Falling into the Fire: A Psychiatrist's Encounters with the Mind in Crisis
by Christine Montross
Penguin Press HC, 2013

If Joan of Arc were alive today, she probably would not be heralded as a saint. The 15th-century French peasant girl instead would be institutionalized or put on heavy antipsychotic medications for claiming divine visions urging her to overthrow the English government. As our knowledge of the brain has advanced since those days, so, too, has our approach to treating mental illness. Yet we still face significant gaps in knowledge.

In Falling into the Fire, psychiatrist Montross describes her experience as a resident and attending physician in a hospital ward. Her tale reveals the incredible challenges psychiatrists face when trying to understand, diagnose and treat severely mentally ill patients.

Consider Eddie, a man who endured 25 elective cosmetic procedures in an attempt to rid his skin of acne, despite having no blemishes. Montross diagnosed Eddie with body dysmorphic disorder, a condition in which patients obsess about one aspect of their body, often checking their imagined affliction hundreds of times a day. Eddie refused the treatments Montross proposed, believing he would be better off saving his money for another plastic surgery. The episode left Montross feeling helpless. She lacked the tools to help difficult patients who reject sound judgment and potentially lifesaving treatment.

Eddie was not the only baffling case. One day a patient named Colin entered the clinic calmly stating he was Jesus. People claiming to be possessed by divine or demonic entities are not as rare as one might think. He showed many symptoms of a strange condition known as Jerusalem syndrome, which manifests most commonly in travelers who visit the Holy Land and suddenly begin wrapping themselves in tunics and preaching scripture.

When Montross saw him, Colin appeared harmless and blissful, but his girlfriend said he had been behaving strangely, such as urinating in soda bottles. Euphoria often opens the floodgates to psychosis, so before her shift ended, Montross sent Colin home with orders to take an antipsychotic. But her limited time with him and understanding of his illness precluded her from assessing the best course of treatment or ascertaining whether he was a threat to himself or others. Montross left the hospital that night feeling uneasy, thinking perhaps she had underestimated Colin's mental illness.

Reflecting on her experiences, Montross writes: “As psychiatrists, we see the mind while it careens and lists, and we are not always sure how—or whether—we can right it. How do we respond when a patient's suffering breeds unbearable discomfort and unease within our own selves?”

Many of the case studies leave the reader hanging. A psychiatric ward physician may see patients only once during their stay and never know what becomes of them later. Uncertainty comes with the territory. In psychiatry as in everyday life, there are no easy fixes or cures. Sometimes, Montross writes, empathy is the best or only tool at our disposal.