Savage Sadness

In this picture, and other versions of it, Lucas Cranach reminds us that there can be a complex relationship between misery and rage, as Dame Melancholy watches children play and sharpens a stick while her dire imaginings gallop through her mind. To cease to care about your own life might perhaps tempt you to value others' less as well, and if you have within your grasp the means of doing harm to others as well as to yourself - say, a firearm, or a passenger aircraft - the situation is dangerous. That this may be true can't justify hysteria about people with mental illnesses, or implications that they - or maybe we, as until I'm dead I won't be sure I won't develop something of the kind - can't be allowed to do any job more responsible than cleaning.

This is a way of linking current news stories with a book I read lately and have been meaning to write about, Christine Montross's Falling Into the Fire (Penguin, 2014). I spotted this at the Science Museum a little while ago, and thought a psychiatrist's account of dealing with mental illness of different kinds would be illuminating in some of the situations in which I find myself. It was: I found myself with new insights into such mental malfunctions as Obsessive Compulsive Disorder (the woman who couldn't rid herself of fears that she was going to harm her children),  Body Dysmorphic Disorder (the man who felt there was something indescribable wrong with his skin), self-harm (the woman who regularly swallowed dangerous objects), and people who are absolutely convinced that a part of the their body - a right foot, say - doesn't really belong to them and want it amputated (Body Integrity Identity Disorder, according to the great Diagnostic & Statistical Manual of the American Psychiatric Society). But this book is less a catalogue of ways in which the mind can go wrong than an exploration of what happens to physicians when they come into contact with such delusions and the people who suffer them. Dr Montross admits:

Before I became a doctor, I had more faith in medicine. I thougbt that medical school and residency would teach me the body's intricacies, its capacities to heal and to falter, and all of our various methods of intervening. ... as a doctor, I have emerged from my training with a shaken faith. If I hold my trust in medicine up to the light, I see that it is full of cracks and seams. In some places it is luminous. In others it is opaque ... My faith in medical knowledge has shifted into a faith that the effort - the practice - of medicine is worthwhile. I cannot always say with certainty whether the course of treatment I prescribe will heal; I cannot always locate with precision the source of my patients' symptoms and suffering. Still I believe that trying - to heal my patients and to dwell amid the many questions that their illnesses generate - is a worthwhile pursuit. 

This book arose from psychiatry's mysteries and my own misgivings, from patients whose struggles I could not make sense of ... How do we respond when a patient's suffering breeds unbearable discomfort and unease within our own selves? What do we do when our patients' symptoms do not relent? When their experiences cannot be accounted for - or helped by - what we know about medicine, or the brain? What then?

Dr Montross explores the helpless, resigned anger the department feels when a self-harming patient they've seen countless times before is admitted yet again for surgery; her first response to Montross is to insult her mercilessly. She examines the fine line between a patient who seems to be simply unco-operative and pretending to be in a stupor from one who genuinely is, and the difference between psychogenic seizure and physical seizure, both of which the patient may experience as completely real.

Most strangely she describes the uncanny ability psychiatric patients often have to perceive the vulnerabilities in those caring for them, and relates the case of a colleague entering the room of his first patient of the day to be met with a barrage of atrocious insults about his mother, who happened to have died the day before. It may be that very disturbed people can have a heightened sort of sensitivity to the sorrows of others, or that they are more willing to say things that others don't and occasionally hit the mark; but I am put curiously in mind of the advice given to Christian exorcists that the demons know your sins and a possessed person will sometimes throw things at a priest they cannot possibly find out by normal means.

I found the book hugely helpful. What is for many of us a terrifying region of human experience is rendered a little more navigable with compassion, if no less mysterious.