Let me not be mad - A.K. Benjamin.
Bodley Head - 2019.
212 pages.
Into the abyss - Anthony David
Oneworld - 2020.
189 pages.
By the time Oliver Sacks died in 2015 he had become something of an untouchable. Not exactly a "national treasure" - but whatever the transatlantic equivalent of that might be. It seems strange to remember that, although he had attained sage-like status at his death (see Vaughan Bell's obituary post for a lovely example of the justified affection Sacks' inspired), he attracted controversy earlier in his career. The ethical worry about Sacks was that he was "the man who mistook his patients for a literary career;" writing for the "voyeuristic cognoscenti."
Whatever other legacies Sacks may have left, he arguably created more or less an entirely new literary genre ("neurolit" perhaps?), and every publisher of popular neurological case studies since has been keen to get "Oliver Sacks" onto the cover in some form, to provide the requisite signal to browsers.
I could read Sacks endlessly. After he died I ploughed through many of the ones I hadn't yet got to. I also worked through some of the expanding shelf of his literary progeny: Paul Broks, Suzanne O Sullivan, Jules Montague, the list goes on. As a psychologist this is all work related, but it is also a guilty pleasure - like detective fiction or spy thrillers.
Two recent books in the Sacks tradition have revealed some of the different things it can offer. A.K. Benjamin is the pseudonym for a mysterious clinical neuropsychologist who writes in the idiom of a world weary psychoanalyst. Anthony David is an academic psychiatrist and giant of his field whose first foray into popular writing is a spare but immaculate primer on psychiatry.
Benjamin's book comes with something of a "twist," for we learn by the end that some of the clinical vignettes within pertain to his own mental health problems. This device is personally revealing, but the use of pseudonym necessarily takes some of the edge off. In the end it is far from the most interesting part of the book.
I wasn't taking notes as I read Let me not be made, but so vivid and honest is the writing that much of it has implanted itself in my mind. Healthcare often involves an element of facade; of adopting a confident professional position and sticking by decisions despite the knowledge they could be wrong. Benjamin sees and - you sense - detests this facade.
In an extraordinary passage he writes of the emotional work that patients (sometimes) do to protect clinicians from the worst of their experiences. Our patients do us a service, Benjamin points out, by dying well. Most of us want a social encounter to feel comfortable and will collude with people, including clinicians to make it so. This is a form of protection, but it is coursing in the wrong direction. The person receiving the salary ought to the be the one doing the protecting. Benjamin invites us to recognise that it is often the other way round. That this is so brings into relief the importance of discomfort. If someone can make you feel uncomfortable, and you can sit with that discomfort and bear it, you might really be doing something for them.
The title of David's book seems to conjure something rather vague and mystical, but it in fact denotes a precise idea. Karl Jaspers once posited an "abyss" between the mechanistic and hermeneutic forms of understanding people. David sees the psychiatrist's task as bridging this abyss, to provide a working understanding of people that draws on both. Much has been made in mental health of the biopsychosocial model. David points out that in offering an apparent theory of everything, this idea threatens to explain nothing. Here he is on the way psychiatrists ought to related to the three strands, bio, psycho and social: "Every time we meet a new patient, we must decide which of the three, if any, is most important." (p.2) This is a punchy and pragmatic version of sense making that I recognise in the referral questions to a neuropsychology department, and it seems potentially at odds with my own profession's sometimes broadly inclusive formulations.
Each case study here seems carefully sculpted to reveal something important about the discipline of psychiatry - there is a patient with Capgras and Cotard's, who allows David to illustrate the meaning of the two-factor theory of delusions; another who illustrates the paradoxical neuropharmacological connection between psychosis and parkinsonism. Unusually for neurolit - David also includes a case that illuminates the issue of race and psychosis - allowing him to weave in some reflections on Frantz Fanon.
My own route into neuropsychology has felt weird to me - like many I was inspired by the intrigue of astonishing neurological phenomena and a desire to understand them. But I came into the field via an interest in psychoanalysis, phenomenology and mental health. What is the appeal of these books to this jobbing clinician? As a psychologist, working in neuropsychology, I realise I read them as something like a form of supervision. Academic texts give you statistical generalities, but there is nothing like a vivid account of the minutiae of clinical work and some startling clinical advice (at one point he abruptly announces to a family affected by head injury that they "will never be the same again") to help you really learn something.
A book like Abyss then is something like a series of lessons - archetypal illustrations of how people can be distressed. It expands ones clinical repertoire, opening up new possibilities for formulating complex situations. This is more or less what you would expect from a prominent expert in psychiatry. The cases are well worked through and served up with aplomb. But they are also like events from a distant past. As a clinician I envied David the unruffled clarity he brings to bear on each situation. A patient appears to recover from a crippling depressive guilt, only to throw himself under a lorry within moments of being discharged. David is unsettled, but seeks solace in Durkeim's writing on anomic suicide and emerges a wiser clinician with what reads like relative ease.
Benjamin's book offers something more emotional, and counterintuitively more reassuring. Here is an author who portrays the startling and graphic events that bring people into contact and inevitable emotional entanglement with neuropsychologists. He is vividly impacted by his patients and has gone searching in some unusual places (tibet, his own dreams; psychoanalytic theory) to try and make sense of them. But as he shows in a remarkably drawn scene of an NHS team meeting ("the decision is made, the knife is readied, and nobody who was there can quite say what just happened" - p.67), there is never really anything like a complete sense to be made. The best we can hope for is to figure things out a little better and a little more usefully. The note of horror, the terrible senseless randomness in the world that lets brains grow tumours and collide with skulls at high velocity, haunts the pages relentlessly.
