Falling Into the Fire: A Psychiatrist's Encounters with the Mind in Crisis - Softcover

Über die Autorin bzw. den Autor

Dr. Christine Montross is Assistant Professor of Psychiatry and Human Behavior, and Co-director of the Medical Humanities and Bioethics Scholarly Concentration at the Warren Alpert Medical School of Brown University.  She is also a practicing inpatient psychiatrist. Dr. Montross’s previous book, Body of Work, was named an Editors' Choice by The New York Times and one of The Washington Post's best nonfiction books of 2007. She and her partner, the playwright Deborah Salem Smith, live in Rhode Island with their two young children.

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(AUTHOR’S NOTE)

The names of all patients and certain details of their stories have been changed in order to preserve confidentiality. For the same reason, the names of some of my colleagues have also been changed.

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(PROLOGUE)

Bedlam

Canst thou not minister to a mind diseased?

—Shakespeare, Macbeth

In early January, Charles Harold Wrigley, a twenty-two-year-old gas engineer, was brought by his family to the psychiatric hospital. “The patient is extremely depressed,” the evaluating physician wrote. “He sat with his hand on his forehead as if in pain during my interview. He says everything he does is wrong and that he is very miserable.” A second doctor’s note adds, “I am informed . . . that the patient has suicidal tendencies and since he has been [at] this hospital has attempted to strangle himself.” Notes like these are familiar to me. As a psychiatrist, I have seen countless patients in emergency rooms, inpatient units, and outpatient offices whom I might have described in nearly identical terms. This patient’s symptoms are not striking; however, the familiarity of the description is, considering that Charles Harold Wrigley was evaluated and treated at England’s Bethlem Royal Hospital in 1890.

Before I became a doctor, I had more faith in medicine. I thought that medical school and residency would teach me the body’s intricacies, its capacities to heal and to falter, and all of our various methods of intervening. Once I mastered these, I thought, I would really know something. That has turned out to be partially true. I know many more things about the body—its wonders and its failings—than I could ever have imagined. But as a doctor, I have emerged from my training with a shaken faith. If I hold my trust in medicine up to the light, I see that it is full of cracks and seams. In some places it is luminous. In others it is opaque. And yet I practice.

At times this doubt is disillusioning. More often, however, I’ve come to view the questions that arise as a vital component of the work of medicine. My faith in medical knowledge has shifted into a faith that the effort—the practice—of medicine is worthwhile. I cannot always say with certainty whether the course of treatment I prescribe will heal; I cannot always locate with precision the source of my patients’ symptoms and suffering. Still, I believe that trying—to heal my patients and to dwell amid the many questions that their illnesses generate—is a worthwhile pursuit.

I have found that one of the gifts of medicine is that it allows those who practice it to participate in the purest and most vulnerable moments of human life. As doctors we share in the utter joy of birth, the irrepressible relief of a normal scan or a benign biopsy. We deliver earth-shattering diagnoses. We accompany people to their deaths. In these moments there is not much room for the protective or insulating layers that people—all of us—put upon ourselves in our daily lives. Joy is joy, and grief is grief, and fear is fear; and in the context of medicine, those emotions are often at their most primitive and raw. As an inpatient psychiatrist, I treat people who are in moments of profound crisis. The majority of them are hospitalized because they might not be safe otherwise. I do not lose sight of the fact that my patients come to me in these precarious states.

I am a few years into my psychiatric practice. Relatively speaking, I am new to the job. Every day that I go to work on the inpatient psychiatry wards, I encounter people who are despondent, or terrified, or raving mad. I see people whose lives have been ruined by addiction. I hear unfathomable things that people have done to others, from familial betrayals to brutal attacks. I talk with people who, more than they have ever wanted anything, want to die. It is not a dull job.

This book was written over the course of my residency in psychiatry and in my first years as an attending psychiatrist. As a resident, I worked in many different psychiatric settings, from prisons to outpatient offices to medical and psychiatric hospitals. These days I work as an inpatient psychiatrist on the locked wards of a freestanding psychiatric hospital. I wrote the book not as a sequential exploration of patients I have encountered over these years but rather as a visiting and revisiting of hard questions that emerged for me about patients, and medicine, and the mind. Questions that stayed with and gnawed at me. This book arose from psychiatry’s mysteries and my own misgivings, from patients whose struggles I could not make sense of, from the doubts and queries that haunted me and kept me from sleep at night.

•   •   •

It was in my current job working weekends on the wards of the psychiatric hospital that I met Joseph. On the weekends I cover an entire adult unit in the hospital, which means that on Saturday mornings I will have eighteen to twenty patients to see. Before I see them, I will have had a brief Friday sign-out on each patient from the weekday doctor. Sometimes this will be a conversation that spans a few minutes. Sometimes it is a phrase written beside a name: “resolving paranoia,” for example, or “manic, assaultive.” The nurse in charge of the unit meets me when I arrive and gives me pertinent information from the last twenty-four hours: vital signs, the degree to which a patient is participating in the unit therapy and activity groups, whether a patient is eating and taking her medications, whether a patient appears to be withdrawing from alcohol or from drugs. The nurse will also pass along anything the staff has noticed, either worrisome or reassuring. It is in this early-morning session that I hear about who wandered out of whose room naked and confused, who has gone two days now without talking to himself, who remains suspicious about whether her medications are poisoned, who was caught with cigarettes.

If a patient has been admitted overnight on Friday, then I will have the record of his emergency-room evaluation, but I will be the first treating psychiatrist to see him. It will be up to me to learn how the patient ended up in the hospital and how his treatment on the unit should begin.

This was the case for Joseph. When I walked onto the unit and saw his name listed as a new patient, I pulled his chart from the rack and flipped to the ER assessment: “42-year-old man with a history of depression who was referred by his caseworker after becoming increasingly depressed, not eating or drinking, not leaving his house, etc. Patient engages minimally with interview. States he wishes he were dead, but denies plan or intent to kill himself. Patient has been on antidepressants for many years, but recent compliance is questionable.”

Because of Joseph’s “minimal engagement,” there wasn’t much additional information in the evaluation. Our records showed that he had been hospitalized here five times before, but his most recent prior hospitalization had been seven years earlier. That was before the hospital had adopted computerized records, which meant that Joseph’s records were entirely contained in paper charts, and those were archived. They could be requested, but it would require several days to obtain them. I needed to begin treating him now.

From the nursing report, I learned that Joseph had arrived on the unit and gone straight to bed, where he had been asleep for the last six hours. When the report had concluded, I made my way to his room to see him. I knocked on his door, and no one answered. I pushed the door open gently and called,...