Head First: A Psychiatrist’s Stories of Mind and Body by Alastair Santhouse.

Published July 15
Atlantic Books


The clues that Alastair Santhouse was destined to become an eminent psychiatrist pervaded his childhood.

He would intercept his sister’s teenage magazines as soon as they landed through the letterbox, turn straight to the problem page and set about coming up with answers.  Eventually, he had compiled “a database of life’s teen difficulties”.

A Cambridge medical degree, years of torment as a sleep-deprived hospital doctor and more exams than he can count later, Santhouse has found his destined niche in an NHS office, with mismatched furniture and absolutely no view, where he tries to fathom the very adult issues of desperate people on the edge of our society, many of whom have flummoxed every other medical department.

He distils years of experience, which remarkably make him more caring than bitter, into a series of chapters that, like many other books written by psychiatrists, are effectively case studies.  What sets his apart are reflections so relevant, important and profound that it should be mandatory reading, especially for our politicians and medical health professionals.

The central thesis is that mind and body go, so to speak, hand in hand and that modern society and medicine are in denial of this basic truth.

“It is hard for us to conceive that when symptoms occur, when people experience pain or fatigue or dizziness, they can both be very real and yet not caused by any underlying problem with the body,” Santhouse writes.

The “body-as-machine” model of medicine, whereby individual parts go wrong and need fixing works only for relatively straightforward cases; an increasingly specialist set of practitioners is unable to see the whole.  When patients, often after months or years of pain and frustration, arrive in Santhouse’s office, he often must deal first of all with their terror of being thought of as head cases.

The reality is we are all head and body cases.  I doubt any one of us has not suffered from a tension headache and considered it to be a physical problem, even though the cause is not an underlying disease.

Santhouse takes us deep into areas we mostly ignore, such as the need for kidney donors to be assessed by a psychiatrist to ensure they are being altruistic – if there is any such thing as totally selfless behaviour – for the right reasons, and Santhouse’s most dreaded task of capacity assessment, when he deals with patients unable to agree – or disagree – with the treatment being prescribed.

He is educating us, but his book does not feel didactic.  He lightly peppers his prose with hair-raising statistics, sporting references, eclectic imagery, the wisdom of experience and his compelling arguments against legalising assisted dying: the more people know about it, the less likely they are to think it should be made lawful.

Although his faith in human nature is robust, he leaves us with a sense the severely over-stretched medical profession – and doubtless many other professions besides – was in a bad state even before COVID-19.

His chapter on the pandemic feels like an after-thought.  Its most striking observation is that we have been brought down in our hubris by something so small it cannot be seen under the most powerful microscope and is innocent of intent – for all our attempts to characterise it as an evil enemy.  He cannot yet tell us what we want to know about its lasting effect on our mental health.  In the short term, it has improved the happiness of anyone who prefers to work from home because they struggle with all the factors – noise, dirt, colleagues – they can’t control in a shared office.  For those battling drugs, alcohol or the millions who face loneliness, it’s likely the opposite is true.

Some of the relatively lucky ones may be making their way to Santhouse’s office, where they would be certain to find the most perceptive of listeners and observers, for whom “all behaviour is communication”.

I was sufficiently gripped by his humanity to read even the final credits, where I solved the mystery of how someone who has devoted hours to people others might view as hopeless cases had found the time to write a book.  In addition to thanking numerous doctors, his family and his “North Star,” his wife Sara, he acknowledges his fellow travelers on the Northern Line, where he wrote on an iPad during his long commutes.

That establishes him firmly, for all his privileges of education and a detached vantage point, as one of the masses.  He may be among the most successful practitioners of psychiatry but he hasn’t forgotten his job has elements of the agony aunt.

Barbara Lewis © 2021.