recapitulate the experience of symptoms, it cannot impose the conditions of it. Before Your Eyes suggests that the truest representation of illness may not be a representation at all, but an imposition of the phenomenological conditions of illness.

References:

Barthes, Roland. The Pleasure of the Text. Macmillan, 1975.

Carel, Havi. Phenomenology of Illness. Oxford University Press, 2016. Silverchair,
https://doi.org/10.1093/acprof:oso/9780199669653.001.0001.

McLuhan, Marshall. Understanding Media: The Extensions of Man. MIT press, 1994. Google Scholar,
https://scholar.google.com/scholar?cluster=4603169387763961023&hl=en&oi=scholarr.

Woolf, Virginia. “On Being Ill.” Family Business Review, vol. 6, no. 2, June 1993, pp. 199–201. SAGE Journals,
https://doi.org/10.1111/j.1741-6248.1993.00199.x.

Web image by medhum.org

The book became, unwittingly it seems, the first of a trilogy ultimately concerned with what conscious is and does. The second book, This is Your Mind on Plants (2021), extends Pollan’s project to three mind-altering compounds found in plants: opium, caffeine, and mescaline, and the third, A World Appears (2026), is his attempt to discern consciousness itself. Here I cover Pollan’s investigation into consciousness across the three books, the results of which frustrated him and required a reconciliation.

The Trips Begin

In How to Change Your Mind, Pollan gives a brief summary of the bumpy history of psychedelics. He recounts how the intense and well-supported interest in them as therapeutic agents during the 1950s was almost completely snuffed out in the 1960s when “a moral panic about LSD engulfed America, and virtually all psychedelic research and therapy were either halted or driven underground” (p. 185). The panic reached its apogee when counterculture movements and their leaders, among them Timothy Leary of “turn on, tune in, drop out” fame, were seen as threats to mainstream society in general. The few remaining embers, though, reignited in the 1990s and by 2006 serious interest in psychedelics revived and research into clinical use resumed through legal means. Structures were in place allowing psychedelic use for specific purposes, opening the way for Pollan’s investigation.

Pollan arranged three separate “trips,” one each for the psychedelics LSD, psilocybin, and 5-MeO-DMT (i.e., “The Toad”). He carefully chose a tour guide for each one. He came through these sessions with what he interpreted as a dissolution of his ego, which made more room for his consciousness: “I was present to reality but as something other than my self” (p. 264). After these experiences and interviews with many scientists, psychologists, counselors, and users, Pollan constructed an argument about how the altered consciousness states psychedelics produce can offer benefits to individuals who are healthy or sick, and to societies that are stable or fractious, by sending “a life or culture down a new path” (p. 407). He is inspiring, vague, and fantastical at times; he gets more so in his follow-up book, Your Mind on Plants.

There’s No Place Like Home

Pollan expands his investigation of consciousness-altering substances by marrying it with his passion for plants and gardening. Therefore, he need not look further than his kitchen and garden for sources serving his interest at this stage: opium (poppy), caffeine (coffee and tea), and mescaline (San Pedro cacti). He explained his rationale for choosing these three mind-altering agents:

Taken together, these three plant drugs cover much of the spectrum of the human experience of psychoactive substances, from the everyday use of caffeine, the most popular psychoactive drug on the planet; to the ceremonial use of mescaline by Indigenous peoples; to the age-old use of opiates to relieve pain. (p. 4)

Pollan received guidance and supervision for his trials of opium and mescaline. As a self-described “heavy caffeine user,” he withdrew from it by giving up coffee and tea, thinking he could make inferences about caffeine effects through reverse engineering the experience.

While Pollan describes the effects these three agents had on his consciousness, he went further morphing from his role as an investigative journalist into roles of historian and anthropologist. Pollan covers how opium, caffeine, and mescaline altered the consciousness of millions of people through the millennia, and in doing so, says they figure in world history and human development, often in rather breathtaking terms. Opium spurred “the Romantic revolution in poetry” (p. 31). “Caffeine was the perfect drug not only for the age of reason and the Enlightenment but for the rise of capitalism, too” (p. 119). “The sins of slavery and imperialism, in a global system of production…could only have been fueled by caffeine” (p. 138).

While he does not credit mescaline with having contributed to human progress in such grand scales, Pollan speaks of its power in healing the most devastating wounds. But insofar as affecting consciousness, for him, mescaline does “what all psychedelics do—not so much change how we feel inside as imbue the world around us with never-before-appreciated qualities” (p. 217).

Pollan may have imbibed too much caffeine while writing this book judging from some of the conclusions he makes, but it may have fueled his subsequent quest to understand just what consciousness is rather than just what it does to his mind and its impact on world history. What he found on this quest, or more appropriately, what he didn’t find, became the basis for his next book, A World Appears.

Pollan Trips into a Cave

If psychedelics and mind-altering plants can change consciousness, then, as Pollan surmises in describing his objective with A World Appears, “consciousness is, at its core, a material phenomenon…[or there is] at least some credence to the idea” (p. xx). So off he goes on more trips, this time to experts working on finding a discernible form of consciousness, a trip that in the end fails, but still produces some value towards the way we think about artificial intelligence.

Pollan’s trips takes him to four ports of call, or “four different dimensions of consciousness” (p. xxxi). His first stop is “sentience,” which refers to consciousness as where in living beings sensations are perceived and responses to them generated. The next stop is “feelings,” the awareness of biological phenomena, the communication link between the body and the mind, serving homeostasis, for example. “Thought” is Pollan’s third stop, accounting for “the stream of thoughts that all of us experience every waking moment” (p. xxxii). His trip ends at “self,” or the ’I’ that takes in all of our experiences.

Each trip constitutes a chapter comprising what is known about consciousness from a particular dimension. Pollan describes and evaluates them with the help of people involved in their development. Across the four dimensions, he consults or references a wide range of experts including among others: neuroscientists, physicists, biologists, philosophers, psychologists, screenwriters, novelists, poets, and Buddhists. He combs through their theories, constructs, data, analogies, stories, and metaphors. Pollan, nevertheless, comes up empty, and is “abashed to say I know less now than I did when, naively, I set out to unravel the mystery of consciousness” (p. 225). It took several days in a cave at a Buddhist retreat high in the mountains of New Mexico for Pollan to reconcile with this outcome, “to let go into not-knowing.” He wound up accepting consciousness “as less a scientific or philosophical puzzle to be solved and more as a practice…Consciousness is a miracle, truly, and remains the deepest of mysteries” (p. 239).

So be it, but what then are we to make of the artificial intelligence industries’ determined attempts to integrate or discern consciousness in their machines? Pollan might say they will need a miracle.

Citations:
Pollan M. How to Change Your Mind. Penguin Books; 2019. 464 pages
Pollan M. This Is Your Mind on Plants. Penguin Press; 2021. 288 pages
Pollan M. A World Appears: A Journey into Consciousness. Penguin Press; 2026. 320 pages

Links:
My blog post elaborating on Pollan’s How to Change Your Mind is here, and on Your Mind on Plants is here.

Along with cohost, Dan Albrant, here’s a link to our podcast episode in which we focus on: consciousness, spirituality, and mysticism as what is at work in the effects psychedelics produce, and how they may delineate limits to biomedicine (rational or not), that is, how they brighten or blur the line between classic biomedicine and whatever isn’t. 

Edited by Lucy Bruell.
Web Image: Cave Man, Tim Brown, CC BY 3.0 <https://creativecommons.org/licenses/by/3.0>, via Wikimedia Commons

The hand’s importance in daily activities is often overlooked even as I look down at my fingers typing these very words. Rudimentary at first glance, the expansive nature of the hand is as complicated as its anatomy and not in the palm reader sense. Its complexity manifests in the intricate duties it performs when acted upon by the user’s brain, and yet there is so much to learn by its simple examination in its resting splendor. The beautiful dichotomy of the hand is illustrated in the simple gesture of hand-holding, a parent’s single finger grasped in their infant’s small palm contrasted with the loose grip of the dying parent with their child. It is in the soft caress that hands are capable of, but also the solid fist of a hard punch, and the complexity of playing instruments, weaving, programming AI and painting.

My office visits begin and end with a post-COVID handshake if the patient is agreeable. The essential job of the clinician begins with listening followed by thorough examination. For it is in examination that the patient map unfurls. From the initial handshake, to how one holds their hands during the visit, little clues are imperceptibly directed at me. The wringing of the patients’ hands is the tip off for anxiety, along with tightly picked nails or scars. The slight hand tremor can be the giveaway of Parkinson’s disease, alcohol withdrawal or thyrotoxicosis. Then there is the yellow-stained thumb and index finger of the habitual smoker. The tiny muscle fasciculations below the skin are the tip off for advanced carpal tunnel syndrome, advanced neck arthritis, amyloidosis or the more devastating amyotrophic lateral sclerosis. The feel and look of the callus distribution on the palm of the construction worker as opposed to the soft and supple feel of the secretary’s palm or those of the computer programmer are all documented subconsciously, while noting the fissuring and hyperkeratotic papules and scale of the mechanic’s hand, or the similar changes on the non-mechanic’s hand suggesting dermatomyositis or anti-synthetase syndrome. Tell me how AI could perceive most of this without the input of touch and observation?

Whether in the office, grocery store or at dinner, examination proceeds whether the person is willing or not, or even aware. Examining the hand is like picking up an oak leaf in the fall with its midrib, venules and variegation all telling you about the health of the tree from which it has fallen. We won’t discuss ornaments that adorn the hands such as rings or nail paintings as this is quite illustrative in and of itself. Rather, I am more interested in scars, irregularities and deformities. Each small finger joint so intricate and important in function, working simultaneously together like the worker bees in a hive or an orchestra.

From the fingertip alone, Terry’s nail, with its loss of the crescent half-moon, ground glass white appearance, and the darker line at the very tip of the nail, suggests underlying liver issues. Move that line of demarcation proximally to affect half of the nail, it transitions into Lindsay’s nail and communicates underlying kidney dysfunction. Should that half-moon crescent change to a blue tinge or even completely change to blue, the patient may be being slowly poisoned by silver or copper. The pale nail bed alone is a tip-off for anemia. A murky longitudinal dark stain, like a comet and its tail tracing from the cuticle to the free nail edge, can be the forewarning of a melanoma. Smaller dark stripes distributed throughout the nail are the potential signs of endocarditis, lupus or vasculitis. Should the patients’ nails look like a pock-marked battlefield, the likelihood of psoriasis as a verdict is greater, especially if they are accompanied by joint aches or a reddish-silver raised skin rash. If the same patient did not choose to paint their nails yellow, and it spontaneously occurred, my pondering moves to lung pathology or autoimmune issues. Lastly, horizontal linear grooves on the nail, named after our friend Joseph Beau, tells me the patient is zinc deficient or enduring chemotherapy. While AI can certainly catalogue each of these physical exam signs and what they indicate, my examination can transpire on a soccer field, train or exam room and without the need for a computer.

Ascending from the fingertips, I look at the profile of the fingers. Do they keep their standard characteristic orientation, straight as an arrow or do they angle? Simply the direction of that angle can tell me so much, as the rearrangement of the interphalangeal joints offers countless clues. Should the patient get angry at all the meddling with his finger and point that finger at me, does his finger hyperextend backwards from the middle joint while the fingertip itself bends forward? Quickly I am carried pondside to see the swan neck of rheumatoid arthritis, lupus or scleroderma. However, should that fingertip hyperextend while the middle joint flexes, this represents the boutonniere deformity of injury or other connective tissue disorders. Moving from the quaint pondside to the opera house, I consider the shortened collapsing finger joints crumpling in a telescoping manner like an erstwhile opera-glass. This is the finger joint destruction of arthritis mutilans or advanced psoriatic arthritis. Now envision that same finger, fat and round like a sausage, and you have the less than delectable exemplar of dactylitis, which may be another sequelae of psoriatic arthritis, lupus or even tuberculosis.

Lest we forget the palm, it can serve as a mirror into superficial and deeper matters both physically and professionally. If there are a collection of cords slowly stealing a digit’s extension, you’ll find the fascial condensations of Dupuytren’s contracture. This patient has either had a long career of intense work with their hands or has been long afflicted with diabetes or may just have one more thing to thank a parent for. Should one of the fingers flex and become locked, trigger finger is now the diagnosis, although no marksmanship is required.

Both AI and I could go on for pages with the exam findings of the hand if necessary, particularly if we wanted to discuss congenital hand deformities or telltale characteristic findings on x-rays such as the appropriately named boxer’s fracture or the hand surgeon’s bane of the scaphoid given its peculiar blood supply. Oh, the many amusing mnemonics to remember the bones of the wrist can be quickly recited, both from AI and by the medical student! Ultimately, the power of observation is vital and a trusted companion of the doctor alone. The world is the clinician’s exam room and once one puts on these glasses and truly observes, it is hard to unsee the pathology vexing us humans. So, I say go forth and learn. Always start with a handshake as this key unlocks so much during the visit and then sit and watch. We physicians are a fortunate few beholden in full to our patients, who are granted access to this vast vocational milieu and this is what sets us apart from machines.

Web image by Medhum.org

New York, NY: W.W. Norton & Company
2026, 192 pages 
ISBN 9781324105695 

Your body speaks to you every moment of the day. In normal circumstances (good health), we hardly pay attention to those signals – the reassuring metronome-like steadiness of the radial pulse or the soft, regimented inhalations/expirations of respiration. But in bad times (illness and injury), we cannot ignore altered rhythms and abnormal emanations – the miserable throbbing of a migraine or wormlike twitching of the muscles of the hand. Megan O’Rourke, a poet and author of the superb memoir The Invisible Kingdom: Reimagining Chronic Illness (2022), has assembled a pensive and probing anthology of illness poetry that addresses altered states of the body. These 83 poems are organized into five sections: diagnosis, clinical encounters, caregiving, “metaphysical reckoning,” and recovery. A sense of betrayal by the body, shame, helplessness, isolation and loneliness, altered interpersonal relationships, and an inescapable confrontation with mortality are some common effects of illness expressed in these poems. Yet other poems communicate impressive fortitude, resiliency, revelation, receipt of compassion, and hope. Many notable writers are represented in the collection including Emily Dickinson, John Donne, Sylvia Plath, James Dickey, Gwendolyn Brooks, and William Blake. In “lumpectomy eve,” Lucille Clifton eerily depicts the difficult night before scheduled breast surgery where a fear of loss is just one of many emotions felt. Ted Kooser’s “The Urine Specimen” combines imagery and whimsy about the excreted waste product (“the heat of this gold your body’s melted and poured out into a form”) with a bit of scientific prophecy (“for the doctor, who in it will read your future, wringing his hands”). “A Story About the Body” by Robert Hass is a prose poem skillfully and sorrowfully addressing infatuation and imperfection. A single poem cannot reliably rescue us from sickness or other misfortunes, but the best of them are certainly capable of offering connection, illumination, and comfort. 

The Human Remains: Drawing Out Compassion in Medicine by Nathan A. Gray 

University Park, PA: Graphic Mundi (an imprint of Penn State University Press)
2026, 256 pages 
ISBN 9781637791059 

The experience of gross anatomy lab in the first year of medical school has a heavy, haunting presence in this graphic memoir of medical education. Employing primarily grayscale art technique, author and illustrator Nathan Gray (a palliative care physician) holds nothing back in this sometimes grim recollection of his training. He describes the required dissection of a cadaver as “dismantling a human body” (p10) and worries about fainting or vomiting. He has recurrent macabre dreams of dancing with the cadaver. Gray begins having doubts as to whether he even belongs in medical school. Fortunately for him, one member of his dissection team provides a well-needed dose of humor and bravado. In his second year of medical school, Gray gets married. His third year clinical rotations start with the surgery clerkship where feelings of insecurity, uselessness, and fear pester him. Yet Gray is emotionally and psychologically aided by receiving small acts of kindness, his sustained wonder of the human body, and a genuine interest in the patients he treats. Upon completing medical school, he enters an internal medicine residency noteworthy for a strenuous schedule with nights on call and some shifts spanning more than 30 hours in the hospital. He labels residency training as “a cruel matchup that pitted our own sanity and survival against the needs of the people we cared for” (p170). Gray chooses a palliative care fellowship where his compassion and joy for practicing medicine are reinvigorated thus completing the arc of his journey infused with the humanity and empathy he originally began medical school with. The Human Remains is the second graphic medical memoir (See One, Do One, Teach One by Grace Farris is the other.) published in 2026. Both are cautionary tales (albeit with “happy endings”) reminding us that medical trainees are at high risk of having the most important things that propel them to choose to become a physician – compassion and service to others – gradually eroded. 

“The News from Dublin” in The News from Dublin: Stories (pages 67-87) by Colm Tóibín 

New York, NY: Scribner
2026, 289 pages 
ISBN 9781476785141 
[The story was first published in New Irish Short Stories.] 

Maurice Webster, a teacher at a Catholic high school in Ireland, has good reason to worry about the condition of his youngest brother. Stephen has a severe case of highly infectious tuberculosis and is confined to home, (At the time this story takes place – prior to the wide availability of streptomycin in Europe around 1948 – there is no antibiotic treatment for TB.) Maurice is afraid to visit his brother and risk spreading TB to his wife and children. Reports surface of a promising new drug that can cure tuberculosis – Streptomycin. The antibiotic is almost impossible to obtain as it is still being tested and likely won’t be accessible for more than a year. Poor Stephen will not live long enough to receive the medication. Maurice travels to Dublin for a meeting with the minister of health in an attempt to procure Streptomycin for his brother. Although sympathetic, the health official says he is unable to help and recommends that Stephen be admitted to a sanatorium. A morose Maurice returns home understanding that Stephen and family were counting on him to retrieve the antibiotic. He has failed them. The only thing he has brought back from Dublin is bad news. With ever diminishing hope for his brother’s recovery, even a miracle seems out of the question. Maurice decides, “There had been enough prayers said, and they had made no difference” (p86). This compact, touching tale about the effect of serious illness on family members highlights their desperation and guilt, withering hope and reluctant resignation. 

Web photo by Wes Hicks

Five Little Peppers and How They Grew by Margaret Sidney is an early example from 1881. This book describes the daily life of the hardworking Pepper family and how they remain cheerful and loving despite challenges associated with 19^th century poverty. The Pepper family consists of widowed Mrs. Pepper or “Mamsie,” 11-year-old Ben who voluntarily takes on the mantle of “man of the house,” patient and selfless 10-year-old Polly, impulsive and food-loving 9-year-old Joel, gentle and conscientious 7-year-old Davie, and beloved baby of the family 3-year-old Phronsie.

Children’s literature during this era was heavily instructional and used relatable characters and stories to teach morals and values to young minds. Illness was rarely just a biological event; it was a test or demonstration of character. In a chapter aptly titled “Trouble for the Little Brown House,” the first challenge that the Pepper family faces is measles.

Notably, this book highlights the ophthalmologic symptoms and sequalae of measles, as first Phronsie, then Ben, Polly, and Joel all catch the infection. Common early symptoms of measles include conjunctivitis and photophobia, which occur before the obvious rash. Ben and Polly, the hardworking older siblings who earn money for the family by chopping wood and sewing respectively, are each in initial denial of infection because they understand the financial repercussions this will have on the family. But the historic reader understands the warning signs when Ben and Polly report visual complaints. Ben tries to reassure Polly by saying, “I’m all right; only my head aches, and my eyes feel funny,” alluding to the itchy and gritty sensation of conjunctivitis, before he becomes bedridden. The narrator describes Polly’s struggles more vividly, “An awful feeling made her clutch the back of a chair, but she managed somehow to get into her clothes, and go groping blindly into the kitchen. Somehow, Polly couldn’t see very well. She tried to set the table, but ‘twas no use.” Polly’s initial visual impairment can be attributed to severe photophobia, leading to blurry vision.

Modern day readers may not know that the measles virus can result in serious vision-threatening complications. It can cause deeper structural damage starting with keratitis – a painful inflammation or infection of the cornea, the clear front surface of the eye, which manifests as blurred vision and intense tearing. If keratitis is left untreated or a secondary bacterial infection occurs, corneal scarring can permanently impair vision. In rare instances, measles can also cause retinopathy and optic neuritis leading to blindness. The severity of eye damage from measles is heavily linked to nutrition. The virus actively depletes body stores of vitamin A. In low-income populations where vitamin A deficiency is already common, measles is more likely to cause permanent childhood blindness.

The Peppers live in poverty and hunger. Mrs. Pepper makes a meager income sewing “sacks and coats” for a local store and “had hard work to scrape together money enough to put bread into her children’s mouths, and to pay the rent of the little brown house.” There is never enough food to go around. Their main source of calories are coarse brown bread and unappetizing cornmeal mush, neither of which contain meaningful amounts of vitamin A. However, the generosity of the parson’s wife, Mrs. Henderson, helps protect some of the Peppers from blindness. Mrs. Henderson gives the Peppers “a little pat of butter,” which Phronsie and Ben put on their bread. Dairy, like milk and butter, is an excellent source of vitamin A. And later, Mrs. Henderson sends over “a little bird delicately roasted,” which Joel consumes with delight. Poultry and gamebirds are another good source of vitamin A.

However, selfless Polly saves the butter and bird for her siblings and ends up being most at risk for permanent vision loss. She develops very painful eyes, suggesting keratitis, and the doctor pronounces that “her eyes are very bad” and warns, “You will be blind!” if she doesn’t take care. Although the author attributes Polly’s illness severity to eye strain from sewing to earn money for the family, it is medically more likely due to vitamin deficiency. The therapeutic value of vitamin A in treating measles was not discovered until 1932 – 51 years after the publication of this book – when British physician Joseph B. Ellison found that administering vitamin A extracts roughly halved the death rate of hospitalized children suffering from measles [1]. Studies establishing the role of vitamin A in reducing blindness in children with measles did not occur until the 1980s [2,3].

Because moralizing 19^th century children’s literature rewards the virtuous, Polly ultimately makes a full recovery. However, reality is not so kind. Even today in the 21^st century, an estimated 15,000 to 60,000 children are blinded by measles every year globally [4]. The World Health Organization recommends that children in low income and developing regions diagnosed with measles receive immediate, high-dose oral vitamin A [5]. This simple, low-cost intervention protects the cornea and has successfully saved the eyesight of millions of infected children [6]. And, those who are vaccinated against measles are spared the risk and need for intervention completely.

[1] https://pubmed.ncbi.nlm.nih.gov/20777111/
[2] https://pubmed.ncbi.nlm.nih.gov/8486934/
[3] https://pubmed.ncbi.nlm.nih.gov/3492298/
[4] https://pubmed.ncbi.nlm.nih.gov/14998696/
[5] https://www.who.int/news-room/fact-sheets/detail/measles
[6] https://pubmed.ncbi.nlm.nih.gov/24407830/

Original Publication: The story was originally serialized in an 1880 edition of Wide Awake, a children’s magazine and later published in a hard cover edition.

Dover Publications, 2006. 224 pages

Web image by Medhum.org

The Sick Child

The sick child is thought to be the artist’s sister. She is not a child but rather a young girl who is lying down or seated, with a blanket over her lower body and she faces a woman who is seated beside her, clutching the child’s left hand. We cannot see the woman’s face – it is turned down as she is bent over in apparent grief. While the painting’s title names the girl as the subject of the painting, it is the grieving woman and her attention to the girl that is particularly striking.

Death and the Child

Death and the Child depicts the anguish of a child who has been confronted with the corpse of her mother lying in bed. The child faces the viewer, hands pressing against her ears – she cannot bear to “hear”/ absorb what she has encountered; her face has an expression of fear and despair

Death in the Sickroom

In Death in the Sickroom several adults are scattered about, some standing, one woman sitting in the foreground; behind her another woman stands facing us. In the back of the room a figure sits on a chair, a blanket draped over her lap – presumably this is Munch’s sister. With his back to the wall an elderly man has both hands pressed to his chest. These individuals have come to help and mourn but they are isolated from each other, which adds to the grimness of the scene.

Image credits: wiki commons

Painting with Empathy: The Expressionist Art of Edvard Munch with Curator Øystein Ustvedt

Russell Teagarden 12.28.23 1848

Edvard Munch’s emotional portrayal of illness and suffering offers profound insights for health professionals and…

Far less dramatic—not even in the same league, but disturbing in its own way—is the record of psychoanalysis during the Third Reich (psychoanalysts were not involved in the two programs mentioned above). Psychoanalysis, pejoratively referred to as “the Jewish science” by the Nazis, was of course created by Sigmund Freud in Vienna. One of the early and seminal centers of treatment, research, and training was the Berlin Psychoanalytic Institute, founded in 1923 (it grew out of the Psychoanalytic Polyclinic, a free clinic founded three years before) by Max Eitingon, who was the director. Many of the faculty, including Eitingon, were Jews; several were also socialists.

When the Nazis came to power in 1933, the Institute’s days were clearly numbered; not only because psychoanalysis was considered “Jewish” and so many psychoanalysts were Jewish, but also because its goals of individual growth, self-knowledge, and independence were directly antithetical to the mindset that a totalitarian government wanted to impose. Freud was now anathema, a new language of “Aryan” terms for analytic principles was devised, all Jews were purged, and the focus of psychoanalysis in Berlin shifted to the furthering of Nazi ideology: treating “war trauma” in soldiers and SS men, prioritization of and obedience to a totalitarian mindset, “reorienting” dissidents towards approved National Socialist thinking, conversion therapy as a treatment for homosexuality, and the like. The talking cure was to be weaponized for state purposes.

Seven months after Hitler seized power, Freud wrote to a colleague in England, “Berlin is lost…” Eitingon was forced to resign and fled Germany and was replaced by two Aryan analysts as co-directors. Three years later the Institute was subsumed into the German Institute for Research and Psychotherapy, known as “the Gӧring Institute,” with a new director, Matthias Gӧring, cousin of Reichsmarshall Hermann Gӧring.

The Institute’s excuse for collaborating with the regime was that it was the only way to “save” psychoanalysis and permit its survival; Freud himself had early on counseled accommodation as necessary to accomplish this end. What the Institute learned was that there is no accommodation short of full cooperation in a totalitarian state. But what was the toll of compromise on the men and women left in the Institute?

This was the history of psychoanalysis under the Nazis, which has been reviewed in a number of scholarly works¹. The novelist Stephen O’Connor has set himself a different task: to examine the life of a fictional non-Jewish German psychoanalyst as it played out against the background of Berlin and the Berlin Psychoanalytic Institute before and after the Nazi seizure of power in January 1933. His new novel, We Want So Much to Be Ourselves, follows its main character, Günter Zeitz, from his initial meeting with Sigmund Freud in 1924 through the years of the Third Reich and beyond. Günter will be our avatar, our surrogate participant through whose eyes we will watch things play out, during the heyday of psychoanalysis and through its suppression. However, the novel is not primarily about the destruction of German psychoanalysis, but about Gunter during the destruction of German psychoanalysis. Günter will be Exhibit 1 in the case for the acute and lingering effects of trauma.

As the novel opens we meet Günter corralling Freud on a street corner in Vienna and asking him to take him on for analytic training, which will consist largely of Günter’s personal analysis, and Freud agrees. In the doctor’s waiting room Günter meets another patient, Josine Rosen, a Jewish woman, and shortly thereafter they begin an affair. It becomes clear that Josine is troubled; she has already had a suicide attempt, and is subject to bouts of depression, but Günter is in love and within a year they marry and soon thereafter have a daughter, Hannah. Despite their ongoing disputes about some aspects of Freud’s “death force” theory, Freud recommends Günter for a position at the prestigious Berlin Psychoanalytic Institute, which he accepts. Over time, the course of true love does not exactly run smooth; Josine is unstable, and the National Socialists are increasing in power and presence in Germany, posing a problem for her as a Jew. Günter and Josine will separate and reunite several times and draw others into their story as their world descends into a very rigidly structured type of chaos. How they all navigate this personal and professional turmoil determines the rest of their lives.

Meanwhile, we listen in as the analysts at the Institute discuss the increasingly dangerous situation, and how to respond. They initially dismiss Hitler and his “gang of toothless throwbacks” (p. 127) as upstarts with no political base and no future (as does much of the German public) until 1933, when it becomes apparent that this is no longer the case. In 1936, after Matthias Gӧring assumes the directorship, new rules for psychoanalysis are introduced; complying with these changes is clearly the only way the Institute will be allowed to continue to function. Some analysts flee, some accommodate, and some join the resistance.

However, the novel is really Günter’s story. Günter is eminently likeable; he is a bright, engaged and engaging character pursuing his academic dream who genuinely wants to mitigate human suffering. We watch him grow from the sheltered son of a country doctor to a confident teacher and practitioner, and we watch him fall in love, repeatedly, almost as though he is “feeling his way” in this world of emotions. When the Institute is taken over and its direction changed Günter finds himself in a moral quandary: he is horrified by National Socialism but feels unable to do anything about it. Can there be a small degree of accommodation, to allow him to continue to help those who need help, or is accommodation a slippery slope which ends in a betrayal of self and principles? Silence or resistance? We watch with him as he tries to keep his professional life intact as his personal life begins to unravel. When he is forced to treat Dr. Gӧring’s nephew, an SS lieutenant recently returned from a murderous detail in the East, he reaches his personal Rubicon.

Günter is an everyman caught in the gears of a machine, and the kernel, the gist, of the novel, is a question: how does one go on living one’s life in a system gone mad, and what are our responsibilities to others and ourselves? How do you go to work and go home to your family, how do you love and hate and gossip and drink your coffee and read your newspaper and pick up your paycheck and go to a movie, when you are convinced that a great evil is being perpetrated, that you are told to be part of it, and that any false step on your part might bring that evil down upon you? When it is your country and your countrymen and your colleagues doing it? What is the personal cost, the cost to yourself, and to your self, when—if— you come out on the other side of the madness?

The other characters, and their interplay, are handled carefully and realistically. Josine is a large and critical part of the story. She is clearly—and sadly—damaged, and her behavior is too erratic for us to “like” her, although she engenders tremendous sympathy . She is a tragic figure and we feel for her, although this is not always easy. The student analyst Elke Weber, who becomes a critical participant in the story, is drawn realistically and sympathetically. Hannah will become important as a character in her own right later in the book. The other characters in the novel, including some of the historical figures, are drawn simply but cleanly and expressively; the reader feels that they know them, if only briefly.

We Want So Much to Be Ourselves is well-written, engaging, and suspenseful. O’Connor’s narrative successfully summons up both the atmosphere in the world of psychoanalysis in the 1920’s and Nazi-era Berlin’s anxiety and paranoia in the 1930’s. The reader who has some familiarity with the history of Weimar and Nazi-era Germany will note a rare factual slip², but nothing that is critical for plot development or that takes away from the pleasure of the reading experience; such are the pitfalls of writing historical fiction. When we reach the last hundred pages or so—the postwar years—the narrative tempo speeds up, and near the very end the novel becomes telescoped into a series of rapid-fire moments in the protagonists’ lives, seeming more an epilogue than a continuous part of the novel; this is the section that catalogues the aftermath. Life hobbles on, though one might wish for a more leisurely unwinding of the tale.

We Want So Much to Be Ourselves asks how a person of moral integrity can function in what the German philosopher and psychiatrist Karl Jaspers has called a Verbrecherstaat, a “criminal state”—not simply a state that occasionally commits crimes, but a state which has been transmuted entirely into a criminal enterprise—and what the price of that functioning, of complicity or resistance, might be. It portrays profoundly human characters who live through societal trauma, from which it is possible to emerge, but rarely to emerge unscathed, and emphasizes the role of connection for moving forward and healing. Importantly, it reminds us that patient care does not exist in a vacuum or a pure state, divorced from the society that surrounds it, and that when it is co-opted and weaponized by political considerations, things go very bad, very fast.

We Want So Much to Be Ourselves
Stephen O’Connor
Bellevue Literary Press, New York 2026: 496 pages
_______________________________________________________
¹The history is complicated…and contested; see Geoffrey Cocks’ “The devil and the details: psychoanalysis in the Third Reich,” in Psychoanalytic Review, 88 (2), 2001; Zvi Lothane, “The deal with the devil to “save” psychoanalysis in Nazi Germany” Psychoanalytic Review, 88(2), 2001; and Cocks’ review (in Psychoanalysis and History 3(2), 2001) of James and Eileen Goggin’s Death of a Jewish Science—Psychoanalysis in the Third Reich, among others. The Goggins feel that psychoanalysis was “destroyed” under the Nazis, while Cocks notes significant continuities in the discipline through this period, although his analysis includes psychoanalysis and psychotherapy.

²At one point one of the characters is said to have been arrested by the police and “…got off the train at Theresienstadt and went straight to the gas chamber…” (p. 425) While the person narrating this event is admittedly unsure that the prisoner went to the gas chamber, the fact is that they could not have; there were no gas chambers at Theresienstadt. In another example, a patient of the Berlin clinic is referred to as a “Leninist” who was a member of “the DKP.” The author is presumably referring here to the German Communist Party, known as the DKP, or Deutsche Kommunistiche Partei. However, the DKP was only founded in 1986. The Communist party in Germany during the Weimar Republic and (though it was rapidly outlawed) in the Third Reich was the KPD (Kommunistiche Partei Deutschlands).

Web image by Medhum.org based on the original book cover.

The diagnosis and clinical management of various mental disorders are aided by knowing the predisposing, precipitating, and perpetuating factors in a given case. Both the themed album and the full-length movie of Pink Floyd’s, The Wall, depict these factors in the course of the main character’s—”Pink’s”— mental health deterioration through music and film. In this episode, we draw from selected songs on the album and from selected scenes in the movie connecting the three factors with particular behaviors Pink manifests. In the process, we show how they are used in medical education and training in real time.

Joining us is Dr. Anthony Tobia, who is the campus chair in the Department of Psychiatry at the Rutgers School of Medicine and is also the Service Chief of Psychiatry at Robert Wood Johnson Barnabas Health in New Brunswick, NJ. Dr. Tobia is certified by the American Board of Psychiatry and Neurology and is certified in internal medicine and psychosomatic medicine. He also holds a secondary appointment in the Division of General Internal Medicine at Rutgers. Dr. Tobia is the Director of Graduate and Interprofessional Education at Rutgers University Behavioral Health and has received the Outstanding Clinical Faculty Member Excellence Award in 2018 and 2019. He is an active contributor to the medical literature with publications, reviews, and abstracts. Dr. Tobia’s educational interests include the merging of popular culture and the field of behavioral medicine, which is evident from this episode and from his previous appearance on the podcast episode featuring The Who’s Tommy. Along with Dr. Tobia for this episode is Kevin Frederiks, who at the time of recording, was a fourth-year medical student at Rutgers.

Citations
For the recorded album: Pink Floyd. The Wall. Columbia Records, 1979.
For the movie: Parker, Alan, director. Pink Floyd The Wall. MGM, 1982.

Link
Please send us comments, recommendations, and questions here, or email to: ru***************@***il.com.

Thanks to Dr. Anthony Tobia and (by now) Dr. Kevin Fredriks for their interesting and insightful contributions to this episode. 

Thanks for listening, and please subscribe to The Clinic & The Person wherever you get your podcasts.

Web image by Russel Teagarden

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Why did you write this book?

I’m encountering more and more people over the last few years, particularly post-COVID, who have the perception that the categories we use in psychiatry have a kind of fixed, objective, and quite rigid reality. Twenty years ago, when I started as a GP, I might have seen somebody who said, “I feel anxious all the time,” whereas now I’m more likely to meet somebody who’ll say, “Well, I have generalized anxiety disorder.” That’s a shift in the way that society talks about mental illness. At the same time, a lot of people are questioning these categories’ usefulness, so there’s a paradox—a sort of polarization.

I wanted to write a book which explains, from my perspective, A, how the way we think about mental illness has always been shifting and evolving. How we think about mental illness changes with culture, time, and geography. And B, if we can adopt a more flexible and humble approach to our current understanding, that actually offers more hope to patients. Because believing “I have generalized anxiety disorder,” rather than “I feel anxious,” can sometimes be helpful, but it can also box you in and become self-fulfilled. I’m seeing that same shift across the whole spectrum of mental illness and suffering, and the book is a call to question that and reassess where we’re at in the mid-2020s—and a plea for a little bit more kindness and flexibility.

What would that look like in practice?

For example, if somebody comes to me saying, “Well, I have generalized anxiety disorder, so I can’t do this stuff,” part of my work is to help that patient adopt a more hopeful perspective: that there are strategies that they can learn, that there are medications that can help, and that our mind is shaped by many different influences. There may be explanations for their anxiety that have to do with the brain and neurotransmitters and so on. But in most people, there are also more influential factors that have to do with their early childhood experiences and their current social setup, the precarity of their relationships or their economic situation, the quality of their sleep, or the substandard nature of their housing. There are all sorts of other factors that are having a bearing on their anxiety that I would seek to help them explore, rather than them just blanketly saying, “I have generalized anxiety disorder—can you give me the pill for that?” I’m trying to encourage my patient to say, “Yeah, there are pills that can help. But there are all these other factors that we need to think about. And do I really find that label helpful?” For some people, once you start to dig into it, they don’t.

We can extend that way of thinking to people who’ve had a psychotic episode. Between 10% and 20% of people who have a psychotic episode will never have another. For substantial numbers of people, their psychotic episode is actually a product of all sorts of stressors that are on them at that time. If you can find a way to modify their stressors, put them in a more supported state, and understand what place that episode has in the story of their life, you can then make a story that makes sense of that episode as the product of a uniquely difficult moment in their life. That can help people get over that episode and also, I hope, make it more likely that they don’t have subsequent episodes. Or, if they do, then they’re able to return fully to their normal functioning in between.

You write, “For the last forty years much Western psychiatry has behaved… as if our thinking is a simple matter of chemical levels in the brain. The truth is far more complicated.” For example, a 2023 study you cite challenged the serotonin theory of depression. [1] Why do you think that the chemical imbalance narrative has persisted?

There’s a number of reasons. That hypothesis came through at a time when our lab technology was starting to be able to measure neurotransmitters, and it offered a good story. If you become depressed, you feel as if you’re lacking something—as if you’re lacking some kind of fuel or energy. That lack translates very easily, in our metaphor-making minds, to the idea that there must be some kind of lack between our brain cells.

At the same time that this technology was becoming widespread, there was the promotion of a drug which seemed to help: Prozac. There’s no doubt that SSRIs do make a difference. Again and again, they’re shown to be better than placebo. The effect is probably a lot smaller than a lot of the drug companies would tend to promote in their materials, but they do help, and I continue to prescribe them. But what that study you’re referring to was saying was that, even if these drugs help, they don’t help by boosting serotonin levels. We can’t find evidence that substantiates that theory.

The first half of the 20th century was governed by Freudian ideas. Psychiatry in much of the West was dominated by those kinds of psychoanalytic ideas. Then, during the ’50s and ’60s, as we started to develop tricyclic antidepressants and experiment with other kinds of antidepressants—the first were anti-tuberculosis drugs—the idea grew that there might be a chemical solution, which fit very well into our technologically and pharmaceutically focused medical culture. Then, from the late ’90s, there was a huge explosion of the idea that, actually, a lot of it was genetic.

Now, even the idea that neurotransmitters are strictly excitatory or inhibitory is starting to be questioned. Essentially, the whole picture is vastly more complicated than the neurotransmitter hypothesis from the ’90s suggested. I don’t take that as a great failure of the hypothesis; it was an attempt to make sense of something very complicated, and the drugs that spoke to that metaphor are useful and are still among some of the most widely prescribed in the world. But the fact that we no longer think that low mood is purely because of low serotonin is a really positive step forward. It encourages us to embrace more fully the biopsychosocial approach to mental illness. The field of psychology and psychiatry is not known for consensus, but one thing everybody agrees on is that it’s not just biology, it’s not just psychology, and it’s not just sociology—it’s all these influences that have an effect on our mental health.

Are there other common assumptions about mental illness that you think deserve closer scrutiny?

Every age uses the metaphor of its highest technology to make sense of the mind. In the 19th century, the mind was famously described as an enchanted loom; the mind was thought to be weaving our experience, moment by moment. We’ve now got these very pervasive metaphors of wiring, which I find quite unhelpful because the brain is nothing like a circuit board. It would be like a circuit board made of jelly that can fix itself. So I think the wiring metaphor, although it has its uses, has gone too far because it’s too deterministic. It’s not organic enough.

Half a century ago, Stanford psychologist David Rosenhan wrote, “A psychiatric label has a life and an influence of its own.” To what extent can psychiatric labels help, and to what extent can they hinder?

There’s a lot of controversy about the Rosenhan experiment. [2] He’s been accused of being a charlatan and fabricating quite a lot of his data. But I think the value of his reflections still stands. I’ve definitely seen in my clinical practice that people will be treated differently because of a label that has been put in their notes, even though that label might have changed several times. I’ve had patients who’ve had four or five different labels in the course of their career, while they’ve had actually pretty much the same kinds of experiences and distress throughout all of those.

What I find really helpful in my conversations with patients is the fact that we don’t always have to give a label. If someone is really keen for one, then I’m happy to explore that with them and tell them, “These are the psychiatric categories that are on offer in the current edition of the DSM. Some people find them really useful, but with every new edition of the manual, they change, so they’re not describing something discrete, fixed, or in the natural order of things. They’re a way of describing and approaching distress, so let’s talk about how much they would be helpful for you.”

Now, in the U.S., I understand that labels can be essential because of insurance-based medical payments. In a U.K. context, a label may not be as useful because our psychiatric services are organized differently. I gently explore with each patient how much for them it’s going to be transformative. If it’s going to help ease their suffering and get them the treatments that they want, then I embrace it and help them get the one that fits best. But if it’s not going to be transformative in terms of how they can access care, then I tend to try to avoid giving a label because that can allow a level of optimism and dynamism about their state of mind. It more genuinely reflects the possibility of change and adaptation, rather than risking somebody changing the way they think of themselves.

As human beings, we’ve got such a huge tendency to put shame on one another. What labels seem to do in our current moment is absolve people of that shame in a really helpful way. I’ve had patients say to me, for example, that until they got their diagnosis of ADHD, they felt so ashamed of not being able to focus properly at work, and what that label did was offer a kind of absolution from that shame because it said, “There is this category of being that is separate from you and which seems to be affecting you, but it’s not your fault.” That can be wonderfully liberating. In those kinds of situations, I’m often keen to embrace the label if it’s going to help the patient cast off their shame. But I’m also questioning: Why have we got that shame? Isn’t it a pity that people often feel that they need to embrace a medical diagnostic label in order to rid themselves of that shame?

What strengths do primary care physicians bring to mental healthcare compared to someone more specialized?

One great advantage of somebody in my kind of role is that I’m embedded in the community. I often know the whole family, and I’m seeing people for all kinds of other problems which have a bearing on their mental health. I’ve become more aware of the connections between families and individuals; a specialist only sees the one individual with a particularly distressing problem—for longer appointments, granted, but removed from that context.

There’s a wonderful GP writer in the U.K. called Iona Heath, who has written a lot about the fact that it’s in the primary care consulting room where suffering is either given a label and understood within a medical model, or not. Some people see primary care physicians as essentially holding a line, or acting as some kind of gatekeeper, between the huge mass of human experiences that are out there and which ones become medicalized. A lot of people will come and see me about something fairly banal—almost to try me out, to try and figure out whether I’m going to be kind, compassionate, friendly, or approachable. Once they’ve tried me with a symptom that they’re not too fussed about, then they’ll risk sharing the one that they’re really worried about.

As a primary care physician, I feel I have a very privileged role: You’re not part of the family, but you’re not part of the establishment—you’re somewhere between the two. I’m often the first port of call for people hoping to make sense of their experience.

One line from your book that struck me: You write that today’s DSM categories will one day “seem as overconfident as the old phrenology charts.” How literal or hyperbolic do you mean that comparison to be?

Phrenology was debunked about 130 years ago. By the late 19th century, it was already starting to lose its traction because good thinkers were realizing it was a load of rubbish. If I could fast forward to 2176 and ask the doctors of that time what they’ll make of the DSM-5, I don’t think they would see it as phrenology, but they would certainly see it as utterly obsolete and unhelpful to them because it’s a cultural document of the West in the early 2000s. We can’t imagine what Western culture is going to look like in 2176. I’d argue that it’s quite likely that it will be very different from our current culture, that our neuroscience and genetics will have progressed in huge leaps and bounds, and that the organization of our society—while it may not have progressed—will have changed utterly. The DSM-5 will be of purely historical interest. When I was born in the ’70s, they were using the DSM-II, which is now considered very much a historical document—and that’s within my lifetime. I’m hopeful that the DSM-6, if and when it ever appears, is going to be an improvement on the DSM-5.

What inspired the book’s title?

From my chair in the clinic, I don’t see people’s minds as brittle and fragile. I see people as immensely resourceful, resilient, adaptive, and dynamic. People are incredible; they always amaze me with their ability to get over even the most extraordinary difficulties, suffering, and traumas. In my seat, I see the mind as far more unfragile than a lot of the rhetoric in our culture suggests.

The Unfragile Mind: Making Sense of Mental Health
Gavin Francis
Publisher: The Experiment, New York. 2026. 256 pages.

[1] Moncrieff, J., Cooper, R. E., Stockmann, T., Amendola, S., Hengartner, M. P., & Horowitz, M. A. (2023). The serotonin theory of depression: A systematic umbrella review of the evidence. Molecular Psychiatry, 28, 3243–3256. 
https://doi.org/10.1038/s41380-022-01661-0

[2] In the 1970s, Rosenhan and eight pseudo-patients feigned auditory hallucinations to gain admission to a dozen psychiatric hospitals across the U.S. Once inside, Francis writes, they “declared themselves free of the hallucinated noises, but found it very difficult to be believed, and be discharged” (p. 47).

Web image created from book cover by Medhum.