February 2014 News – Book Review – The Shock Of The Fall By Nathan Filer

This first novel has recently won the Costa Book of the Year after winning Best First Novel. Nathan Filer was a psychiatric nurse so is writing from his own experiences, albeit as a worker, of mental health services. The novel is written in the first person and tells the story of Matthew Homes. The fall of the title is the fall and death of his older brother Simon ten years earlier. Simon was two years older than Matthew and had learning difficulties.

Every book about mental health services has a political element to it and this is no exception although from what Filer himself has said about the novel this may not have been his intention. It is by turns funny, touching and insightful. For me the writing grew in stature as the book went on. Although one’s heart goes out to Matthew he is not a tragic figure and I found the ending inspirational.

The novel is set ten years after the death of Simon when Matthew is nineteen but does give an account of his history from his point of view. Matthew has been diagnosed as schizophrenic and there are some very witty passages about the whole process of diagnosis and what constitutes symptoms. What does come across strongly is the lack of privacy a patient experiences either as an inpatient or as a user of a day centre. Filer describes vividly how the concept of patient involvement in their treatment is actually illusory.    Unlike some other novels it doesn’t resort to ‘splitting’ and staff are not portrayed as villains but as much subject to the system as patients.

In one sequence staff have clearly been told that the day unit is to close but they are having to reassure patients that all is well despite the distress they are experiencing. In another Matthew sees a man he has become somewhat attached to restrained and how different staff react to this. Filer hasn’t written a polemic and by not engaging in the ‘splitting’ he creates a much more realistic picture.

Matthew’s own ambivalence about how he views himself is crucial and moving. After expressing anger or difficult emotions he will berate himself as a bad person. It is set up quite clearly from the onset that Matthew is an intelligent and extremely sharp young man but he is often infantilised by staff and not treated with much respect for his intelligence or insight. Matthew at one point manages to see his notes and discovers that his absorption in the computer is described as ‘writing behaviour’. He then goes on to ponder that perhaps any interest could be pathologised as ‘behaviour’.

Filer, speaking through Matthew, has a keen awareness of some of the absurdities of biological psychiatry and mentions the Rosenhan experiment of the early 1970’s. This famous US experiment consisted of several ‘healthy’ volunteers, including Rosenhan himself, posing as prospective patients with a controlled set of symptoms. When they were admitted as inpatients they found that even their perfectly ‘normal’ behaviours were pathologised. I believe that some of the volunteers at the end of the experiment did find it difficult to get discharged!

There is a horribly funny sequence where Matthew lists all the possible side of his medication and says he has all of them. One can’t help wondering if these terrible side effects would be acceptable in any ongoing treatment other than mental health. Perhaps what comes over strongest is that of the tedium of life as an inpatient. Perhaps even more so for the younger patients and inpatient units are now predominantly filled with the younger less ‘compliant’ patient. Older patients are much more likely to be ‘managed ‘in the community as is illustrated by the pig man in the novel. Additionally, and with much rage, Mathew rails against the awful questionnaires so beloved by CBT and the current NHS.

As for Matthew’s family they have unwittingly contributed to his condition. They are not the grotesquely awful parents of Ken Loach’s, ‘Family Life’. They have been as traumatised by Simon’s death as Matthew. In particular, Matthew’s mother, who he describes as being ‘mad’, becomes so over protective that she doesn’t allow him to return to school and schools him at home until he moves to secondary school. It is very touching how Matthew describes intentionally making mistakes so that she can feel more useful. Matthew’s beloved father slips into a helpless silence which Matthew experiences as another terrible loss.

Fairly classically, Matthew’s schizophrenia emerges in late adolescence and when he leaves home. It is at the point in his life when reminiscence develops and this is when he fragments. Here the actual physical construction of the book is beautifully used. When Matthew is an inpatient or regularly attending the Day Centre he writes on computer and the text is in a standard book font. However when he is not, the text becomes that of the old fashioned typewriter his adoring grandmother buys him. It is here that the extent of his struggles are revealed. It is very revealing about why he has difficulty complying with oral medication and thus, as part of his care order, he is forced to have fortnightly injections. If he doesn’t have medication he has both visual and auditory hallucinations of Simon. Simon repeats over and over to him, ‘We’ll play together for ever’. These bring some form of comfort to Matthew even though he recognises he is no longer the nine year o!ld he once was but Simon. of course, remains an eleven year old boy with learning difficulties.

Several years ago I went to a day conference on risk and risky behaviour. One of the speakers was a young man from an online group of self harmers. He spoke eloquently and movingly for the group. He said something that has stayed with me. He said that to simply remove the ability to cut or self harm was not a good idea as it removed the established coping mechanism and that other ‘healthier’ mechanisms needed to be in place before that could happen. Similarly, Matthew needs to find some way to begin grieving the loss of Simon. In terms of ‘talking therapy’ there seems to be little available and Matthew clearly doesn’t feel safe enough to open up to staff. The medication takes away from him all that he feels he has left of Simon and this is devastating. I have worked with patients who have had baric surgery for obesity who have become suicidal because they have lost the ability to manage their psychological problems. They have lost their only means at that time to stem their feelings of emptiness.

‘The Shock of the Fall’ is a worthy winner of the Costa main prize and deserves to be widely read. Filer has managed to create a very vivid character and explore the devastating effects of trauma on a family. He shows how bereavement can so easily become disordered under these circumstances reveal the state of mental health services today and how it not only affects patients, but staff as well.

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