Doing the Best

Is Psychiatry Being Stumped By the Mental Illnesses It Has to Treat?

Psychoanalyst Matthew Tiffany on an important new book that shows just how complicated the issues and challenges are in the field.


Set aside an afternoon to go online and search for how psychiatry is failing. You’ll discover a cottage industry—a slew of books, editorials, essays, and news features covering the crumbling mental health services in America. Coast to coast, from The Los Angeles Review of Books to The New York Review of Books, there are essays on over-diagnosis, misdiagnosis, under-diagnosis; there’s a Greek chorus singing the zealotry of how doctors are all-too-frequently throwing medications at mental illness, while the pharmaceutical industry pulls the strings, like a malevolent Oz. We have a culture that favors fast, quantifiable results through measurable, evidence-based treatments—in schools, in the workplace, and in medical care. Get in, put a bandage over the problem, submit your bill to the insurance company, and get out. Problems that develop over years, decades—even over generations, as the patterns of one pass on to the children—are increasingly expected to be set right in a few sessions.

Christine Montross’s Falling Into the Fire: A Psychiatrist’s Encounters with the Mind in Crisis is as good an account of the labyrinth of mental health care as you’re likely to read. Her work in critical care psychiatric settings is the source material, and she launches from discussions of clients into larger questions about the nature of psychiatry and of mental health.

Montross writes beautifully about the deep-seated illnesses that challenge therapist and psychiatrists. For one, there’s always a struggle to help patients hold together a semblance of a happy life, and at the same time provide comprehensive treatment. And sometimes, there are questions about mental illness that just can’t be answered in a way that can inform good quality care. What do psychiatrists do then?

Some questions might be easier to answer. Montross writes about a client with body integrity identity disorder (BIID). Imagine being plagued, all the time, with an unshakeable feeling that you aren’t supposed to have one of your legs, or arms. You’re perfectly sane, but you’re also tormented with the conviction that your right leg is only supposed to go as far as the knee. It overshadows your every waking moment. Medications aren’t helpful; psychotherapy isn’t either. Is it Montross’s responsibility to recommend a below-the-knee amputation of a perfectly healthy limb? Good luck—no hospitals will allow elective amputation. Even if they did, do you really need to check your health insurance to know that “elective amputation” isn’t going to be covered?

Another case study details a patient who regularly engaged in self-injurious behavior—she would eat broken glass, razor blades, knives. She would get hospitalized, fail to respond to any interventions that were aimed at easing whatever root causes were behind it, have said objects surgically removed, and end up back in the hospital weeks later for the same problem.

In the former case study, Montross couldn’t do what was in the best interest of the patient; in this study, despite her certainty that the medical response was exacerbating and feeding into the underlying causes, the hospital had little choice but to remove the objects the client had swallowed. Montross writes with a great deal of compassion—everyone involved here is caught between a rock and a hard place, the other hospital staff are burning out on this patient, and there simply are no straightforward answers.

I am a mental health practitioner as well, and we do as much as we can do. When we’re not being expected to keep the ship afloat while simultaneously flooding it, we get to feel some of the most visceral cognitive and emotional satisfactions you could possibly imagine. Achilles comes to us and shows us his heel, trusting we’ll do what we can for him. Families sit down with us and lay bare their struggles and failures—as parents, as children, as people. Reality becomes an itch they can’t scratch, and when we do our best to help restore order, the best solutions we can offer often come at the expense of some other aspect of their lives—their weight, their ability to feel anything other than a static-gray, a complete reshuffling of the deck. The new hand is not always better than the last they were dealt.

Meanwhile, practitioners of mental health treatment continue working in a system where, I’ve been told time and again, “you can only do as much as you can do,” as if that sort of reassurance isn’t a direct line to needing one’s own counselor. Many days, doing what I can do as a clinician involves feeling like I’m running through a series of booby-trapped tunnels wearing a fedora, somehow staying only a few steps ahead of a fast-moving boulder. Show me a clinician who hasn’t once found the system we work in to be at least as big an obstacle as the mental illness we’re trying to treat, and I’ll show you socialized medicine.

All too often, books akin to Montross’s are published with the most fantastic, unusual case studies—no doubt because they simply make for a better story. Montross doesn’t entirely avoid this trope, but the emphasis here is less on the peculiarities of the illnesses these patients present, and more on the questions raised for them and for her.

The profession remains a knotty tangle of influences and causations and aggravations and insurers. The truth, though, behind all of the end-of-days reporting on the failures of psychiatry, is that achieving measurable results in the field has always meant trying to force a round peg into a square hole. Every day brings successes and failures, and rarely do we get one without the other, in some form. We learn from both, and go through the maze again armed with new information. And even though the path home is never the same, we can at least do the most we can do. For Montross, writing this book—asking these questions, wrestling with the answers—goes a long way toward helping the rest of us do the same.