Abstract
Many readers of the Journal will be familiar with The House of God, Shem's description of internship in a large teaching hospital in the United States. Shem is a Rhodes scholar with a PhD from Oxford and a graduate of Harvard Medical School where he remains on the faculty. The House of God was very widely read in this country and provided a satirical distraction for many Australian interns. Mount Misery follows the principal character Roy Basch into his first year of psychiatry residency at a ‘BMs’ (Best Medical School) affiliate institution. Basch commences his training under his intended mentor, a psychiatrist who heads the residency program and is an expert in suicide research. When his mentor dies suddenly, a more senior trainee takes Basch under his wing and he begins rotating through a series of increasingly more bizarre settings. Each rotation gives some delightful descriptions of the varied training experiences offered.
Blair Heiler, the borderline expert, works out of ‘Emerson’ and enrages his staff and patients through adhering to the theories of his guru, one Renaldo Krotkey. Heiler is at his best when dishing up appalling treatment to his patients and justifying it with psychodynamic gobbledegook. In ‘Toshiba’, the admissions unit, Basch learns to grossly abbreviate history-taking to achieve a DSM diagnosis suitable for the managed care fund and the hospital's balance sheet with the patient coming a distant third. ‘Thoreau’ is the analytic unit where the female director wears dark suits cut in a masculine style and carries a cigar. She supervises Basch by carefully writing notes in two columns in a ‘crisp new ledger’, one column for actual content and the other for interpretative comments. Her own raison d'etre is to expand her theory of the ‘Oedipal oscillator’. In the biological unit, drug company minions deliver all inpatients a similar cocktail of new psychotropic agents. They thrill in performing psychosurgery at all hours in secret labs under strange halflight while being fuelled by their own chemical intake. Throughout the proceedings, Schlomo Dove the entrepreneurial analyst specialises in initial assessment and referral but keeps some patients for himself. He reviews the lucky few in his loft amid rotting banana plants.
I particularly liked this book's depiction of the changes felt by the psychiatrist in training as he is whirled through different models of psychiatry. Basch self-medicates on the biological ward, becomes neurotic and craves for analysis on Thoreau and feels part of a dehumanising system on the admissions ward. His shifts in personal style affect him deeply and are reflected in his problematic private life. He grapples with dependency on various individuals as they come and go throughout his training. In Basch's world of residency training, elements of psychopathy and other personal psychopathologies are seen in all the senior figures in his institution. Some readers may have little trouble drawing at least some parallels with their own training system!
Clearly, the book provides a very black commentary on American psychiatry today. In an internet interview, Shern states that the work is mostly true for all its harshness. In the book, Shem shows his true colours as a therapist who strives ‘to be in good connection with people’. His humanistic therapy style probably owes much to his work with drug and alcohol patients based on the 12-step model. He has gone on to write a play about Bill Wilson and Dr Bob, the founders of Alcoholics Anonymous.
In the review comments inside the front cover of the book, Jeffrey Masson describes it as a ‘report from inside the slowly crumbling fortress of psychiatry’. Masson is well known for his view opposing psychoanalysis and now seems to extend his attack to psychiatry in general. The important point about this work is that it is fiction: Shem uses gross irony and at times tragedy to provide an engrossing read. Psychiatry is not accurately represented in this work, especially not Australian psychiatry. One hopes that several of the worst aspects of the US system depicted in this work will never reach our shores. However, in some ways I wish Shem could have experienced the recent rise of ‘community psychiatry’ in our country and lampooned it, surely not too hard to do.
At worst, the book may give the lay public extreme views on where our specialty is today. At best, this book can be immensely entertaining especially for those of us struggling to work or train in the psychiatry system at present. Mount Misery provides some lovely insights into the eccentricity and egomania behind some of the current theoretical schools in psychiatry. It also highlights some of the personal struggles that can become part-and-parcel of doing training in this era. I would recommend this book to all psychiatry trainees both for entertainment and an insightful perspective.