Falling Into the Fire: A Psychiatrist's Encounters with the Mind in Crisis Read Online Free

receives the correct diagnosis. The fifth and final chapter recalls Joseph and patients like him whose bodies are overtaken by the illnesses of their minds. How do we treat a woman whose seizures have no neurological cause? What possible explanation can there be when groups of men are convinced that their penises are shrinking into their bodies? The chapter asks how well we doctors, trained to act and fix, are prepared to sit with patients in—and accompany them through—the trials of their illnesses.
    Life, of course, changes how we see things. As I wrote this book, my partner, Deborah, and I were raising our young daughter and our even younger son. It turns out that parenting children and caring for psychiatric patients have their fair share of similarities. I mean that in all the ways in which that sentence can be interpreted: with love, and frustration, and gratification. With fear, and awe, and ineptitude.
    My children do not age sequentially in this book. My daughter may be four, and then she may be a newborn. I have found that I experience the pasts of my children in this jumbled way. A snapshot of a year ago and then a flowing current of their infancies and then today, with their book bags and lunch boxes and shoes that tie. I imagine that the memories will intermingle like this throughout their lives. Those memories, too, will shift with context. My son will become an engineer, and we’ll nod knowingly, claiming to have seen it coming from the years of infinite Lego structures. Or he’ll be a comedian and we’ll say,
We knew because he always made his sister laugh.
Hindsight is powerful in parenthood, as in medicine.
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    I n its quest for effective treatments of mental illness, the evolution of psychiatry has been characterized by both inspiring and inglorious moments.
    The Bethlem Hospital to which twenty-two-year-old Charles Harold Wrigley was admitted in 1890 was founded as a priory in 1247. It became a hospital in 1330 and took the first patients classified as “lunatics” in 1357, making it the first and oldest recognized institution in the world to give care to the mentally ill. By the end of the fourteenth century, the hospital began to be used exclusively as a hospital “for the insane.” Over the centuries the hospital grew, as did the demand for the care it provided. But for nearly three hundred years, Bethlem housed only twenty patients at a time and operated as an institution for so-called short-stay patients.
    Today my colleagues and I use this term for hospital admissions whose duration is less than forty-eight hours. In the current state of health care, only the most severely ill patients are admitted to the hospital; even then the average stay is five days. Managed-care companies will phone physicians, sometimes daily, to interrogate them about their clinical decisions and treatment plans. If the insurance companies do not feel that the patient continues to meet their own narrow criteria for inpatient treatment, they will refuse to authorize additional days of hospitalization. Physicians have the right—indeed the mandate—to make clinical decisions based on patients’ needs rather than insurance companies’ pressures, but we are aware that unauthorized days in the hospital will result in staggering bills for our patients, many of whom are already in financial turmoil. If patients cannot pay, the costs of their treatments are frequently absorbed by the hospitals themselves—an obviously unsustainable practice. These factors combine to form the present reality: Today’s inpatient care is most often crisis management. Patients are discharged from our wards as soon as they begin to stabilize, once they are no longer acutely psychotic or no longer in imminent danger of harming themselves or others. This means that patients are often released from the hospital in a tenuous state of mental healing. In many cases their symptoms recur and they return to the hospital for