Falling into the Fire by Christine Montross

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Written by Victoria Best

I begin to wonder whether there is an entry in the DSM (the Diagnostic and Statistical Manual of Mental Disorders) for readers like me, who find themselves fascinated by accounts of people struggling with the different illnesses it defines. I’ve long been a reader of ‘shrink lit’, books based on psychotherapy, and now I’m branching into the popular literature on psychiatry, for which Oliver Sacks is the main torch bearer. Following in his footsteps with great compassion, intelligence and a wealth of completely bonkers patients is Christine Montross.

Falling into the Fire presents an engrossing portrait of the frontline work undertaken by Montross in her time as emergency admissions doctor to a hospital’s psychiatric inpatient ward. Given that Montross is an American, there are strict boundaries to the amount of care and the kind of care her patients are entitled to. None of this makes helping them any easier, not when the illnesses they have are fiercely resistant to cure or even understanding in the first place.

The book opens with the case study of Lauren, a young woman who, in times of emotional stress, repeatedly eats the most extraordinary diet of smashed light bulbs, screws, scissors, cutlery and bedsprings. When admitted to the hospital for emergency work with gastroenterologists playing fairground gripper with their high-tech equipment, she is likely to swallow any medical equipment lying around just as soon as she comes to from the anaesthetic. This means the amount of time and effort involved in her care is immense: hospital rooms have to be specially cleared to hold her. And Lauren shows no gratitude for the care taken; she is hostile and rebarbative, able to latch onto even the meagre insecurities Christine Montross suffers from in order to unsettle her in interviews. Inevitably, she is viewed with anger and resentment by the staff. A nurse dismantling an IV pole admits:

‘As if I’m not busy enough, I gotta waste time pulling all this apart for our most frequent flier every time she decides she wants a little attention. It’s not like there are other patients of mine who are… I don’t know, actually sick or something. God forbid I spend my time doing things for them.’

Montross is particularly good throughout the book with the vexed issues of compassion and empathy for mental illness. Doctors have the most punishing workloads, often going without sleep for 30 hours (how this can be legal, I do not know). And then they must defend themselves in some way against the pain and suffering they face daily. On top of this, patients like Lauren, and like those suffering from problems like psychogenic nonepileptic seizures – what used to be the old seizures of hysteria – give doctors the impression of having had one pulled over on them, of being duped because the patient failed to be ‘genuinely’ unwell. Such patients are easily seen as malingerers, because if the illness is in the mind, there is nothing wrong with them.

There is a common and erroneous belief that psychiatric illness is not real, that mental illness is ‘all in your head’ and can therefore be cured by force of will. Such a belief has no credibility; stacks of scientific and anecdotal evidence oppose it. And yet even for psychiatrists – who know well the capacity of the diseased mind to produce problematic behaviour – it can be a challenge to remember that a patient’s actions may not be a reflection of his or her will.

This becomes a pressing issue when the patient is a mother who fears she might harm her child, for example. It’s too easy simply to be horrified or appalled, and such judgement means that many women at risk do not seek the help they need. Up to 70% of mothers who have babies suffering from bad colic admit to having aggressive thoughts towards them, and when you think of the cocktail of hormones screaming in their veins for days and nights on end, it’s no surprise. Help is available – the real tragedy is when it isn’t taken.

Christine Montross intersperses her accounts of her patients and the science behind their issues with glimpses into her private life; often ones that find her experiencing the mildest versions of her patient’s extreme behaviour. The desire to feel alive by jumping into a freezing ocean seems laudatory, in a way swallowing knives does not, but the impulse is the same. Yet it felt strange that, while celebrating her own happy and sane existence, she never looks closely at the fact that her marriage to another woman with whom she is raising two children would have been heavily condemned three or four decades ago. And then she would have been subject to some of the social pressures her patients have buckled under. Nor does she consider the fatal tendency of medicine to be hypnotised by fashion – like the prescription of ritalin for children, or the x-rays of pregnant mothers that, even with data proving the link to childhood leukaemia, were used for another twenty years. She sticks to the conviction that not enough people get the drugs they need, which may well be true.

She does raise vital issues about the near impossibility of decent after care for her patients, as well as the ethical problems surrounding their treatment with regard to the patient’s right for choice and autonomy when compared to the unsettled balance of their minds. This was a gripping book and a fair and compassionate one; the sheer difficulty of finding answers to the problems she highlights only shows how essential it is to keep thinking about them.

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Victoria is one of the Shiny Editors.

Christine Montross, Falling into the Fire; A Psychiatrist’s Encounters with the Mind in Crisis (Oneworld, 2014), 256 pages.

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